When I picked up the phone, I noted the desperation in her voice..."I'm going crazy trying to figure out what's causing my rash", she said.  "I've been everywhere, and no one has helped me..."

...usually I don't have time to talk to potential "new patients" on the phone, but I had an unexpected lull in the office the day she called...just hanging out and reading some journal article about some obscure immunological aberration that I would probably never see in my practice...so when I was paged I took the call.  The more I talked to her, the more interested I became.  "Ive been to xxxBLEEPxxx clinic, and they biopsied the rash and couldn't figure out what it was so they gave me a burst and taper of Prednisone and it still hasn't helped.  And my dentist keeps finding I am getting infections in my mouth for no reason.  I'm a TOTAL mess."  

... Well, at this point I figured I had about 5 minutes of time left on the phone, so I'd take a wild stab at this problem and decided to ask her what most physician't DON'T ask about and DON'T take a history on and DON'T factor into the differential diagnosis--her diet.  "So what do you typically eat?" I asked.  "I'm suspecting I have a food allergy" she said.  When the rash first began, I cut out most foods and now I'm eating green peas, hamburger, and brown rice and the rash is worse than ever..." 

...A thought crossed my mind.  "I want you to NOT change  your diet until I see you in the office," I said.  "And I think I know what's wrong with you.  We need to do a blood test to confirm it..."

...When she came into my office she appeared to be a frail, pleasant blonde who had a rash principally scattered over her lower extremities, but also seen on her back and the nape of the neck.  The lesions were punctate red excoriated areas with shallow scratch marks.  She proceeded to tell me her story, and brought in records for review: 

The rash had been insidious in onset, for about 2 years duration.  Her prior Immunofluorescence biopsy was negative for IgG, IgM, IgA, C3 and fibrinogen.  Skin biopsy reveated no evidence for dermatitis herpetiformis, lichen planus, vasculitis, or immunobullous disease.  There was no lupus band.   She had had fungal serologies and viral serologies, including herpes titers, and these were negative.  She had taken a systemic steroid course, followed by Cortaid application with occlusive dressings which did not help her symptoms significantly.  A boatload of blood work turned up nothing...her ANA, endomysial antibody and tissue transglutaminase antibody were negative (among others) , and she was told she had "neurodermatitis with excoriations". 

Wait...but there's more!  I found out that she would get diarrhea from eating most fresh fruits; she had known this for years:  as a child, she recalled that there was never any fresh fruit in the house  because her mother and sister couldn't tolerate it. Her gums looked somewhat sore.  She had dental problems, and so I ordered a

                         serum ascorbate level

I ran the test thru Mayo Medical labs, and the result was 0.3 mg/dl, with a normal range of 0.6--2.0.. 

Diagnosis? 

                                                Scurvy.  

I placed her on Vit C 500 mg tid, and a general multiple vitamin.   Her lesions healed in a month.  Also, her dentist was happy with me.  And her repeat Vit C level was 2.0. 

What made me suspect Scurvy?  Well, for one thing, her diet of green peas, meat, and rice had no significant Vit C and of course her lack of response to steroids suggested a cause other than immunological inflammation.  Once again, this shows the power of history-taking:  her case was figured out over the phone, and the blood test was merely confirmatory...(so much for her prior "million-dollar workup")

Comments:

There are several "morals to this story", and lessons to be learned:

1.  Not everything that a patient suspects is food allergy is actually food allergy.

2.  A prestigious medical institution missed the diagnosis because no one had bothered to take the patients dietary history.  And the cost (emotionally and financially) to the patient was enormous...

3.  She (and other family members) probably had a hereditary fructose intolerance, and she was probably marginally Vit C deficient her whole life, and then when the rash began, she restricted her diet further, taking out the vegetables out of her diet that were buttressing her Vit C level, and her skin rash and dental absesses began...

4.  Just because she had Scurvy didn't mean she was ONLY deficient in Vit C.  She desperately needed general vitamin repletion.  (I quickly checked a Zinc level with her dental problem as well, and she was also deficient in this).

5.  As allergists, we need to be aware of nutritional deficiencies for our patients.  It's not enough that we are "asthma doctors."  This patient wouldn't have been helped with inhalers or antihistamines.  Period.  

5.  If we're good doctors, we'll get more of our "bread and butter" allergy patients.  Ironically, this "non allergy patient" has referred me patient after patient for allergy care!

Later, Dude