How right he was... 

I've been slowly reading it, kind of like sipping a fine glass of wine...savoring a chapter or so every few days...and afraid I'll come to the end of it too soon.  Every allergist should read this book.  Although an endocrinologist by training, Dr. Meador's insights reasonate with me.  In the next few blogs, I'll sermonize on various aspects of his book, but let's just take a few excerpts for starters"

"Scientific reduction is not the same process as clinical medicine...It is the sheer scientific power of the biomolecular model that has blinded so many as to its clinical limitations and restrictions...The biomolecular model is so pervasive that unless one can posit a possible molecular explanation for a phenomenon, the subject is excluded from research.  In other words, until the molecular basis is known, no phenomenon exists..."

Note to allergists:  replace the words "biomolecular model" with "IgE immunological model", and re-read the above paragraph. 

What "nonphenomena" exist in the allergy world today?  Many.  Here are just two examples (among many):

1.  What is the clinical significance of the late phase skin test reaction?  This is a phenomenon I see every day.  Most allergists ignore it because it doesn't fit into a nice "IgE model" of illness.  Since we don't understand it, it doesn't exist.  So it's not something to talk about in polite allergy circles.  Yet, for example, it is certain that the strong delayed reaction to molds is not without biological significance.  In my experience, delayed mold skin tests correlate with delayed sickness in these patients. 

2.  How much of a role does the central nervous system have in responding to allergens?  This is a subject also not talked about in polite allergy circles.  Since this is an organ system that isn't "ours" like the sinus and respiratory tract, we simply exclude it from our interest...to the detriment of our patients.  The patient who gets extremely tired after breathing mold or eating the wrong food is...simply put...a nonphenomenon. 

What distinguishes superior physicians like Dr. Meador, in my opinion, is an overwhelming sense of curiosity...I've blogged about this before, in my entry "Curiosity Killed the Cat"  When approaching a difficult or challenging patient with a sense of curiosity, an open mind, and a strong sense of compassion, often unexpectedly great insights can be obtained.  Too often the allergist is trying to "document" or "not document" IgE mediated allergic disease.  Nothing wrong with that--provided we're open to other avenues of immunologic aberrations.  Too often, however, curiosity is an inadvertant casuality of the visit to the allergist.  Nonphenomena happen.  And the allergist has one of the longest lists of "nonphenomena" that any specialty has. 

Later, Dude

 

 

 

 

 

 

I have said before that our field of Allergy is most similar in dimension to that of Infectious Disease. Simply put, the infectious disease doctor is interested in a wide array of

First, the "usual" allergist is just interested in how allergies affect  ONE organ system (the respiratory tract) and gives lip-service to other target organs.  We've even changed the name of our official societies to include the word "asthma".  Now how would it go over if The Infectious Diseases Society of America changed its name to "The Infectious Diseases and Pneumonia Society of America?"  (For example, how many allergists got excited and wrote Letters To the Editor on the recent article on "Atopic Irritable Bowel Syndrome" Published in The Annals of Allergy by Tobin et. al? Any lectures or talks on this topic at our recent annual allergy meetings??)

The second area we come up short in is our emphasis on CONTROL of symptoms, and our poor diagnostic skills in finding the CAUSE of symptoms.

Here's a scary thought:  What if the Infectious Disease Specialist behaved like the typical Allergist?  A quick scenario:

...the patient is in bed, hot and feverish, with a stiff neck and drifting in and out of coherancy.  The Infectious Disease specialist is called in...he examines the patient and makes the diagnosis of "Meningitis", and promptly tells the nurse of the Meningitis Action Treatment Control Plan.  Temperatures are bracketed into green, yellow, and red zones, and a peak temperature monitoring system (PTM) is used to chart the temperatures. The patient's relatives are taught to use the thermometer and record the peak temps.   Intense attention is paid to using cold packs and aspirin in escalating doses based on the PTM.  Even an algorithm is derived for optimal control. ("more fever?"--add a step two medication to the regimen, like tylenol, in addition to the basic aspirin) The action plan is written down by the nursing staff.   Everybody's happy.  

