It was a beautiful day in May, a few years ago, when she first walked into my office.  She had an earnest look on her face...before I could introduce myself and welcome her to our clinic, she blurted out her urgent concern:

"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