A Half-truth is a whole lie

 --Old Yiddish Proverb

Cindy sat across from me in my office and shyly smiled.  This 8 year old girl was being brought in by her parents for allergy assessment...

But with a twist.

"We want Cindy checked for food allergies" her mother said, "but nothing else--she's had all the routine blood work."   Their finances were limited, she explained, and Cindy's asthma was "being taken care of" by her other allergist.  As I looked over the enclosed ELISA IgE antibody report from Cindy's  other allergist, I found astoundingly high IgE values for dog, as well as for dust.  And...yes, she had a dog at home.  Furthermore, she had seasonal hayfever in the springtime.  And what, you might ask, was her treatment for her allergies?  

Flovent 110 2 puffs bid.  

Her mother explained that Cindy's asthma really "wasn't an issue", but she had been scared the preceeding week when Cindy had an acute anaphylaxis episode after eating.  It didn't surprise me that Cindy's anaphylactic episode might occur during the spring allergy season. Her seasonal springtime hayfever told me she was probably tree pollen sensitive.  A recent article By Vetander et al published online March 15 in Clinical & Experimental Allergy found that "our study suggests an associated risk for anaphylaxis during leaf tree pollen season among 35 pollen-allergic individuals." And clinically I see this all the time in patients. For example,  I can recall one girl who had 6 episodes of anaphylaxis, all clustered around the ragweed season.    In her case a combination of ragweed and food sensitivities  would reach a "critical mass" and trigger a severe reaction.    

When we did intradermal skin testing on Cindy, she had strongly positive reactions to dust, dog, multiple spring & fall pollens, and alternaria mold.  

And here she was, her parents only wanting her to be assessed only for food allergy, because her asthma "was just fine" on Flovent, and her hayfever "was being taken care of" with antihistamines.   

Cindy's parents had unknowingly bought into The Big Lie.  

Somehow, somewhere, the message we Allergists have given our patients is that symptom-controlling medication is all we can--and should--offer most of our them. In truth, Cindy's immunological reactivity was spreading--first hayfever, then asthma, and now anaphylaxis.  In essence, although her asthma was "controlled" most days, her allergic reactivity wasn't.  

But if we look further, we can find what's really behind The Big Lie  --And that's The Big Secret.

The Big Secret is we indeed have a potentially disease-modifying treatment at our disposal:  immunotherapy.  However, as allergists, we don't talk about it enough, educate patients enough, and use it enough.  Period.  Think I'm wrong?  Check out the recent USA Today Allergy Supplement.  There you will find a semi-comprehensive guide to asthma.  Why do I refer to it as semi-comprehensive?  Because there is no mention of immunotherapy as an option.  None!  And yet, there is a nice write-up about Cystic Fibrosis--a non-allergic disease!  

Let's get back to the basics:  As allergists, we discover allergies and then try to induce tolerance with immunotherapy. To a large extent, the ability to do immunotherapy defines who we are and what we do. In that regard, we are like surgeons, only we do "knifeless surgery" on the immune system.  What would your reaction be if you read a USA Today Supplement on Surgery and only medications and "control" of illness was discussed, and not actually surgery? Would something be missing?  

Of course, I have some understanding why immunotherapy is not "shouted from the rooftops" by my colleagues--and that's because subcutaneous immunotherapy (SCIT) can of course be dangerous.  The beauty of sublingual immunotherapy (SLIT) is it's safety and effectiveness.  It has the chance to breathe new life into our specialty.  And for someone like Cindy, who began SLIT the day I saw her, it gives her hope of a better future.

Later, Dude 

Bob sat across from me in the office.  He was seeing me for chronic sinusitis, and he was feeling better. But his eyes told a different story.  Since I had last seen him, I found out that tragically, one of his children was accidentally killed.  But the truly horrifying thing was  it was the second child in his family that had been accidentally killed....