Except the patient.

Another specialist is called in.  He agrees with the diagnosis, but isn't satisfied it's the ultimate diagnosis.  He's not satisfied with only symptom controlling measures.  A spinal tap reveals meningococcus.  Now real treatment--based on the underlying cause--can be begun.  

I don't know how many patient's I've seen who come into the office "patched up" on Advair, Singular, topical nasal steroids, and who had been shipped off the the GI specialist for "irritable bowel syndrome" and then to the psychiatrist for "chronic fatigue"--when it's all connected to issues the allergist diagnostically is responsible for, and unfortunately missed.  Patients come into my office with a bevy of prior peak flow readings, asthma action plans, and yet...feel miserable and frustrated.   

...This issue is almost a philosophical one. There are "layers" of diagnoses, like Russian Dolls.   What we may think of at first as the "real" diagnosis may be, upon further investigation,  only a secondary issue behind a primary allergenic cause.   There are "layers" of diagnosis, aren't there?  Was the correct diagnosis in the parable above "Meningitis"?  Technically it was, but the causative agent is critical to treatment.  

Jerome Groopman in his book "How Doctors Think"  tells the poignant story of the man who came into the ER and had fallen--he was diagnosed as having a broken leg from the fall.  The leg was casted in the ER.  He went home.  He became progressively weaker, and was found to have fallen and broken his leg because of anemia.  The anemia eventually was found to have been because of colon cancer.  ...layers of diagnoses.

The Allergist should NEVER be content in labeling a disease and forgetting about looking for underlying triggers.  Diagnoses often come in layers, like Russian dolls.  A compassionate ear, an attentive manner, and an inquisitive mind in the allergist can often unravel all manner of puzzling problems.  Diagnostic excellent can never be fully attained, but should be constantly sought.  

Later, Dude 

I'm thirsty...a drink of water wouldn't hurt, would it? Yet most of us are aware of

...Such were the thoughts in my mind when I read the report in the August issue of The Journal of Allergy and Clinical Immunology by Cochard & Eigenmann entitled "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy".  

In their article, they present 2 cases of patients who suffered serious consequences when they took undertook SLIT.  Each patient had stopped prior SCIT also because of side effects.  Their conclusion?  "Special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."

hmmm.  And as I showed above, water is not totally safe either...

As some of you know, I've used SLIT for 29 years (this coming Feb), and as someone who has had not inconsiderable experience in treating patients who have experienced prior anaphylaxis from injection immunotherapy, I just have to weigh in on this one. I think the following comments are in order:

First, remember the literature---most of the published European literature is on monosensitized patients.  Both of the patients reported in the article were multiply sensitized.   

Secondly, the literature comments on the use of protocols designed for the stable allergy patient--the protocols weren't specifically designed for highly sensitized patients with prior reactions to SCIT.  

Thirdly, why would one give an ultra-rush protocol to patients previously found so reactive to SCIT that they had to discontinue it.  In short--what's the rush?  Looking for trouble?  

Fourthly, I have a suspicion that the total allergy load of at least one of the patients was not completely addressed. Something was missing.  Here's the story--the first patient (a 14 year old girl) was successsfully able to work up 8 drops a day with no major problem, but then 1 week later--at home--she reported a severe asthma attack together with mouth itchiness immediately after SLIT, lasting several hours.  Well, how come she could handle the SLIT the other 6 days without problems?   Most likely, she has some other stressor affecting her system, and partially limiting her response to the treatment...since she was birch, grass, ragweed, and alternaria sensitive, could she have had a hidden concomitant food reaction going on?  How about a hidden cereal grain allergy since she's grass sensitive?  Or a fruit sensitivity to banana, melon, apple, etc. ??  Furthermore, the authors were not, from my understanding, treating her alternaria allergy--just grasses. What were the Alternaria mold counts on the day of her severe reaction?  Incompletely treating allergy load doesn't help the situation here.  

