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The Renaissance of an Allergist....of Memoirs & Myths

"I'm a big fan of the misunderstood, the vilified, the underdog, the breaking of myths..."

--Dominic Monaghan

"In the French language, Renaissance means "rebirth".  In medicine, I am convinced that a rebirth--like birth--is inherently a painful process.  It involves giving up many cherished ideas; abandoning comfortable ideas and embracing others that may be closer to The Truth.  In my field of allergy, we have many old ideas that need re-addressing.  And the worst "old ideas" are actually myths.  Here are the Top Ten, written in no particular order which permeate our field:  

1.  Candida is only a harmless commensal doesn't cause allergic disease.

2.  Irritable bowel syndrome is unrelated to food sensitivity.

3.  Vaginitis can never have an allergic component.

4.  High-doses are needed for sublingual immunotherapy (SLIT) to be effective.  

5.  Delayed food allergy (if it even exists) is a rare event, mainly confined to FPIES in pediatric patients.  

6.  Delayed skin test reactions are of uncertain or minimal significance.  

7.  Rheumatic syndromes such as fibromyalgia and idiopathic polyarthralgia have no potential allergic input.

8.  Eosinophilic esophagitis is exclusively triggered by foods.

9.  An allergy workup for chronic urticaria is unnecessary and generally unfruitful.

10. The Total Load Theory in allergy does not apply to allergy patients.  

Next month I will celebrate my 40thy year as a physician.  Over those 40 years, I have given up many cherished ideas and undergone a "rebirth".  Significantly, this rebirth has been done largely without the aid of our major allergy professional societies (of which I am either a Member or Fellow).  Why is this?  Because our professional societies continue to focus almost exclusively on IgE mediated respiratory disease.  There are however, occasional "Bright Spots", such as the discovery of alpha-gal allergic disease.  I am convinced that if we had the same level of curiosity brought to gastrointestinal and rheumatic fields in general, we could make enormous strides.  However, we have made two extraordinary mistakes which exceed all others:  

We have taken a field of medicine (allergic reactivity) and have artificially constrained it in two areas:

1.  Anatomically demarcating our field, when no anatomic demarkation should exist.  I have said before that our field most closely resembles that of Infectious Disease.  Infections can involve virtually any part of the body, and our colleagues in this field don't limit themselves to the respiratory tract.  Imagine how ridiculous it would be if the Infectious Diseases Society of America had changed their name to "Infectious Diseases and Bronchitis Society of America?  Now what would that imply?  Yet, both of our major allergy professional societies have tagged the word "Asthma" in their name.  As a result, we have moved from becoming Allergists to....Asthma doctors.  Only.  What a tragedy.

2. Immunologically demarcating our field to IgE-mediated allergy.  Delayed food sensitivity is conveniently not really explored in many potentially breakthrough areas--like gastrointestinal and rheumatic illness. Oh sure, we give Lip Service to the idea when discussing certain illnesses like EoE or FPIES but do we really pursue study in the broader context I have mentioned above--Irritable Bowel Disease or Polyarthralgia?  I think not.  After all, we're "asthma doctors"...

So where does that leave us?  With professional societies still overtly--or tacitly--perpetuating the Top Ten myths listed above, largely through anatomical and immunological self-constraints.  Our professional societies are in desperate need of Rebirth.  Our self-imposed and arbitrary constraints need to be ruptured.  And unless we go through a painful Rebirth, our field can expect atrophy and decay in the future.   

And that's not a Myth--that's The Truth.






Posted on Saturday, May 16, 2015 at 04:04PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment | References1 Reference

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