As an allergist, I am of course primarily interested in finding out the allergic problems my patients face, and alleviating their suffering. But my allergy textbooks take a sterile, clean approach to allergic disease, and you won't find the word "suffering" in any of them.  Furthermore, in the course of talking to many patients over thirty-one years, I have found out the disappointing truth that, in reality, I help a very, very small amount of Suffering.  And even more disappointing was the realization that I often don't have an effective way to alleviate their greatest suffering.  

But I have a story.  

When my children were little, they came to me and implored me to build a playground.   Bright, anxious voices bubbled with excitement telling me how blissfully happy they'd be if only I would get this for them. And, of course, since I loved them so much, I had a playground built.  And I have to admit, if I say so myself,  it was a beautiful one.  I mean I really think it had everything my children would want. (And apparently it did, judging by their reaction...!)  But I knew one thing, and I dreaded it:

They'd get hurt while playing.   Gravity, force, and mass were impartial to wishes on the playground.

As it turned out, one day Lizzy came in, screaming.  She had fallen and hurt her knee.  And it was a pretty bloody mess.  And of course, she said,

"Daddy, make the pain go away...now!"

And, honestly, I think she thought I could.  

Because, up to this point, she thought I could do everything. After all, I was her Father, a Doctor for goodness sake, and soooo old and wise that I could really work magic.  After all, I'd made the playground, right?  And she had heard stories of me helping many people in the office, right?  So why couldn't I help her when she really needed it? When she was suddenly, against her will, engulfed in a world of pain?    

And, frankly to me, having decades of life on this world, I looked at her pain as a "small thing in the big picture".  But I cared for her.  And so her pain wasn't really "small" at all, but important to me.  But as I cleaned her knee and  put ice on it,  the funny thing was she didn't feel my arms around her, or my love, because she was hysterical with pain.  And she wanted it gone. Now.  She was oblivious to me and the love and sympathy I had for her pain.  She was angry.  But I wasn't angry at her even though she shouted at me.   I made the playground, and now I wasn't  going to help her take away her pain?   Behind her tears, she really was saying,

Life was so unfair.  And disappointing.  And painful.  

As I said before, I can't take away many of my patients' suffering.  And I don't have an easy, pat answer for most of it.  But I remember my experience with my daughter.  And my role as Creator of a playground for her.  And I knew that someday, when she was much older and no longer playing on that playground, but in a different world, a world more mature, the bruised knee-- and more importantly, the memory of that bruised knee--

would heal.

Later, Dude

She handed me an article, and somewhat sheepishly said, "I think you might want to see this".  It was an article from the StarTribune Lifestyle section, called "Doubts cast on food intolerance testing."   

"I know your advice has worked for me", she said.  "But what can I tell other peope after they've read this article?"

Indeed.

Through a combination of detailed history-taking, open- challenge testing here at our office, AND IgG testing, I had diagnosed Ellen as having delayed-type food sensitivities. 

The article mentioned casts doubt on the utility of IgG testing in the diagnosis of delayed-onset of food sensitivity.  But in doing so, I think it misses a few key points. As an allergist with 30 years of experience in diagnosing and treating this troublesome problem, and with extensive experience in looking over hundreds of IgG food tests,  let me weigh in with a caveats:

In Vitro Food Tests should never be utilized alone  to diagnose food sensitivities.  Results should  only be interpreted in conjunction with a thorough history taken by an experienced clinician.  Period.  

False positives occur with IgG food allergy testing.  In reviewing hundreds of these tests, and comparing them to later open food challenges, false positives do indeed occur.  The experienced clinician will often be able to spot these on an initial review of the test results.  

Despite the above, the IgG food testing results often give an excellent "starting point" to begin to look for delayed food sensitivities in a chronically ill patient.  It is an excellent screening tool.

The IgG ELISA/RAST can be cost-effective if done properly.  In our lab, we run a "targeted" IgG RAST to selected foods, based upon the patient's history AND the experienced physician's impressions.  Why check for blueberry allergy, for example, if the patient doesn't even know what a blueberry IS?     