In my opinion (after nearly 3 decades of experience), these authors would have more likely had a successful outcome with both patients if they used multi-antigen threshold dosing, and perhaps selective preseasonal moderate dose therapy as an add-on, after thoroughly looking for hidden food sensitivies that could make  these patients brittle.  It works for me.  

Indeed, often when I see a patient poorly tolerating SCIT, (like these 2 patients), it's because of usually only 2 reasons:  either the doseage administered was technically a failure, or there was a hidden sensitivity in the patient that hadn't been addressed, and stressed their system, making them "brittle".  More often, it's choice number 2 rather than choice number 1.  Although it could be either.

Soooo, what's the verdict?  I agree with the authors conclusions--"special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."  Yes, and water can be poisonous.  In my opinion, a better title for the article (rather than "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy" would be

"Sublingual immunotherapy  in ultra-rush protocol to multiple sensitized patients who may have other hidden sensitivities is not always a safe alternative to subcutaneous immunotherapy" would be a much better title.   

My real fear is that the typical allergist likely perusing this article will go AHA!  SLIT ISN'T SAFE!  SEE! SEE!  And he/she will settle back comfortably into the complacent shot-giving attitude that is so common now-in-days, making the search for a better form of immunotherapy nonexistant.  And you know what?  The allergist is being bypassed in all this--by the ENT physicians and others who are increasingly using SLIT. Most ENT's  know SLIT can have side effects, and the one's that are friends of mine aren't using ultra-rush protocols on their patients either...

The search for a "universal" dose of SLIT that fits all patients in allconditions is nonsense.  To apply the European protocols for monosensitized patients to multi-sensitized patients with severe SCIT reaction histories should only be done at the doctor's (and patient's) own peril...SLIT is incredibly versabile, and like any oral therapy (antibiotic treatment immediately comes to mind) different dosing protocols, depending on the condition you're faced with, make intuitive sense.  (I won't treat an acne patient and a lyme's patient with the same dose of doxycycline, would I?)

So think about these things, and while you're at it--pour me a glass of water, would ya?

Later, Dude

When I first started to blog, I read a cardinal rule--"post on your blog site regularly"...as those of you who follow my blog are well aware, I have violated this rule repeatedly...and as a result, I've probably lost most of my readers...but such is life.  I blog for myself, and to divulge the innermost secrets--my passions--in the allergy profession I've dedicated my life to.  I've been busy getting lectures ready for our annual allergy meeting, so I suppose that is a meager excuse for my tardiness on my blog site.  But in the process of giving a talk on diagnostic techniques used by the allergist, I once again come back to the critical importance of the history in allergy diagnosis...

It's funny that when I take a past medical history on my patients, so many of them say "I went to an allergist and had skin testing"...but none--and I mean none--have ever said 

"I went to an allergist to get a good allergy history and appropriate testing"

It's as if the procedure of skin testing tells the whole story.

It doesn't.

...I'll be getting a colonoscopy in the near future.  I really don't expect the colonoscopist to know my whole story...he's a technician designed to look at my colon--and to see if anything is abnormal. But he can't put the findings into any clinical context.  That's for my doctor to do...I don't expect him to give me any answers except for what he sees at the moment.  

I saw a patient last week...the man looked absolutely miserable. He had a history of sneezing, congestion, facial swelling initially beginning in the spring, but then building up and getting worse each summer and fall.  The problem had been going on for several years.  He had a nice skin response to a histamine control, but his skin tests were largely negative.  It has been an aphorism of mine that the allergist can stop thinking when the skin tests are strongly positive, but needs to start thinking when the tests are negative in someone with a clinical history of allergic problems. He'll undoubtedly be a delayed reactor to molds on is skin tests in 24-48 hours. I'll be interested in his delayed-reaction report.  

Another patient had seen me recently, with the onset of congestion in the summer of 2008, continuing throughout the winter and into the summer of 2009 when I had seen her.  She was also miserable. My initial impression of possible dust mite sensitivity didn't show up on skin testing--in fact, skin testing failed to reveal anything of importance.  More significantly, further history-taking had revealed she had traveled from Minnesota to Arizona over the winter, with absolutely no improvement in her symptoms.

