Diagnostic Synthesis in Allergy: Part IV--Mult Food Sensitivities; Summary
Shhhhh...we're quietly discussing a taboo subject, so I want to keep this quiet. Over the last several journal entries, I've focused on how "simple" allergy patients become "complex" allergy patients with multiple food sensitivities involving multiple target organ involvement. This is an important subject, because we see these patients not infrequently in our allergy practices. And what I'm going to say next will probably put you at risk for a dangerous elevation of your blood pressure, or even a seizure, so be forewarned--I've inserted another notorious black box warning for your protection, so read further at your own risk:
We get scant guidance from our professional societies on how to approach these patients. Our professional societies prefer our immunology complex but our clinical patients simple. We want to keep our focus on one target organ (the respiratory tract) and one set of triggers (inhalant allergens--preferably pollens). In short, allergists arguably have some of the narrowest minds in medicine when it comes to thinking of their patients. Narrow is not good. Narrow is bad. Narrow is very bad. Check out this quote by Konrad Lorenz
Every man gets a narrower and narrower field of knowledge in which he must be an expert in order to compete with other people. The specialist knows more and more about less and less and finally knows everything about nothing.
But allergists aren't the only ones who succumb to the "tyranny of narrowness". For the allergic patient, narrowed diets are equally bad. And many allergy patients have them. The combination of narrowed diets in patients with increased intestinal permeability is a disastrous combination. Why? Because narrowed diets promote repetition of foods--often items with high native allergic potential. As an old engineer, I like to think in terms of system analysis, and formulas. Here's a formula for you. A formula that has helped me figure out hundreds of difficult cases over three decades of practice. You won't see this formula repeated in any allergy society meetings. I sure haven't. But it's a killer when it comes to application:
allergic predisposition+ increased intestinal permeability+repetitious/narrowed diets= development of multiple food sensitivities
Check out this flow chart for a more in-depth analysis:
As you might expect, the permutations on this formula are endless. Just take one item from the left hand box (narrowed diet) and one item from the right hand box (representing causes of increased intestinal permeability), and ...voila! instant food sensitivities! Let me present a few cases to you to illustrate what I've seen over the years:
Patient X presents to me with a history of getting sick from "everything she eats". She had an interesting history--initially had seasonal respiratory allergies, followed by the development of recalcitrant diarrhea. She finally had a small intestinal biopsy confirming celiac disease. So she went on a gluten-free diet. Diarrhea transiently subsided, only to return with a vengeance, AND with the development of worsening respiratory allergies, accompanied by urticaria. The problem? Intestinal permeability was enhanced by gluten enteropathy, she stopped gluten--and substituted corn for every snack food and main meal she was eating. Guess what? She was highly sensitive to corn. And I knew this even before I did the RAST test and challenge test to confirm it...
Patient Y presents to me with the development of progressively feeling sick from everything he is eating...He had a history of relatively minor allergies earlier in life, "but he outgrew them" (his quote). In midlife he went through a period of severe personal stress : New job, divorce, etc. etc. Limited time to eat, so he began to eat repetitiously the typical "fast food" meals I call "The McDiet". This was accompanied by liberal alcohol intake, causing increased intestinal permeability. I knew before testing him that he was sensitive to milk, wheat, yeast, and probably potatoes.
Patient Z had a history of colic as an infant, and trouble tolerating all formulas. She probably had a dairy allergy at birth, which "went underground" for a number of years. It resurfaced in hidden form her elementary school years, when she had multiple recurrent respiratory infections, requiring multiple antibiotics. The cause was missed. As a teen she took 2 years of tetracycline for acne. And then? She presents to me with bloating, gas from multiple foods she eats, cravings for sweets, and fatigue, cognitive dysfunction, and worries about completing her college studies because she feels so bad. Guess what? She's got intestinal permeability enhancement from repetitiously eating a primary food allergen all her life (dairy) accompanied by intestinal dysbiosis from recurrent antibiotics later in life. And her current diet? The typical college students monotonously repetitive "fast foods" diet. Not too hard to figure out.
Clinical pearls:
1. In the patient with developing multiple food sensitivities, look for causes of intestinal permeability. It pays off.
2. In the patient with developing multiple food sensitivities, look for repetitive eating patterns. Foods with high native allergy potential (eggs, milk, soy, yeast, wheat, corn) would be immediately suspect if eaten repetitiously.
Hope this helps.
Later, dude.
