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 

Congratulations!  After two years of Fellowship Training, you're about to be done...and be certified as an Allergist.  The whole "World of Allergy" awaits you...and you're about to take the big step forward into directly caring for patients on your own...As someone who has been "in the trenches" for nearly 30 years in treating allergic diseases, I have a few words of advice.  This letter could be entitled many things, but perhaps the best title would be

"Mistakes I've made and Lesson's I've learned"

For you see, I've found that not everything you've learned in your training program applies to the Real World of allergy. Naming and learning leukotrienes is one thing, but dealing with patients is quite another...Here are some things to think about when you begin to see patients--lessons I've learned in the last 28 years that have helped me in my practice:

1. Lesson 1: In the Real World of Allergy, patients don't give a damn whether they're sick because it's "IgE-mediated allergy" or not--they just want to get well. You'll see many, many patients with adverse reactions to foods and molds where your prick test is negative, and telling the patient "they don't have an IgE mediated allergy" is very cold comfort to them. They want answers, and telling them what it ISN'T is not nearly as satisfying to the patient as telling them what it IS. A practical point--they're not likely to refer you a whole lot of future patients, either. Here's the clinical pearl: In the Real World of Allergy, you've got to get comfortable with non-IgE mediated reactions--and fast--if you want to be a superior allergist...

2. Lesson 2: You've got to get experienced in delivering immunotherapy regularly in your practice, and preferably in a well tolerated, safe and effective form: SLIT. If the only thing you're interested in is treating asthma and allergic rhinitis with only drugs, you'll be a very lonely--and poor--Allergist. Face it: we have alot of competition for treating the asthmatic patient, and the allergic rhinitis patient. We've got good symptomatic drugs too--which the family physician and pulmonologist and otolaryngologist can all deliver. You've got to deliver something the family physician and the pulmonologist and the otolaryngologist can't deliver--and that's immunotherapy. SLIT is the wave of the future. Bone up on it. Fast.

3. Lesson 3: There are other things in the Allergist's life besides asthma. Open up your vistas, and start thinking of ALL mucosal organs (and the skin) as targets for allergic disease. Our professional societies have done a good job at "marking our territory" as asthma--that's all well and good, but you'll see plenty of patients with urticaria, migraine headaches, fatigue, and other issues besides asthma. Many of these patients come with a mix of IgE and non-IgE mediated illness. In truth, the allergist who only treats asthma is like the musician who only plays one song: It gets pretty boring, and is an incredible waste of talent...

4. Lesson 4: Revel in the mystery of allergy--and develop your sense of curiosity in your practice. Just because we can't EXPLAIN a patient's reaction in terms of what we presently understand from our training program, there is no need to deny it exists or delight in the mystery of how it happens: Why does Mrs. Smith get tired shortly after eating wheat products? Why does Mr. Smith get a headache 12 hours after cleaning up a moldy basement? Why do Mr. and Mrs. Smith have negative prick tests and IgE negative RAST tests to wheat and mold? There is a subliminal tendency in many young allergists to not be interested in anything they can't explain. An observation is DENIED because the PATHOPHYSIOLOGY is unclear. That's backwards. It is the patient reactions we can't explain that should interest us the most! Thinking should begin with the NEGATIVE prick test and the NEGATIVE RAST test...not the positive ones. There are many, many, things we do not understand about how food and aeroallergens affect the patient, and the sooner we humbly acknowledge this, the better. This is the "Grand Mystery" of allergy. Accept it, embrace it--and study it...

Keep these four lessons in mind as you start your practice--you'll have a satisfying and rewarding practice for many years to come.

Later, Dude

 week ago, I celebrated 60 years of life on this planet...and I began to reflect on 25+ of those years dedicated to studying and treating allergic disease...It continues to amaze me regarding the sheer diversity and variety of allergic manifestations that the human body can manifest.  However, after nearly 3 decades of experience, certain "patterns" seem to show themselves amidst all of this diversity.  I have already reported on what I termed "Eaton's Sign", whereby a patient's site of former skin testing can unexpectedly erupt again, following a cross-reacting allergenic exposure.  Here's another:

Morris's Sign:  An allergic reaction to an inhalant or food may preferentially target a site of prior neurogenic trauma in a patient.  

I have seen multiple examples of this sign over the years:

Case Example 1:  A previously diagnosed food-sensitive patient develops the shingles.  Now, with accidental ingestion of corn, a faint tingling and burning occur in a dermatome distribution site where the patient previously experienced shingles.

Case Example 2:  A patient with prior reflex sympathetic dystrophy accidently ingests milk.  Her right arm flushes and reddens immediately after ingestion.  

Case Example 3:  A patient tells me that she always experiences her urticarial eruption first at a small site on her abdomen.  On examination, the spot turns out to be a small scar from a prior laparoscopy procedure.  

Case Example 4:  A former food allergy patient returns to see me.  In the interim since I had seen him, he was in an automobile accident, and suffered a seriuous whiplash accident in the neck.  Now, when he accidently ingests his allergen, he not only gets nasal and sinus congestion, but his neck and shoulders ache intensely, just as they first did after the accident.

To my knowledge, this observation has not been commented upon or officially published in medical journals.  And yet allergists like myself see this sign "play out" on regular encounters with our patients, often on a near-daily basis.  Why have the presumption to name it myself?  Well, somebody has to do it.  Why name it Morris's sign?  Easy--Dr. David Morris, a consumate allergist and my mentor in sublingual immunotherapy (SLIT) has just retired after a profoundly productive lifetime of caring for patients.  The tribute is inadequate, but it's one small thing I can do to show my gratitude for all of the knowledge on SLIT he has passed on to me and my colleagues.  