So it was back to the history, once again...

What was going on last summer 2008 that was "out of the ordinary?" I asked.  "Nothing, she replied, except that I had had diverticulitis and was hospitalized briefly for it", she stated.  "Did anything change after that?" I asked.  "No, except that I began eating very large quantities of yogurt to help my intestine, she said".

It turns out that after additional testing I found out that she was milk protein sensitive, and the dramatic increase in milk protein beginning last summer was enough to cause her problems from that point onward--and would explain why she hadn't improved with a change in climate from Minnesota to Arizona.  

The most important diagnostic tool we have is not the needle we stick in the skin, but the grey matter between our ears.  

Skin testing and colonoscopies are fine, but only tell part of the story.  The rest is up to the doctor and the patient.

Later, Dude

In my last entry, I asked the question "Where are today's Leonardos?" in the allergy community. If I was the head of an allergy training program in a University (which thankfully I am NOT), I would not only (of course) emphasize superior critical analysis and clinical problem solving, but also very unconventional creative thinking sessions among all trainees. Why? Because I firmly believe that the clinical triad of a superior allergist is technical knowledge (i.e., thoroughly knowing disease states we deal with), wisdom (which comes from experience in dealing with patients), and...curiosity (i.e., creative stimulous).

The Book by Von Oech, "A Whack on the Side of the Head" would be mandatory reading for every allergy fellow.

It is my contention that truly creative allergists are in short supply...and that's because of blocks to creativity that every allergist subconsciously "employs" in his or her practice. And these blocks to creativity slow down advances in the allergy community. Advances that are within our reach if we think creatively. How can we have a Renaissance of creative thought in our Allergy Community?

By removing the Roadblocks to Creativity...

Allergy Creativity Roadblock #1: There is only one "right answer".

To quote Von Oech, "Nothing is more dangerous than an idea when it's the only one you have". Example: SCIT works for immunotherapy. Stop there. Don't ask the question--can we deliver immunotherapy more safely, effectively, than with SCIT? We have one idea. SCIT works. Nothing else does. And nothing else is even considered.

Allergy Creativity Roadblock #2: Logic can kill creativity.

As a former engineer, this rule absolutely kills me, but it's still a rule we have to follow for creativity. Simply put, there is a time and a place for logic--I use it minute-by-minute to solve clinical problems daily encountered in my practice--but there is a time and a place for creative thinking as well. What we need as allergists is a "time out" from logic so we can get as many ideas as we can, no matter how crazy--the crazier the better. For the Creative Allergist, it is the patient who "doesn't make sense" that is the patient we can learn the most from.  Last month, I mentioned the recent review by Bahna on food additive sensitivity, in which he concluded that there was not one report in the medical literature on desensitization to food additives (despite of course multiple reports on successful ASA desensitization). Well? Doesn't anyone have a crazy idea?

Allergy Creativity Roadblock #3: Break some Rules

As creative, Renaissance Allergists, we need to ask ourselves the tough question, "What 'unwritten' rules are currently in place in my profession that are stopping me from helping more patients productively?" Here are a few "unwritten rules" in our profession--1. To paraphrase Patrick Henry, "Give me IgE or give me Death", 2. Head, neck, lungs. The allergists domain. Nothing else. We all need to break a few rules, and see where our thinking leads us. The pathetic tragedy is most allergists can't think outside the box, because they don't even realize they are in one.

Allergy Creativity Roadblock #4: Being Creative is 'Not my Job'

The good allergist, we're taught, plays by the rules, and follows the lead of our professional societies--we rely on them to be creative. Nonsense. We can never rely on a professional society to be creative, when it has vested political, financial, and other outside interests which can atrophy any feeble attempts at creativity. As individual allergists, we have to realize that we are NOT fully doing "our job" UNTIL we approach our field in a creative fashion. Creativity starts with the individual allergist, not the professional allergy societies. Not the other way around.