George F Kroker MD FACAAI
in Diagnostic Synthesis in Allergy
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Reader Comments (4)
Dr Kroker,
It was a great pleasure hearing you speak at the recent allergychoices conference. I applaud you and your coleagues for developing a clinical approach rooted in traditional allergy methods for treating non-IgE mediated hypersensitivity conditions that most allergists would shake our heads at and say "nope, this isn't an allergy, there's nothing I can do."
I am also proud that your group is comprised of some allergists and was disappointed not to see other board certified allergists among the attendees. I felt like I was the only one.
But I am still not convinced that intradermal titration testing is necessary for applying your group's methodology. This is perhaps because I do not see the need to define safe starting concentrations for each individual patient. I have practiced for years using very conservative starting dilutions for medication desensitization and immunotherapy without preceding titration testing. I find that starting with extremely dilute concentrations and then steadily and rapidly increasing doses is both efficient and safe. I do not believe that degree of sensitivity measured with "quantitative testing" whether it be ELISA for specific IgE or intradermal titration correlates well with severity of clinical reaction. History is a much better correlate and I will reduce my starting doses only on the basis of clinical history reflecting a high degree of allergy. That being said, do you feel there are other benefits to intradermal titration I may not be recognizing?
This leads me into a quandry as I am now convinced of the value of intradermal testing to detect delayed reactions to molds. I am trying to find a compromise to avoid testing at more than one intradermal dilution. In your experience, will a 1:1000 intradermal testing dilution pick up most of the delayed mold reactions? Put otherwise, if you could do only one dilution for intradermal testing, what would it be?
Thank you for your valuable time and insight.
Aslam Lateef, MD
Hamilton Allergy Center
New Jersey
Hi Dr. Lateef (Aslam)
Thanks for contributing your insightful comments to the blog, as well as your kind remarks...Regarding delayed reactions, I think that a dilution #2 is generally a good one to look for delayed reactions of significance to mold. If you clinically suspect (by history) that a patient is reactive to molds, and dilution 2 is only weakly positive by delayed reaction, then applying a dilution #1 on the next visit would be appropriate.
I share your viewpoint on the importance of the clinical history as being paramount in consideration for starting doseages in immunotherapy. I "interpret" the IDT testing always with this in mind. As I had mentioned in my lecture, I feel that the major benefits of IDT is it gives one a guide to starting at the highest & safest treatment dose for a variety of allergens, by quantitative assessment. When you are building up dosing for multiple antigens by history alone--let's say you are treating dust, grass, and ragweed--all at very small doseages--how rapidly do you build these? If they have difficulty on the buildup, which allergen is most likely the culprit to be causing the problem? If a patient isn't responding to a gradual buildup program, and are impatient at their lack of progress, and you want to increase dosing more rapidly, then which one could be increased the fastest? These are some scenarios where IDT might be of help...Again, you might prefer your more conservative program, and that is fine. But IDT would give an excellent way to quantify low dose treatment for delayed mold allergy--something that would not respond well to "build-up treatment", and be made worse on such a program.
I'd be happy to have a "thread" with you on these things, since they are common concerns among all of us! Hopefully, we'll have more board-certified allergists at our meetings in the future!
George
My daughter, 3.5 yrs has multiple food allergies and sensitivities. After consulting with two allergists, subsequent testing and results -- I'm just as in the dark as when she had her first 'clinical reaction.'
I've written allergists off for a while, since they (sorry to categorize) don't have any more answers than I do -- just a handful of samples for treatment of symptoms. My intention is to attempt actual healing -- if not to resolve the problems -- to at least decrease them.
My daughter avoids the foods that she is highly allergic to (specific nuts) and I've pulled from her diet the foods that she is sensitive to. She's has also developed seasonal allergies. Also to dust, cats, etc. The allergists, at this point, shrug their shoulders saying, 'she's an allergenic child' and write a prescription for steroid cream (eczema).
My questions to you are these:
If keeping a person with multiple food allergies on a limited diet (avoiding offending foods) will cause more food allergies/sensitivities -- what is your recommendation? Not to continue with these foods, I'm guessing -- but to be diligent about varying the diet?
Also, if one is taking steps to heal intestinal permeability, would limiting the diet temporarily have a negative impact?
Thank you.
Hello Julia,
I am sorry about the struggles you have had with your daughter's allergies. I am a firm believer in aggressive immunotherapy for baseline inhalant allergies that continually stimulate your chlid's immune system. Cooling down her continual reactions to inhalant allergies would be wise...Also, diversifying her diet and avoiding repetitious eating of any one food would help protect her against developing new food sensitivities. Finally, if she has been on recurrent antibiotics, then the addition of a probiotic would be helpful.
Take care.
Dr. K.