The restaurant was perfect:  fine food, a delightful atmosphere, and the company of my wife and daughters celebrating a "back-to-school" final meal.  Lizzy & Kristi were soon leaving for college, and my wife and I wanted to give them a "going away" present of one memorable meal before they settled into the pitiful menu of dorm-food.  We were in a relaxed mood, talking and sipping a few drinks before dinner was served.  But I suddenly noticed a shadow had been cast over me and sensed someone standing behind me..My wife and daughters abruptly looked up, and focused on something over my shoulders.  I then heard a strange voice say

"Excuse me," she said, "are you Dr. Kroker?

"Yes, I am", I said.

"I want to thank you for saving my daughter's life", she said simply.  

For a moment, I said nothing.  As a physician, I have had the privilege and honor of having those words spoken to me in a variety of fashions over my 33 years of practice. And no matter how many times they are spoken--once or a thousand--they never ever become ordinary.  And my response to those words has never, in my opinion, been something I have been able to adequately handle.   It is absolutely impossible to convey the enormous surge of emotions they stir up in me when I hear them.  For these emotionally-charged words every physican--young and old--always dreams of hearing.  Hopes to hear. Wishes to hear.  And the hope to hear these words, or something like them, gets many of us through all of the tiresome days of filing out "prior authorizations", insurance forms, and fighting medicare bureaucracy.  Mostly, over the years I don't remember the exact words as much as the faces, and the eyes that spoke them.  The words, faces, and eyes are seared--burned--into my memory forever, with each encounter.  So when I heard those words, an enormous swell of joy, gratitude, coupled with some embarrassment and (yes) guilt (did I really deserve this accolade?) began to swirl in me.  Who was this person?  Who was their daughter?  As the woman spoke, it suddenly came back to me....

...Janice was a young woman from a large Midwestern City, several hours away from La Crosse.  She presented with a "mystery illness" of headaches, dizziness, fatigue, and aching.  Her illness had been going on for many months, and she had seen the finest doctors in the largest tertiary care centers in the area, and had a first-class internal medicine and neurological workup.  

Except for one thing.  

Although she had multiple illnesses ruled out, she still hadn't seen an allergist.  Fate intervened.   At a party her mother was confidentially discussing her case with one of her own friends.  Her friend suggested her daughter come to see me to find out "if she had any allergy".  And (true enough) although Janice seemed to have seen nearly every physician, she hadn't seen an allergist.  On the surface, it is logical her physicians hadn't entertained "allergy" in their differential diagnosis because she didn't have the usual "sneeze and wheeze" presentation that every physician recognizes as allergy.  But headaches, dizziness, fatigue, aching?  That's another story.  Surely, it can't be "allergy", right?  

Or could it?  

When I saw Janice, it was interesting to note that many of her symptoms had begun shortly after moving into an older apartment 2 years earlier.  The apartment had overt signs of mold, and everything from the refrigerator to the carpet seemed to bear signs of it.  

What was even more interesting was her skin test response.  When we had tested her, she had absolutely no reaction to any antigen at 10 minutes, even though her histamine control was appropriately positive.  However, since Janice was staying in town with her mother overnight, I suggested she come back the next day to our office and have a re-examination of her skin test sites.  So as I raised her sleeve up and examined her arm testing the next day, 

The diagnosis was made.

She had an enormous delayed reaction to several molds, including aspergillus sp. and penicillium.  Each site had swollen several centimeters in diameter, and was red and angry in appearance.  I explained delayed-onset mold allergy to Janice, and insisted she immediately leave her apartment.  Again, fate intervened.  Her lease was nearly up.  She promptly left the apartment on my strong encouragement, and began SLIT.  

And her recovery began.  

Thoughts from the story?  Several, in my opinion.  Here are a few:

1.  Thought 1:  I didn't save Janice's life--but I saved her quality of life--and for some patient's (and parents), they are nearly indistinguishable.  For a life with headaches, dizziness, aching, and fatigue is really no life at all.

2.  Thought 2:  The lack of appreciating late-onset mold reactions is one of the great tragedies in modern medicine (not just allergy).  Recently I was attending a lecture by a well-respected allergist from another large midwestern city, and we were discussing late-phase skin test reactions.  His response?  "You know, I was trained that we really don't know what late-phase skin test reactions really mean".  Well, I'll tell you what they generally mean--serious illness.  To paraphrase the late Prof. Keith Eaton, Strong late-phase skin tests to molds are not without biological significance.

3.  Thought 3:  SLIT works like dynamite for late-onset mold reactions:  When I saw Janice back in followup recently, her strong delayed reactions were dramatically reduced.  This was probably a combination of reduced total load (from changing residences) as well as SLIT, but I have seen identical responses with just the use of SLIT alone.  Young allergists frequently want to know where to first incorporate SLIT into their practices.  The answer?  For troublesome late-onset mold allergy.    

4.  Thought 4: As a specialty we must evolve.   The allergist must be more than a "wheeze and sneeze" doctor.  Atopic disease is yesterday's story. Patients need--and demand--help with delayed-onset inhalant and food allergy.  Now.   If we are to adapt to the times, we must broaden our horizons.  I was pleased with Dr. Stanley Fineman's "President's Message" to ACAAI members, part of which I share below:

"In my Bella Schick lecture presented in Miami, I encouraged allergists to expand what we do in our practices.  Besides seeing a variety of patients with allergic sensitivities and continuing to manage asthma and allergic rhinitis, we also must make clear that the scope of practice includes helping patients with food allergies, skin diseases, chronic rhinosinusitis and immune deficiency problems."  

Darwin's theory of natural selection is relevant for us allergists:  Adapt and evolve with changes in the environment...

As allergists we must broaden our horizon.   Quickly.  Changes at a "glacial pace" are not fast enough for people like Janice, who are sick today.   And the payoff for the allergy profession? Simple.  A single phrase:

"Thank you for saving my daughter's life".

Later, Dude