Allergy Creativity Roadblock #5: Fear

I've saved what I feel is the most potent roadblock to allergy creativity to the end: Fear. Face it: It is hard to be creative when you are fearful. And if there is one disease that Allergists suffer from currently, it is a (possible terminal) case of fear:Fear of declining reimbursements from insurance carriers--especially if we use SLIT and not SCIT. Fear of increasing competition from ENT's, Family practitioners, etc for our patients. Fear of SLIT-based pracitioners and pharmaceutical companies making better and better treatments that "take away" the need for an allergy referral and put allergy management back into the hands of the primary practitioner. Fear of "internet educated" patients desiring help with delayed food sensitivities and other areas we aren't really interested in or know how to deal with. In truth, we are a fearful lot. And, as I've said, it's hard to be creative when you're fearful. But there's a cure:

There is no fear in love [dread does not exist], but full-grown (complete, perfect) love turns fear out of doors and expels every trace of terror! For fear brings with it the thought of punishment, and [so] he who is afraid has not reached the full maturity of love [is not yet grown into love's complete perfection]. —1 John 4:18

Simply put, if we love our profession, our patients, and our calling with enough passion, we'll approach creativity without fear.  And then advances in allergy can really be made.

Later, Dude

"Perhaps it is time for a rebirth, a time to create a better world through the energies of the Class  of 2009"...The Renaissance was a period when our search to perfect one's worldly knowledge transcended obstacles and bridged intellectual divides.  Students of creative thought--including da Vinci, Michelangelo, Copernicus and Galileo--questioned conventional wisdom...  Just as the Renaissance masters cast away conventional concepts, so too shall we discard friction that creates inertia in our thoughts."

Conventional Wisdom in the allergy community today involves several key underpinnings, which permeate all thinking and research in the field and (in my humble opinion) don't exactly "transcend obstacles and bridge intellectual divides".  Here are 3 key points in allergy Conventional Wisdom:  

1.  Since IgE mediated disease is the only "true" allergy, it is the only sensitivity we should be concerned about. Delayed food reactions, mold reactions, etc. really aren't our concern...so let's sweep them under the rug.  Let them die a death of benign neglect, not flourish in an atmosphere of curiosity...

2.  Asthma and upper respiratory disease should encompass what the allergist is "all about".  Other organ systems (besides pulmonary) should (once again) die a death of benign neglect as it regards interest in them as allergically responsive systems.  

3.  Other chronic disease states--chronic fatigue syndrome, fibromyalgia, migraine headaches, interstitial cystitis, have no allergic component, because everybody knows they don't.  So let's not be curious and study if indeed they DO have an allergy component to them.  

Examples of this "intellectual straightjacket" abound.  You can generally pick up any current issue of any allergy journal and see Conventional Wisdom at work--and trumpeted...Here's just one small example:  In the June issue of Current Opinion in Allergy and Clinical Immunology DRs. Randhawa and Bahna wrote a comprehensive review entitled "Hypersensitivy reactions to Food Additives".  They comprehensively review the protean manifestations of food additive reactions, and I heartily recommend the article for those allergists who see this problem in clinical practice.  However, near the end of their article, they state:

To our knowledge, there are no published reports on successful desensitization procedures.  

What?  You mean there isn't even a single case report in the entire body of medical literature on successful desensitization to food additives, despite multiple articles on successful aspirin desensitization?  Hello--isn't anyone anyone curious & interested?  Where's creative thought?  

It was this form of unconventional thinking that drove me to try oral desensitization to yellow dye #5 in a patient I had seen in my office earlier, who had presented with a history of seasonal allergic rhinitis, and repeated urticarial reactions to foods containing yellow dye.  As with many allergy patients, she wanted help with the "difficult issue" (dye sensitivity), and not the "easy issue" (allergic rhinitis).  As a businesswoman, she frequently went on trips and ate at restaurants, and found it always a risky procedure

We began her on a progressive program of yellow dye oral desensitization, starting with dilution #9 of yellow dye #5, and working progressively up to a dilution #1 without serious problems.  We knew we had successfully desensitized her when she told me she was on a business trip and gulped down a glass of Tang, which she had mistaken for Orange Juice, and had no reaction. Conventional Wisdom would have just treated her for her allergic rhinitis (which she could handle just fine with an OTC antihistamine, thank you).  

