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

Cindy came into my office, delighted that the severe facial eczema she had struggled with for 6 years had gone into remission.  We had found the triggers--dairy and mold--that had precipitated her problem, and treating her had resulted in dramatic improvement.  

"I want to introduce you to a new patient today", she said.  "My sister".  Cindy's sister Joan was the only member of their family who didn't have "traditional" allergy symptoms.  Having 6 siblings, Cindy had related that 4 of them had hayfever, rashes, and "allergies" like she did.  

But Joan was different.  

Joan had arthralgia. No other "traditional" allergy symptoms... And, taking a cue from her sister Cindy, she decided to remove dairy from her diet, and her arthralgias were markedly better.  Simply put, Joan wanted validation that food sensitivity could be related to her joint pain.  

Switch scenes:  That same day, a younger partner of mine, another allergist in the clinic, came in to my office later in the day to consult with me on a curious case he had seen of a lady with springtime hayfever...

...and migratory arthralgias.

As I had blogged about earlier, Warren T. Vaughn had written about palindromic rheumatism related to allergic disease.   Furthermore, D.N. Golding, writing in the Journal of the Royal Society of Medicine, wrote an interesting article entitled "Is there an allergic synovitis?"  In this article he presents 9 patients with episodic allergic rheumatism, related to a variety of precipitating factors--dairy, streptococcal infections, Hayfever, etc.  His conclusion?

It seems that allergy is an occasional cause of episodic rheumatic pain or synovitis in certain atopic patients, whether or not they have an underlying arthritis.  

 In fact, idiopathic eosinophilic synovitis with Charcot-Leyden crystals in joint fluid has been reported by Antes, et. al in the Scan J Rheumatology in 1996 in their article "Idiopathic Eosinophilic Synovitis.  Case Report and Review of the Literature.  

Rheumatic complaints from food sensitivity is not new stuff.  H. Berger, wrote about "Intermittent hydroarthrosis with an allergic basis" in JAMA 112:2402, 1931.  There are others.  

So where does this information put us in 2011? Simply put, allergically-induced rheumatic complaints are an "orphan illness" that no single specialty  is willing to adopt.  Today's allergist has made an a priori decision to limit his/her specialty largely to the respiratory tract, and skin.  Today's rheumatologist is so caught up in autoimmune phenomenon that exogenous triggers are simply overlooked.

And this is a tragedy.  We "dis" joints.  In a word, we're disjointed.  

Allergy should be (and really is) the true Queen of Specialties.  It cuts across multiple organ systems, including the synovial membrane.  To "be all that we can be", to be a Renaissance Allergist, we need to take rheumatic histories on all of our allergy patients.  We might be surprised at what we learn.  

Later, Dude 

"Dr. Kroker", she said, "could I bother you for just a moment?".  Her eyes looked at me expectantly.  

I asked her to come in.  What happened next was something I didn't expect...

"I have something for you..." she said, and handed me a cup to take.

"This cup is something my son wanted to give to your mentor, Dr. Randolph, but since he passed away he asked that it be given to you, since I know you trained under him for 3 years..."

"There is a story behind the cup", she said.  A long time ago, when my son was in high school,  he was quite sick.  He couldn't concentrate, and struggled with his grades.  The school guidance counselor met with us, and in "so many words" essentially said he "wouldn't amount to much" and that pursuing any higher education for him was simply out of the question.  He remained quite ill.

Then we took him to Dr. Randolph.

"After his allergies were discovered and he was treated, he was a different person.  He graduated from high school, and eventually went overseas for study and earned an advanced degree at Cambridge. He's successful and happy in his chosen field.  Dr. Randolph changed his life.  And he wanted to thank him."

I took the "Cambridge Cup" from her, and as I held it, a flood of memories came back to me of my tutelage under Dr. Randolph.  It's fashionable in medicine to think that "if it hasn't been published in the last 10 years, it hasn't been discovered". This short-sighted mind-set has caused many allergists to overlook  Randolph's work and to miss the sheer genius of it and to fail to realize that many questions and concepts in allergy were addressed by him, years ahead of its time.  