It is the height of hypocrisy for the allergy community to criticize this test, when not admitting they don't have a diagnostic solution to the problem, and aren't even interested in pursuing it.  Hiding behind the IgE food-allergy mantra is a smokescreen to distract us from a much bigger problem--and that is that delayed onset food sensitivities are (in my humble opinion) at least as important in scope as IgE mediated food sensitivities.  Just because a food makes a patient sick hours after eating it, and not immediately, and just because the food sensitivity is non-IgE mediated, should we be uninterested?  As part of the Renaissance in our profession, we need to be the masters of ALL food reactions.  

In truth, the patient who doesn't know about delayed-onset food allergy is uninformed, and the patient who sees the allergist and asks about dellayed-onset food allergy usually leaves misinformed.

Delayed-onset food allergy.  IgG testing.  Something to investigate.  Not denigrate.

Later, Dude

And so my journey began.  And, after 33 years, I am still on it.

But I am on another journey too.  A journey involving the use of Sublingual Immunotherapy (SLIT) and probing it's depths to determine how best to treat my allergy patients.

Candida related illness is a disease in search of a pathogenic mechanism and diagnostic test.  SLIT is a therapy in search of a mechanism of action and therapeutic efficacy. 

However, in reflecting on these two journeys I've been on, it occurred to me that the struggles for Candida-related illness to gain acceptance has striking parallels in the struggles for sublingual immunotherapy (SLIT) to gain acceptance

  Consider these points:  

1.  Both concepts were developed outside mainstream academia.

2.  Both concepts suffered from "The Tomato Effect".  As described by Goodwin & Goodwin in their landmark article in JAMA in 1984, the tomato effect is derived from the true story that no one in America ate tomatoes in the early 19th century because "everyone knew it was poisonous".  Why?  Because "we just knew it".  Never mind that Europeans were eating this New World Fruit (imported from Peru) by the bushelbasketful! Finally, in 1820 Robert Gibbon Johnson sat down at the Courthouse steps in Salem, New Jersey and shocked the townspeople by eating a tomato and not dying.  The contention of Goodwin & Goodwin is that the Tomato Effect retards progress in medicine when a treatment doesn't "make sense" in the prevailing medical atmosphere.   

In the case of SLIT, allergists knew it didn't work because "they just knew it".  In the case of Candida, the same thing happened--Candida just causes infections and not allergic disease, because, well, "we just knew it".  

3.  In both cases, rather perfunctory, negative studies were done by academia which dismissed Candida and SLIT as not being worthy of further study. (think about the Dismukes study on Candida in the NEJM in 1990 and the studies by Nelson et al in 1993 on SLIT for cat antigen as good examples)

4.  In both cases, later studies showed efficacy but American academia was still reluctant to enthusiastically endorse either of these concepts.  They just "didn't make sense".  

5.  In both cases, despite academic resistance, general practitioners found the efficacy of antifungal treatment for Candida-sensitive patients and SLIT treatment for allergy patients was just too good to ignore.  Regarding SLIT, our European colleagues have begun utilizing  this form of treatment more and more extensively.  Regarding Candida and antifungal treatment, our Alternative Medicine colleagues have also utilized this form of treatment more and more extensively.  

6.  In both cases, of course, (as to be expected), insurance problems exist with both issues--both reimburse as well as coding problems.   

And what about the future?  Here again, there are similarities with both Candida Related Illness and Sublingual Immunotherapy:

1.  In both cases, much more study is needed in area of mechanisms--in the area of SLIT, we need to further research the  mechanisms of therapeutic action, and in the area of Candida related illness, we need studies in the mechanism of disease pathogenesis.  

2. In both cases, we need to encourage American Academic Institutions to perform studies in these two areas.

And the biggest similarity in the struggle for SLIT and Candida-related illness to gain credence?  Easy answer:  

They both highlight the glaring deficiencies in the mind-set of our general American Allergy Community.