So here's the thought for the day--are we graduating Leonardo's from our allergy training programs, or just good Asthmalogists and technicians?

Do allergists think "outside the box"--or inside a straightjacket? 

Later, Dude

...when Duke published an article in JAMA on the role of platelets in hemostatis, probably few individuals realized that this report would be judged as one of the outstanding contributions to the science of medicine during the first half of the 20th century...this JAMA Classics article by Duke is historically important for 2 reasons:  it defined the role of platelets in hemostasis and it documented the therapeutic efficacy of blood transfusion in treating thrombocytopenia..."

There is always a danger in "cherry picking" a great physician's body of published work--you might give the erroneous impression that's ALL they really accomplished....  I pointed this out in my earlier commentary on a recent article on Dr. Warren Vaughn, another Renaissance Allergist, published in the JACI that didn't (in my humble opinion) adequately due justice to his contributions to the field of food allergy.  

In truth, I count 97 total publications by Dr. Duke over his lifetime.  Less than 10% of these actually deal with platelets.  Dr. Duke was fascinated by the wide range of symptoms that food sensitivity could cause, and abided by the maxim "one mucosal surface" instead of the mantra "one respiratory tract" (used by so many "allergists" today) to describe the wide range of manifestations that allergic disease could cause.  Here are some articles he also published:

Duke, WW:  Food Allergy as a cause of abdominal pain.  Arch Int Med.  Chicago 28:151, 1921.

Duke, WW:  Food Allergy as a cause of abdominal pain.  South M J Birmingham 15:599, 1922.  

Duke, WW:  Food Allergy as a cause of bladder pain.  Ann Clin Med 1:117, 1922.

Duke, WW:  Food allergy as a cause of irritable bladder.  J Urol, Baltimore 10:173, 1923. 

Duke, WW:  Meniere's syndrome caused by allergy.  JAMA 81:2179-1923.

Duke, WW:  Urticaria caused specifically by the action of physical agents (light, cold, heat, burns, mechanical irritation, and physical and mental exertion) JAMA 83:3, 1924.  

Duke, WW:  Mental and neurologic reactions of asthma patient.  J Lab & Clin Med 13:20, 1927.

Duke, WW:  Allergy as a cause of gastrointestinal disorders.  South M J 24:363, 1931.

Duke, WW:  Rapid and more accurate method of determining pollen count in air.  JAMA 99:1686, 1932.

Duke, WW:  Soybean as a possible important cause of allergy.  J Allergy 5:300, 1934.

Duke, WW:  Wheat miller's asthma.  J Allergy 6:568, 1935.

I stress this is only a fraction of the allergy articles published by Duke--it is by no means a complete list.  It is ironic that the commentator of the article on Duke and platelets (Dr. Thomas Kickler) did not at least reference JAMA's OWN TRIBUTE on Duke's life:

William Waddell Duke 1883-1946, JAMA 130:1185, 1946.  

Duke was obviously a brilliant allergist who made important contributions to the specificity of food allergy, in addition to making important contributions in the field of hematology.  How do I know about Duke?  One of my mentors (Dr. Theron Randolph) recalled seeing Dr. Duke at an allergy conference in 1933 in Atlantic City New Jersey, while he was a senior in Medical School.  He studied Duke's life, and published his bibliography.  I have a copy of that bibliography.  Dr. Randolph stated that  

"Duke's remarkable book published in 1925 really opened up the field of food allergy...Duke related specific foods and simple chemicals to a wide range of allergic symptoms, including headache and bewilderment resembling delirium..."

William H. Duke:  Pioneer in Platelet Research

                             AND...

                    Renaissance Allergist.

Something to think about.

Later, Dude

"Dr. Kroker, please help me with my Myasthenia gravis..."

Of course, as an allergist, my first thought was "you've come to the wrong place, lady", but I resisted the temptation to say what immediately was on my mind, and asked her to simply tell her story...