In particular, Randolph was so well aware of undiagnosed allergies limiting school performance that he presented a paper on the subject to the Annual Meeting of the American College Health Association in 1951:  

Randolph TG:  Allergic Ills Limiting Student Performance.  Proc 29th Ann Meeting Amer College Health Assn 31:46-48, 1951.  

But there's more.  A whole lot more  In the 397 (yes, that's right, 397) papers and publications he wrote over his lifetime, many were seminal and breakout papers.  A few brief examples of "concept papers" he published 

The link between food allergy and migraines?  Randolph wrote about it in 1935:

Sheldon, JM, Randolph TG:  Allergy in Migraine-like Headaches.  Amer J Med Sci 190:232, 1935.  

The link between allergy and unexplained fatigue?  Randolph wrote about it in 1945:

Randolph TG, Hettig RA:  The Coincidence of Allergic Disease, Unexplained Fatigue and Lymphadenopathy:  Possible Diagnostic Confusion with Infectious Mononucleosis.  Amer J Med Sci 209:306-314, 1945.

Randolph TG.  Fatigue and Weakness of Allergic Origin--to be Differentiated from "Nervous Fatigue: or Neurasthenia.  Ann Allergy 3:418-430, 1945.  

The link between allergy and behavioral problems in children?  Randolph wrote about it in 1947:

Randolph TG:  Allergy as a Causative Factor of Fatigue, Irritability and Behavioral Problems of Children.  J Pediat 31:560-572, 1947.

Randolph's discoveries influence my practice of allergy on a daily basis. As an example,  I had been recently communicating with a patient's mother regarding corn allergy, and advised against corn-based IV's because the dextrose component is corn-based and can cause problems.  And Randolph?  He know about this in 1950 and published on it:

Randolph TG, Rollins JP, Walter CK.  Allergic Reactions following intravenous injection of Corn Sugar (Dextrose).  Arch Surg 61:554-564, 1950.   

Randolph wasn't interested in monitoring Peak Flows.  He was interested in Peak Life  To him (and me) the field of allergy is so much greater than the respiratory tract.  Renaissance Allergists recognize this, and practice accordingly.  

...And the cup?  To me, it represents what a true Renaissance Allergist can do to transform a patient's life. On a larger scale, it also symbolizes the  Holy Grail of Allergy-a treasure of healing once possessed, and now lost to the average allergist.  

And I hope our allergy societies can search for it.

And find it.  Again.  

Later, Dude

--Fitzhugh Dodson

A patient's eyes tell a thousand stories...when I walk in an exam room it's the first thing I tend to notice about a patient.  In Mary's case, they were filled with despair...

"I've had these hives for 2 years, and nobody can seem to give me an answer as to why they occur", she told me.  She told me about the unexpected and frightening trips to the emergency room.  

Then, unexpectedly, her eyes abruptly changed.  They flared.

With anger.  

"You know, my doctor told me HIS goal was to manage my hives to keep  me out of the emergency room."  That wasn't MY goal at all--I wanted to find out the CAUSE of my hives."  

Patient-centered goals:  something we don't emphasize enough when we see patients for their initial visit. I had an interesting experience recently--When we recently had a team of coders here at our office, to help us properly "document" a patient's visit in order to get the best insurance reimbursement, it was once again emphasized how critical it was to have the patient's "chief complaint" listed in each and every initial workup.  

When I asked the coders about the importance of having a patient's goals documented--i.e., whether that was deemed important for insurance reimbursement and coding, I merely received a "deer caught in the headlights" blank look.  Truth be told, the patient's own goals are not even counted as a critical part of an exam for insurance reimbursement.  A chief complaint, pertinent history of illness, review of systems, family and social history, thorough physical exam, and review of outside records are all deemed important.

But not the patient's goals.

They don't make the cut.

And, in my opinion, that's outrageous.   

Why is it important for an allergist to list a patient's goals?

