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Three Words...

Kristin sat on the exam table, ready for me to place the tongue blade on her tongue and look into her mouth.  As my tongue blade moved forward, she put her hand on my wrist, stopped me, and said

“You know, I’m no longer saying those three words….”

 I stopped my movement.  I held the tongue blade in my right hand. Expectantly waiting for her to continue...

One sign that all doctors are aware of is the so-called “doorknob syndrome”, in which a patient will say something of crucial importance (to them and usually to the doctor) as the doctor puts his hand on the exam room doorknob to leave the room.  I’ve seen a similar phenomenon in patients as you’re  placing a tongue blade into their mouth.  You could call it the "tongueblade syndrome".  It’s as if, subconsciously, patients not only  want to have their mouth physically examined, but their words as well…

 “What three words?” I said. My curiosity was immense...

Kristin had come in to be initially evaluated 4 months earlier, when she had presented with a history of Meniere’s disease since 2000.  She had begun having classic symptoms of vertigo, tinnitus, a sensation of fullness in her ears and low frequency hearing loss and saw a University-based ENT physician who diagnosed her with the illness and had recommended allergy evaluation as part of her work-up.  She had subsequently seen an allergist, and was found to have significant multiple inhalant allergies, including tree pollen, grass pollen, and ragweed.  She was  begun on injection immunotherapy and took it  from 2000 through 2005, and the immunotherapy treatments, coupled with a low sodium diet, diuretics, etc.  had dramatically improved her symptoms.  She quit immunotherapy in 2005, and remained reasonably stable until March of 2008, when symptoms of severe vertigo returned.  In September, she finally saw her ENT physician again, and it was recommended she be rechecked for her allergies, so she again saw her allergist, who retested her and found that her tree, grass, and ragweed allergies were “off the chart”.  She reinitiated allergy immunotherapy in the fall of 2008, working up to a maximal doseage for her pollen & weed allergy, taking monthly injections.  However, this time around, she didn’t experience the dramatic improvements she had had before.  In fact, from September 2009 through my initial visit with her Febuary 2010, symptoms were increasing.    

Historically, Kristin had always had a “reprieve” of symptoms in the winter season.  This was the one time of the year when she could count on feeling better.  But this last winter of 2009-2010 was different.  She did not feel better.  She continued to suffer.  In fact, when I had seen her at the end of the winter season (in February), she had had averaged 3 vertigo attacks per month during that season. 

In addition to the lack of help with the re-initiation of immunotherapy, she had begun experiencing symptoms of flushing on her chest, back, and neck, which also was greatly distressful.  She had congestion and was using Flonase and Zyrtec to help with these additional symptoms.   

She had been told by her allergist that she had “mild reactions” to egg and corn but that no change in her diet was required.  She continued, however, to follow a low-sodium diet. 

Her work-up by me confirmed strong reactivity to ragweed (28 mm on dilution #3 by IDT testing) but improved reactivity to grasses and trees (8 mm on dilution #3 by IDT testing.) There were no significant reactions to dust mite, animal danders, or indoor molds—“winter time allergens” that might cause problems.  Her food ELISA test,  however, told a different story:

 

Food

IgE ELISA Conc IU/ml

IgG ELISA Conc ug/ml

Egg

.24

>100

Milk

.17

>100

Wheat

.11

14.04

Beef

.05

12.77

Candida

 

99.82

 

My impression was that Kristin had been suffering from hidden food allergies and Candida sensitivity that were progressively worsening her condition, and preventing a wintertime “reprieve” from her symptoms. 

I had Kristin continue her injection immunotherapy from her allergist, but I began her on an additional program of:

1.  SLIT for offending food allergens

2.  A hypoallergenic diet eliminating eggs, dairy, and sugar and utilizing wheat and beef in limited amounts

3.  Fluconazole 100 mg daily for 14 days.  

And now she returned to see me, a few months later. her vertigo episodes, skin rash, and congestion were in remission.  In her own words, she stated "This is how my body used to feel 10 years ago!". But she had additional words for me,

Three words, to be exact...words she was no longer saying:

What words?

"If I'm well..."

"What do you mean, I asked?"  "What's special about those three words?"

It seemed like minutes passed before she could compose herself enough to explain.  She swallowed hard, and then began...

"You see," she said "my 10 year old son came up to me a few weeks back, and said "Mom, when I ask to do things with you now, you no longer say those 3 words", and I said "What words, honey?" and he said, "If I'm well".  I hadn't realized it, but I had paraphrased everything my son asked to do with me--taking him shopping for sports gear, having a birthday party, watching a movie with him--with those three words.  I never knew for certain  if I'd be well enough to do those things when he asked me, so I never promised...and in response to each of his requests, I said the same 3 words over and over...'if I'm well.'

"And now my son says those words have vanished"

She looked down at her hands, and then at me.  I won't forget the look in her eyes at that moment...  

So what can be learned from this "Case Report"?  

On a technical level, there are indeed several learning points worth mentioning:

1.  We are not "asthma doctors".  We are allergists. And some cases of Meniere's can be helped with immunotherapy.  

2.  When a patient with inhalant allergies under immunotherapy inexplicably worsens, food allergy should be kept in the differential diagnosis.  Always.  

3.  As food allergies progress, they may target other parts of the body in addition to the area of the "Chief Complaint"--including the respiratory tract and skin.

But what else can we learn from this case?  On a deeper, more profound level, one of the hidden "curses" of allergic disease is the "Curse of Uncertainty":  patients wake up each morning, and never know how they'll feel, or what the day will be like.  Can you imagine what that's like?  The anxiety that situation can provoke?  

"Will I have a migraine today--or not?"

"Will I have an episode of hives today--or not?"

"Will I have an asthma attack that will send me to the hospital today--or not?"

"Will I have a vertigo attack today that will make me sick--or not?"

It's our duty as allergists to try to lift "The Curse" from our patients.  So that those three words--"If I'm well"-- are never spoken by our patients again.  

Later, Dude

 

 

 

 

Posted on Sunday, June 27, 2010 at 05:00PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments3 Comments

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Reader Comments (3)

Dr. George:

Can you pls offer your thoughts regarding:

>> the use of IgG4 Vs IgG in the measurement of Delayed Food Allergy Sources.

>> the role of Balancing the Innate Immune System in a Patient's Allergy fight.

My Thanks for your Allergy Insights & Patient Compassion.

Best Health = Wealth Regards,

S

Best

July 6, 2010 | Unregistered CommenterStephen

To my hero Dr. Kroker,
Because of you, I have many more days that I am well. I was always an "If I am well person" until I started seeing you. My quality of life has greatly improved (as long as i don't cheat too bad on my diet!) Thank you for your help and patience! I look forward to seeing you in November.
Sincerely,
Sarabeth Salan Stielow

June 28, 2011 | Unregistered CommenterSarabeth S. Stielow

Very nice reading, thanks for sharing!

June 25, 2013 | Unregistered CommenterAdriano

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