"I've had Myasthenia for about 4 years, confirmed at a large tertiary care center...I use Mestinon, primarily for ocular symptoms, but because of GI side effects, I try to minimize it whenever possible."

"I've also had allergy symptoms in the spring and in fall for many years.  I was allergy tested in the 1960's and was on injection immunotherapy for about 2 years when in Oklahoma.  That helped reduce the respiratory symptoms, but now I've been in the Midwest for about 4 years, and I've noticed that in the spring and fall, when my respiratory allergies flareup, my eyelids will droop, I'll get facial weakness, and need ALOT of mestinon. At other times, I'm relatively fine.  I take Flonase for my nasal congestion, and haven't been on injection immunotherapy for many years".

"I also have itchy skin, and use Allegra all the time.  I'm also prone to fluid retention, and use "Lasix".  

"Do you think you can help me?"

The desperate look in her eyes was accentuated by the drooping of her left eyelid...In truth, I have seen many cases of what I call "The Allergy Interface"--whereby an allergy condition aggravates a coexisting chronic disease.  We must never forget that when we read about any chronic illness in a medical textbook, website, or magazine article, there should be a caveat attached to the disease discription:  i.e., "this is the disease's presentation, natural history, and response to treatment, assuming that there are no other coexisting illnesses, and the patient is otherwise in fine health" (italics mine).  Believe me, I have seen allergic disease aggravate many other coexisting chronic diseases, including chronic fatigue, fibromyalgia, and even more "exotic" illnesses like Hereditary Cerebellar Ataxia (but that's another story for another time...).

We did intradermal testing, and found strong responses to molds, and (very interestingly), a 14mm wheal on dilution #2 of TCE and a 15mm wheal on dil #2 of Candida antigen.  

I found the strong immediate responses to molds--and especially Candida intriguing...she had been on multiple antibiotics and steroids in the past, and undoubtedly had significant commensal colonization of Candida.  

What was most interesting was that after skin testing her, her left eye drooped further, and became almost totally closed...

We began her on a program of SLIT for molds, and Candida, and a course of fluconazole for 14 days.  We subsequently found a RAST positive score for Candida of >100 ug/ml of antigen in her blood.  Also elevated antibody levels to wheat and egg.  We changed her diet, began SLIT, and had her keep a pill count for her Mestinon useage....

Over the next several years, she has had dramatic improvement in spring and fall respiratory symptoms, as well as her seasonal Myasthenia flares...She stated on her followup visits "my eyes are real good" and took an overseas trip without difficulty.  Her use of mestinon has been reduced by perhaps 75-80%. She doesn't want to discontinue SLIT under any circumstances...When I would see her in the clinic, her eyes were bright, not drooping, and...most importantly..she no longer had the desperate look in them that she had on her first visit with me.  

The Allergy Interface.  Something to think about.

Later, Dude 

Congratulations!  After two years of Fellowship Training, you're about to be done...and be certified as an Allergist.  The whole "World of Allergy" awaits you...and you're about to take the big step forward into directly caring for patients on your own...As someone who has been "in the trenches" for nearly 30 years in treating allergic diseases, I have a few words of advice.  This letter could be entitled many things, but perhaps the best title would be

"Mistakes I've made and Lesson's I've learned"

For you see, I've found that not everything you've learned in your training program applies to the Real World of allergy. Naming and learning leukotrienes is one thing, but dealing with patients is quite another...Here are some things to think about when you begin to see patients--lessons I've learned in the last 28 years that have helped me in my practice:

1. Lesson 1: In the Real World of Allergy, patients don't give a damn whether they're sick because it's "IgE-mediated allergy" or not--they just want to get well. You'll see many, many patients with adverse reactions to foods and molds where your prick test is negative, and telling the patient "they don't have an IgE mediated allergy" is very cold comfort to them. They want answers, and telling them what it ISN'T is not nearly as satisfying to the patient as telling them what it IS. A practical point--they're not likely to refer you a whole lot of future patients, either. Here's the clinical pearl: In the Real World of Allergy, you've got to get comfortable with non-IgE mediated reactions--and fast--if you want to be a superior allergist...