First, we may find that (as doctors) what we ASSUMED the patient wanted to accomplish is not what they wanted to accomplish at all.  This was the case in Mary's own tale.  And I've experienced it myself on more than one occasion...

Example:  one woman came into our office to see me with the "chief complaint" of chronic hoarseness. But her goal?  To be able to sing in her church choir.  In my own mind, succeeding in the latter issue was just as important as succeeding in the former.

Secondly, having a goal established allows us to work towards health with a fixed directive in mind.  As Basil S.  Walsh said, "If you don't know where you are going, how do you expect to get there?"  As I've worked with a patient over time, it's a mutually satisfying experience for myself and my patient to look back on the first office visit, and to celebrate the goal(s) achieved.  

Thirdly, finding out what a patient's goal(s) are on their first visit is important, because sometimes their goals are simply unrealistic.  Having a frank and open discussion, and reformulating goals is then necessary, and prevents alot of future frustration.    

Fourthly, some patient's simply haven't consciously thought of a goal they want to achieve from their consultation.  It is our job to help define a set of mutually agreed upon goals, and then to work towards them...

In my opinion, one of the biggest problems in the allergy field today is the marked discordance between patient-centered goals, and the often unspoken goal of the allergist himself/herself.  Our goals?  "Let's control the asthma" "What's the best inhaler to use?"  "Let's see if this is an IgE mediated allergy, and if not we've done our job?"  "What's another drug I can try on this patient with allergic rhinitis".  The list goes on.  And we rarely see if our own goals match up with our patient's goals.  We usually don't even bother to ask.  Is it because we're afraid?    

It's been my experience that most patient's are like Mary.  They want to accomplish 3 things:

1.  Get to the bottom of what's causing their symptoms.  They've been given the drugs, and they want more...

2.  If possible, be given a disease-modifying treatment (like SLIT) and not simply symptomatic control. 

3.  Get on with their life, and accomplish personal goals XYZ.  

In Mary's case, I verbally acknowledged that we were in agreement on the goal she had--namely, find out what was the cause of her hives.  And with a little detective work, aided by a computer search, we found that the chronic hives were likely caused by a change in medication right before the onset of her problem--all it took was some time and patience, and not a knee-jerk reaction to try another antihistamine on her...  

As allergists, we need a Renaissance in our field.  Not only should we ask every patient what their own goals are for each and every visit to our offices, but we should take a hard look at our own goals for patients when they see us...  Are our goals compatible with our patient's goals?  

In short, can we deliver what our patient's want?

Now that's a goal worthy to have.

Later, Dude 

I sat stunned in my office chair.  Across from me was my new patient John.  A moment ago I was explaining his skin test results to him. Then suddenly--completely unexpectedly--he burst into tears, and told me he had an overwhelming feeling of depression, "just like I have when I'm in my basement".  As tears rolled down the big man's cheeks, he apologized profusely for what he thought was a "stupid" emotional show, but he simply couldn't help it.  He told me he wasn't upset with my findings.  In fact he was happy someone could come up with an answer.  

But that didn't help his sense of overwhelming depression.  

He had just had skin testing for allergens, and had strong immediate reactions to multiple mold antigens.  When I had initially seen him for his intake history, he struck me as a matter-of-fact business man in a nice business suit who "had it all together".  He told me he had a business at home, and (happily because his internet business was fluorishing) he had to move to less cramped quarters, and moved his computers and hardware from his upstairs location to his musty basement.

The longer he was in the basement, the more sinus congestion he had.  THAT was why he came in to see me.  But upon talking with him further, he had a sense of overwhelming, inexplicable depression that he had never experienced before, and made no personal sense to him because "everything else" was going fine in his life. He couldn't understand why he felt so depressed, even when he was meeting with increasing success in his business.   

In a sense, I was seeing two completely different people today: 1.  John before allergy testing and 2.  John after allergy testing.  The results couldn't have been more dramatic....

One of my fellow colleagues pointed out to me a recent story on CNN.COM called "Sad in the spring?  Allergy-mood link is real".   I recommend reading it.  