As a group, we have had a myopic, restricted drug-oriented, immunotherapy-minimizing, one-organ system (respiratory tract) viewpoint that frankly embarrasses me.  We need to enlarge considerably and (yes)  embrace and welcome  different viewpoints and new ideas and concepts.  Let's quit our intellectually  lazy "business as usual" mindset, and broaden our horizon beyond the respiratory tract and IgE mediated sensitization states.  We need to open our eyes to new ideas and treatments.  SLIT?  Bring it on!  Candida related illness--let's check it out!

So joint me on my journey.  And trust me:  It's worth it.  

Later, Dude

The entire inside of her mouth started to itch.  Badly.  

Janice had a long list of food sensitivities--wheat gave her malaise and aching, and milk gave her nasal and sinus congestion.  But only one product caused her mouth itch:

Carrageenan.  

Carageenans belong to a group of polysaccharides extracted from red seaweed.  Commercially they are used as an emulsifier and  thickener in the food industry.  And it can cause allergic reactions.  It's even been responsible for anaphylaxis in barium enema solutions.   

WIth some prior detective work, we had discovered the source of Janice's chronic mouth itching, and after Janice changed her toothpaste, and avoided items with carrageenan, she was fine

Until now.  

She looked down at her meal.  The same meal she had eaten at the restaurant a week before.  On top of the potato was sour cream--on a hunch, she asked the waiter,

"Did you change your brand of sour cream, and does it have an additive in it called carrageenan?" she asked.  After a dumbfounded look, the waiter agreed to check.  And he came back to her table with the answer:

Yes, and...yes.

Janice had known she had a unique reaction to carrageenan--what I call an "allergic fingerprint."  Her symptoms were so characteristic of contact with this item, that even in the absence of observing the she was eating something with it, she knew she had.  Just like a detective who can dust for fingerprints and determine that so-and-so was at the scene of the crime, even tho the detective had never seen the criminal there himself.  

As I've worked with patients over the years, I've been intrigued with the phenomenon of "allergic targeting"--i.e., a person can be blood-test  positive to 3 foods, but the symptoms each food elicit may be completely different--i.e., like Janice's case with wheat, egg, and carrageenan each affecting different target organs.   "Allergic fingerprinting" can often be the result of these discoveries, and this, in turn,  can help the patient be their own detective.  

In another situation I recall a husband telling me he would buy his allergic wife the same organic flatbread that had calcium proprionate and NO sodium metabisulfite in it, since she was quite sensitive to sulfites.  One day he bought the usual "safe" flatbread at the store.  His wife prepared the meal with it, and as she ate it she started to cough and itch. 

"What brand did you buy" she asked.

"The same as usual" he said. "The one without sulfite--they use calcium proprionate in it instead."

"Well, I don't care if it is the same brand, it has sulfite in it," she exclaimed.

So the husband rummaged through the garbage, found the wrapper, and upon reading it he discovered they had changed from calcium proprionate to sulfite as the preservative!  

There is an important corollary for this story--all allergic patients must re-read the label of every item they pick up at the store.  Just because you are buying the same named product doesn't mean the ingredients haven't changed.  The wife's certainty she had discovered an "allergic fingerprint" led to the realization by the husband that (surprise!) labels (and ingredients) can change. And these ideas even carry over to medications and vitamins that a person takes.  Consequently, an attitude of vigilance is needed for every allergy patient.

"Allergic fingerprints".  Something to think about.  And an invaluable tool for the Allergy Detective.  

Later, Dude

Winston Churchill

As I entered the exam room, Michelle looked up and smiled.  The despondent look of so many visits ago was gone.  In her hand was a card. Her eyes were bright and sparkled.   Before I could say anything, she handed it to me.

"Here, I want you to have this", she said.  

And she handed me a Christmas card.  

