"I just don't understand it", Tim said.  "And I'm absolutely miserable."  

Tim was a staff physician at our hospital, and was coming in with a new problem.  He had a strong dust allergy which I had treated successfully with SLIT, and I had not seen him in several years.

Until now.

"I've been having these painful sores in my mouth for months", he said.  "And no one can find the cause.  I've checked in with an oral surgeon, and he assures me I don't have some terrible disease.  But no one can find the cause."  

"Was anything--anything at all--going on at the time you developed these sores?" I said.

"Well, yes", Tim said.  "But it really doesn't have anything to do with allergy.  I was diagnosed as having a high cholesterol."

"And what did you do for that?"  I said.  

"Well for one thing, I changed my diet."  I stopped having eggs every morning for breakfast" he said.  

"Well, what did you eat instead for breakfast?" I queried.

"Grapefruit.  Lots of them.  I figured they are healthy for me.  And you know what?  My cholesterol is coming down!" he said.  Tim smiled for the first time during our meeting.  

Tim's problem immediately became obvious to me.  He was having allergic stomatitis from citrus fruits, something I have seen before. This isn't something new, and others have reported on it:  Ettelson and Tuft, writing in the J Allergy 536-43, 1956 reported on "Canker sores from allergy to weak organic acids (citric and acetic).  Also, Kutscher, AH et al reported in the J Allergy 438-41, 1958 on "Citric Acid Sensitivity in Recurrent Ulcerative (aphthous) stomatitis.  

But is "the moral of the story" that excessive dietary intake of citric acid can trigger allergic aphthous stomatitis?  

Hardly.

You see, time and again, I see situations where the worlds of allergy and medicine collide.  Often with disastrous results.  The world of medicine often "prescribes" dietary intervention with the intent of utilizing something repeatedly to aid a condition.  But dietary repetition is something that isn't necessarily good for the allergy patient.  One of my allergy aphorisms is that "Repetition  may be the best thing for an aspiring musician, but it is the worst thing for an allergy patient aspiring to get well.

Worlds collide.

I have seen this problem played out in various scenarios over the last 30 years.  Consider these few examples taken from my practice:

--The pregnant mildly dairy-allergic pregnant woman who is "encouraged" by her obstetrician to drink plenty of milk during her pregnancy.  Even though she really doesn't feel well ingesting it.

--The heart patient who is egg allergic who starts a "healthier" diet and consumes poultry (instead of red meat) with every evening meal.  With disastrous results.  

--The patient with irritable bowel disease who is told to eat several cups of yogurt daily, and begins to have sinus congestion and more irritable bowel disease.  

--The allergy patient with hypoglycemia who is encouraged to frequently eat nuts between meals to stabilize her blood sugar, who then develops headaches and urticaria within six months.

Dietary diversification--not repetition--is essential for the allergic patient.  When a diet becomes "lop-sided"--even for the best of medical reasons--problems can ensue.

And Tim?  He came back to my office a few weeks later with a smile on his face.  His mouth sores were gone.  "I've learned my lesson", he said.  "The old saying--'practice makes perfect'--may be true, but it also makes allergies"

Well said.

Later, Dude