Having been a practicing allergist for nearly 3 decades, I think allergies can affect mood two ways:  indirectly AND directly.  

Certainly, the average seasonal allergy sufferer can be more tired, irritable, and depressed during the allergy season because of their chronic recurring symptoms.  That is something we see over and over again in our practice.

But less frequently--but more dramatically--I think I see patients like John who have a direct dramatic effect of an allergen on their mood.  In John's case, he had the onset of severe depressive symptoms (without a preceding history) that correlated with some sinus congestion on moving into a basement environment.  Over the years, I have found that certain allergens seem to do this with greater frequency than others.  In particular, mold, gluten, and Candida sensitivities would head the list as causing a "primary" allergic depressive response, but in reality nearly any other allergen can do it, such as corn and dairy for example.  I have had patients with a so called "primary" allergic depression be able to go off of anti depressants successfully, after years of incomplete and disappointing help beforehand.  (One patient I had seen who turned out to be  severely gluten intolerant had been making arrangements for her burial just before seeing me because she was so depressed and exhausted.  Now she is fine, off anti depressants, and has made referrals for her daughter, son-in-law and grandchildren here at the clinic.)

Am I the only Allergist who has postulated a direct connection between mold exposure and mood?  Not by a long shot.  When I was lecturing several years ago, I was in Manchester England.  The late Dr. Keith Eaton, one of the earliest menmbers of the British Society of Allergy and Clinical Immunology and a physician of impeccable credentials and reputation, excitedly came up to me and asked (as if to affirm his own belief)   "Do you think mold allergy can (directly) cause depression?"  

One of the ways we can truly have a Renaissance in the allergy field is to be more cognizant of this mood-allergy link in our patients, and determine if it is a direct or indirect link. The respiratory tract isn't the beginning and the end of allergy.  It is just the starting point for a thorough and comprehensive allergy evaluation.  We aren't treating lungs.  We're treating patients. 

In John's case, the story turns out happily...he is now out of the basement, on SLIT immunotherapy, and couldn't be happier--even though he is back in his more cramped quarters upstairs.  Allergy?  Depression?  A link?  If you don't think there is, for goodness sake don't tell John.

He's a big guy.  And--believe me--you don't want to make him angry.

Later, Dude

Sometimes it just doesn't get any better...I was sitting in the living room, a quiet fire going in the fireplace, and a beautiful view of the lake.  Sitting next to me was one of my closest friends, a brilliant ophthalmologist from a large Midwestern city.  There is nothing I enjoy better than talking to Steve.  As usual, our conversation meandered through a wide range of topics.  Then, somewhat unexpectedly, he said 

"You know, before I die, I would really like to find the cause behind uveitis and pars planitis".  "I sure suspect some of it is environmentally triggered."  He went on:

"I have talked to all of the local allergists near where I practice, but you know what?"  

"They're boring".  

"What do you mean?"  I said.  

"They're boring--they're just interested in asthma, and nothing else. If they even sense it isn't IgE mediated, they're out of the picture".  

Frankly, his comments are a spot-on indictment of the narrow-mindedness of our profession.  We won't look beyond the end of our albuterol inhaler.  Is he crazy to think their might be an environmental trigger to uveitis?  

I don't think so.

About a third to a  half of the cases of Uveitis, (inflammation of the uvea) have an unknown cause.  Old time allergists such as Albert Rowe, writing in their classic text on food allergy  suggested that food reactions could be the cause of some cases (and presented case reports in support of this)  but complained of the lack of referrals from ophthalmologists to give them more experience in the matter.  

There is medical literature supporting the fact that English Walnuts can exacerbate Behcet's syndrome, a condition often associated with uveitis.  Marquardt et. al. wrote a paper entitled "Depression of lymphocyte activation and exacerbation of Behcet's Syndrome by ingestion of English Walnuts."  Steve mentioned that the recurrent uveitis experienced by one of his professional colleagues each Thanksgiving was "cured" by stopping the ingestion of walnuts on that holiday.  