Michelle had started to see me a year and a half earlier, struggling with eosinophilic esophagitis, asthma, and hives.  Prior to seeing me, she had seen another allergist and had been unsuccessfully placed on an elimination diet without help in her symptoms.  In reality, she had a complex mixture of food AND inhalant sensitivities, and it was in June of 2008, at the height of the grass pollen season that she felt like she was chewing and swallowing glass, and the diagnosis of Eosinophilic Esophagitis was made.  We had placed her on sublingual immunotherapy (SLIT) for multiple severe inhalant and food sensitivities, modified her diet, and she was went into symptomatic remission.

And so she gave me a Christmas Card.   

The Christmas season is a wonderful time of the year in many ways, but as an allergist it is a very special time...

Because of Christmas gifts I receive from my patients.  I still don't believe it, but not only cards, but ornaments, plaques, and even Christmas stockings have graced my walls during the Holiday Season.  I am blessed.  

For those of you analytically inclined, please note that there is no medical literature or study on Christmas Cards.  A search of the PubMed data base shows only 4 articles on search, and none of these studies the phenomenon whereby doctors receive Christmas Cards.  What type of patient sends these cards? How often are they sent?  What message do they convey?   My impressions are anecdotal, but perhaps worth noting, since I have been their grateful recipient for  many years, and I can't find the least bit of discussion on the topic:  

As I study the cards I've received I've observed that most of them fall into two broad categories.  The first group are the patients that have received treatment and have felt remarkably better.  The name(s) at the bottom of the card are usually instantly recognizable to me--extremely challenging cases that have recovered sufficiently to have a quality of life they never had, or perhaps had in the distant past but never felt they could regain.  I'm not talking about people with variable asthma, or a few sinus infections--these are people who've had deep allergic disease--usually delayed onset food and inhalant allergies missed or ignored by other doctors.  The names on the cards conjure up a picture of people who were once terrified and felt helpless with their fatigue, fibromyalgia, irritable bowel syndrome, chronic severe sinusitis, etc. Their disease is better, a semblance of life has returned, and they want to share their joy with me, symbolically, 

With a Christmas Card.

But there is another group of people I have received cards from.  Once again, I usually immediately recognize the names.  But this group is particularly intriging  to me Because  in this group are people I don't feel I've helped enough. Or at all.   I haven't made their disease go away, or "cured" them in any sense of the word. In the strictest sense, I've totally failed them. 

So why in the world are they sending me a Christmas Card?  

Let's start with the obvious, and then hypothesize:  The suffering person wants his/her suffering to be alleviated.  Completely.  However, if the suffering can't be completely eliminated, but it can be transformed or refined by a companion in suffering they can absolutely trust,  then progress towards health can still be made.  The person may (with hard work) be able to transform themself from being "a disease", to a place where they feel they are a  "healthy person" with a bad illness. There is an enormous gulf between these two viewpoints, but with hard work and patience, a person can often achieve this state.    And if the allergist can partner with his/her patient, and be a companion on their journey, the patient can be extremely grateful.  They recognize they can talk to the doctor without fear of a "lecture", truly reveal their deepest worries and most intimate concerns, in an atmosphere of nonjudgement and true advocacy.  But please don't get me wrong.  I am no Mother Theresa.  I am just an allergist who is challenged and frustrated as any other doctor to care for somebody they don't see that they have helped. I sometimes get frustrated that I haven't helped someone more than I have.   But the rewards to companioning with a seriously ill patient seems sometimes to mean more to the patient than anything I can imagine.  So I try to do my best, even if I sometimes think I come up short.  

So, what was Michelle saying to me with her Christmas Card?  I think she was saying "Thanks for helping me live life to its fullest".  But, other cards I get from other patients in the second category seem to be saying "Thanks for Being There for me".  And I realize both messages are from the heart; I just hope my patients realize what these messages mean to me, and although I can often fail on both accounts, I (like my patients) keep on trying.  And that is the true spirit of Christmas.   

Later, Dude

"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

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