2. Lesson 2: You've got to get experienced in delivering immunotherapy regularly in your practice, and preferably in a well tolerated, safe and effective form: SLIT. If the only thing you're interested in is treating asthma and allergic rhinitis with only drugs, you'll be a very lonely--and poor--Allergist. Face it: we have alot of competition for treating the asthmatic patient, and the allergic rhinitis patient. We've got good symptomatic drugs too--which the family physician and pulmonologist and otolaryngologist can all deliver. You've got to deliver something the family physician and the pulmonologist and the otolaryngologist can't deliver--and that's immunotherapy. SLIT is the wave of the future. Bone up on it. Fast.

3. Lesson 3: There are other things in the Allergist's life besides asthma. Open up your vistas, and start thinking of ALL mucosal organs (and the skin) as targets for allergic disease. Our professional societies have done a good job at "marking our territory" as asthma--that's all well and good, but you'll see plenty of patients with urticaria, migraine headaches, fatigue, and other issues besides asthma. Many of these patients come with a mix of IgE and non-IgE mediated illness. In truth, the allergist who only treats asthma is like the musician who only plays one song: It gets pretty boring, and is an incredible waste of talent...

4. Lesson 4: Revel in the mystery of allergy--and develop your sense of curiosity in your practice. Just because we can't EXPLAIN a patient's reaction in terms of what we presently understand from our training program, there is no need to deny it exists or delight in the mystery of how it happens: Why does Mrs. Smith get tired shortly after eating wheat products? Why does Mr. Smith get a headache 12 hours after cleaning up a moldy basement? Why do Mr. and Mrs. Smith have negative prick tests and IgE negative RAST tests to wheat and mold? There is a subliminal tendency in many young allergists to not be interested in anything they can't explain. An observation is DENIED because the PATHOPHYSIOLOGY is unclear. That's backwards. It is the patient reactions we can't explain that should interest us the most! Thinking should begin with the NEGATIVE prick test and the NEGATIVE RAST test...not the positive ones. There are many, many, things we do not understand about how food and aeroallergens affect the patient, and the sooner we humbly acknowledge this, the better. This is the "Grand Mystery" of allergy. Accept it, embrace it--and study it...

Keep these four lessons in mind as you start your practice--you'll have a satisfying and rewarding practice for many years to come.

Later, Dude

Morris's Sign:  An allergic reaction to an inhalant or food may preferentially target a site of prior neurogenic trauma in a patient.  

I have seen multiple examples of this sign over the years:

Case Example 1:  A previously diagnosed food-sensitive patient develops the shingles.  Now, with accidental ingestion of corn, a faint tingling and burning occur in a dermatome distribution site where the patient previously experienced shingles.

Case Example 2:  A patient with prior reflex sympathetic dystrophy accidently ingests milk.  Her right arm flushes and reddens immediately after ingestion.  

Case Example 3:  A patient tells me that she always experiences her urticarial eruption first at a small site on her abdomen.  On examination, the spot turns out to be a small scar from a prior laparoscopy procedure.  

Case Example 4:  A former food allergy patient returns to see me.  In the interim since I had seen him, he was in an automobile accident, and suffered a seriuous whiplash accident in the neck.  Now, when he accidently ingests his allergen, he not only gets nasal and sinus congestion, but his neck and shoulders ache intensely, just as they first did after the accident.

To my knowledge, this observation has not been commented upon or officially published in medical journals.  And yet allergists like myself see this sign "play out" on regular encounters with our patients, often on a near-daily basis.  Why have the presumption to name it myself?  Well, somebody has to do it.  Why name it Morris's sign?  Easy--Dr. David Morris, a consumate allergist and my mentor in sublingual immunotherapy (SLIT) has just retired after a profoundly productive lifetime of caring for patients.  The tribute is inadequate, but it's one small thing I can do to show my gratitude for all of the knowledge on SLIT he has passed on to me and my colleagues.  

Later, Dude