But there's more.  Uveitis peaks in the spring, according to Dr. Samir Tari, the lead researcher in the study.  This possible seasonal linkage needs to be further investigated.  

Finally, there is an intriguing link between autoimmune uveitis and antigenic mimicry of environmental allergens.  In the article "Autoimmune uveitis and antigenic mimicry of environmental antigens", Dr. Gerhild Wildner and Dr. Maria Mohring make the point that one mimicry antigen is from rotavirus, a common pathogen causing gastroenteritis, and another mimicry antigen is from bovine milk alpha-2 casein.  Lewis rats developed uveitis after immunization with both mimicry peptides and casein protein.

Their "take home message"?  

" Breaking oral tolerance to food antigens or defensive immune responses against pathogenic epitopes both mimicking autoantigens are potential initiating events for autoimmune diseases like uveitis"

Oh, and one more thing--just check out a few message boards on the web regarding people suffering from uveitis, and their anecdotal stories regarding environmental triggers.   In my opinion, there's a "smoking gun" here...and precious few people are interested in the connection...

So, could a GI rotavirus infection and casein ingestion trigger a Th1 aberrant response (not Th2) and participate in the initiation of uveitis in susceptible individuals?  I don't know.  But I do know I am "following" some of my patients with non-IgE mediated food sensitivities and uveitis...with very interesting results.  

But my main message...a specialist outside of our own allergy field makes the discovery that allergists are "not interesting people"

They're boring.

And why?  Because we are so narrowly focused on the respiratory tract that we simply aren't interested in anything else.  

And that, my friends, is not only boring...it's tragic.

To have a Renaissance in our field of allergy, we need to break the shackles of artificially demarcating our field to one organ system, and (like our infectious disease colleagues) realize that our field is system wide.  

And that's not boring--that's exciting!

Later, Dude

The young allergist walked out of the exam room...the picture of Mrs. Shelby was fresh in his mind--a young mother afraid of her increasing asthma...but the picture faded away, and was replaced with

                                               The Question

Everytime he saw a new patient, the Question loomed in the foreground, like the dark clouds of an overwhelming storm, and threatened him with dark foreboding.  What was he to do with The Question?  His best teachers had not prepared him for it.  He had gone through 4 years of medical school, a year of internship, 3 years of residency, and 2 more years of fellowship, and hadn't really had to face The Question seriously.  It wasn't deemed really relevant to his education. Until now. Now it had morphed until an ugly specter that swamped his thinking about each patient.  So he began to study it, asked his most knowledgeable colleagues for a concrete answer to it, and even called in so-called "experts in The Question" to help him answer it better.  But it was always the same. 

The Question was sometimes hard.  

The Question was sometimes impossible to answer.

And everytime he answered The Question, a haunting voice in the back of his mind would whisper, "Have you truly answered The Question correctly?

Sometimes he really didn't know if he had...

Everyone wanted to know the answer to The Question.  He thought again of Mrs. Shelby.  It would affect her.  In fact, it would affect people that he hadn't even seen.  People miles away.  Was this what he had studied medicine for?  To become a specialist in Allergy, and have to face The Question?  

And he had to face The Question.  Everytime he walked into a room with a new patient.  Everyone was affected by The Question.  All were influenced.  No exceptions.  

He even found he was beginning to think about The Question as he would examine a patient.  He always tried to push it from his mind.  Some people thought if you could answer The Question correctly, then you were a "good doctor". But he knew better.  It was a lie.  

It seemed that more and more time was being devoted by people--people he never knew or met--who criticized his answer to The Question.  Sometimes his answer to the question was deemed "wrong" and he was left puzzled, frustrated, and occasionally just plain angry. And impotent.   

So as he left the room, the image of Mrs. Shelby gradually faded from his mind.  Her concerns seemed less important, the distress she was in seemed almost immaterial.  She wasn't important--at least not compared to The Question: 

     Should he code her as a 99203 or 99204?

Later, Dude