Later, Dude 

In my last entry, I talked about 3 reasons why sublingual immunotherapy (SLIT) has been slow in gaining acceptance: "turf wars" between ENT's and allergists, the "tomato effect" in medicine, and the commitment and work it would take an allergist to change his/her practice from SCIT to SLIT.  

But wait...there's more.

In pondering this issue and discussing it with my colleagues, an obvious answer exists--the proverbial "elephant in the room" that nobody discusses:  

Allergy society leadership.

Let's face it--many of our society leaders are academic allergists.  Their viewpoint--philosophically AND financially--is far different than the allergist "in the trenches"  coping on a daily basis with  competition for patients between ENT's, family physicians, chiropracters, etc...

Although I love to read the Annals, and the JACI, and delve into the esoterics of various allergy issues (I didn't know that prostatic kallikrein was a major dog allergen until now), I was trained as an engineer.  I do what works.  Practicality and positive results are what count--for my patients and for myself.  I've utilized SLIT in my practice since Feb, 1981.  And despite "competition" from local allergists using SCIT, I've more than managed to survive.  This "real world" experiment answers the question "can an allergist convert from SCIT to SLIT and still be successful?"  It's been done.  At least once!  

Later, Dude

In my last entry, I've written about the extensive history of SLIT--going back over one century...many, many years prior to the European literature,which largely began in the 1980s...Invariably, in any discussion about SLIT the one key question that arises is...

Why has recognition of this technique as a safe and efficacious treatment for allergic disease taken so long?  

To my knowledge, there has never been a medical article that addresses that question...and it seems to be a perfect blog topic...so here goes...

Lack of American acceptance of SLIT as a viable treatment modality is probably because of several factors:

1.  The "turf wars" between ENT's and Allergists:  Face it.  The majority of early proponents of SLIT were not allergists.  They were ENT  physicians (Hansel, Pfeiffer), or non-ENT non-allergists (Dickey--a urologist by training).  Medical history has a tendency to repeat itself...when Edward Jenner discovered vaccination for smallpox, his discovery was unrewarded by the medical establishment, largely because of bias against him--he was a rural general physician and his 1798 paper was rejected and never published by the medical establishment.  Similarly, why would a board-certified allergist look kindly on a technique condoned--and discovered--as effective by his non-board certified colleagues??

2.  The profound implications of SLIT--it's potential to revolutionize the office practice of allergic disease:  Let's face it.  As allergists, we can rapidly incorporate a new medication into our practice with minimal problems...but incorporation of SLIT into an office practice would take far more work, and (according to conventional wisdom), considerable financial  risk.  Technicians would have to be trained, and a doctor would have to be educated and confident of his success in using it...in the face of non-insurance coverage.  The American allergist, before he/she dives into a SLIT-based practice, simply wants iron-clad, irrefutable, American-based evidence that SLIT is safe and effective.  Anything less is simply unacceptable...Money can be made with SCIT, and with SLIT...well, insurance coverage just isn't there...yet...so "let's wait and see", right?

3.The "tomato effect".  Allergists were trained during fellowship to believe that SLIT didn't work, because...everyone knew it didn't work. This is an example of "The Tomato Effect", written about by Goodwin, JS & Goodwin JM, JAMA 251:  2387-2390, 1984.  Briefly put, the tomato effect is defined whereby a potentially efficacious medical therapy is discounted because "it doesn't make sense".  The conventional wisdom--common knowledge--is that "it just doesn't work".  In 1560, the tomato was becoming a staple of the European diet, having been brought back from Peru.  As the Goodwins put it, 

“Of interest is that while this exotic fruit from South America was revolutionizing European eating habits, at the same time it was ignored/actively shunned in America.  

"The reason tomatoes were not accepted until relatively recently in North America is simple:  they were poisonous.  Everyone knew they were poisonous, at least everyone in North America. “Not until 1820, when Robert Gibbon Johnson ate a tomato on the steps of the courthouse in Salem, New Jersey, and survived, did the people of America begin, grudgingly, we suspect, to consume tomatoes..."

4.  If SLIT is accepted, we have a technique safe enough that potentially even non-allergists will do it and create increased competition for the allergist.  This gets into my "hidden agenda" blog post from earlier.  To the trained allergist using SCIT, there is only one solution to the dilemma of having a form of immunotherapy that is simply "too safe"...and that is to "spin" SLIT to make it as dangerous as possible...this benefits the allergist--since it keeps the treatment "in his camp".  No one but the board-certified allergist would dare to do it (pretty much like injection immunotherapy presently).  Presentations and studies by American allergists will therefore be overly cautious and negative in their portrayal of the benefits of SLIT...

In short, the American allergist (unlike their European counterpart), comes with psychological "baggage" of years past regarding inherent bias against SLIT (a technique largely proposed by non-allergists), and a fear about maintaining financial security when adopting this technique and giving up SCIT.  Instead of objectively looking at European studies and aggressively pursuing SLIT, we employ a strong "denial of reality"--a defensive, fearful posture--we think "if we just don't think about SLIT, it'll go away"...And we employ tired, worn arguments (i.e., "it's not FDA approved, we don't have American studies...") that don't even make rational sense (after all those of us who use SLIT use FDA approved extracts in an off-label useage--something perfectly legal).  

It's hard to be creative and innovative when you're fearful, and that's just the place where the American Allergist is...now, more than any other time in our history, the American Allergist needs to be resourceful, creative, and innovative.  Not fearful.  Our attitude with SLIT is but one example of something that needs to be changed...and soon.  

Later, Dude