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"Allergic Fingerprints"

Janice couldn't be happier at the restaurant.  Everything was as it should be--the atmosphere was nice and the food was perfect. Because of food allergies, she tried to keep her diet simple when eating out--generally nothing exotic, just a fine steak and a baked potato.  She had eaten at this restaurant before and usually had the same meal--and it worked.  Good food.  No allergy reaction.  A great combination.  But this time it was different:

The entire inside of her mouth started to itch.  Badly.  

Janice had a long list of food sensitivities--wheat gave her malaise and aching, and milk gave her nasal and sinus congestion.  But only one product caused her mouth itch:

Carrageenan.  

Carageenans belong to a group of polysaccharides extracted from red seaweed.  Commercially they are used as an emulsifier and  thickener in the food industry.  And it can cause allergic reactions.  It's even been responsible for anaphylaxis in barium enema solutions.   

WIth some prior detective work, we had discovered the source of Janice's chronic mouth itching, and after Janice changed her toothpaste, and avoided items with carrageenan, she was fine

Until now.  

She looked down at her meal.  The same meal she had eaten at the restaurant a week before.  On top of the potato was sour cream--on a hunch, she asked the waiter,

"Did you change your brand of sour cream, and does it have an additive in it called carrageenan?" she asked.  After a dumbfounded look, the waiter agreed to check.  And he came back to her table with the answer:

Yes, and...yes.

Janice had known she had a unique reaction to carrageenan--what I call an "allergic fingerprint."  Her symptoms were so characteristic of contact with this item, that even in the absence of observing the she was eating something with it, she knew she had.  Just like a detective who can dust for fingerprints and determine that so-and-so was at the scene of the crime, even tho the detective had never seen the criminal there himself.  

As I've worked with patients over the years, I've been intrigued with the phenomenon of "allergic targeting"--i.e., a person can be blood-test  positive to 3 foods, but the symptoms each food elicit may be completely different--i.e., like Janice's case with wheat, egg, and carrageenan each affecting different target organs.   "Allergic fingerprinting" can often be the result of these discoveries, and this, in turn,  can help the patient be their own detective.  

In another situation I recall a husband telling me he would buy his allergic wife the same organic flatbread that had calcium proprionate and NO sodium metabisulfite in it, since she was quite sensitive to sulfites.  One day he bought the usual "safe" flatbread at the store.  His wife prepared the meal with it, and as she ate it she started to cough and itch. 

"What brand did you buy" she asked.

"The same as usual" he said. "The one without sulfite--they use calcium proprionate in it instead."

"Well, I don't care if it is the same brand, it has sulfite in it," she exclaimed.

So the husband rummaged through the garbage, found the wrapper, and upon reading it he discovered they had changed from calcium proprionate to sulfite as the preservative!  

There is an important corollary for this story--all allergic patients must re-read the label of every item they pick up at the store.  Just because you are buying the same named product doesn't mean the ingredients haven't changed.  The wife's certainty she had discovered an "allergic fingerprint" led to the realization by the husband that (surprise!) labels (and ingredients) can change. And these ideas even carry over to medications and vitamins that a person takes.  Consequently, an attitude of vigilance is needed for every allergy patient.

"Allergic fingerprints".  Something to think about.  And an invaluable tool for the Allergy Detective.  

Later, Dude

 

 

 

 

Posted on Sunday, January 8, 2012 at 04:03PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

Christmas Cards

We make a living by what we get, but we make a life by what we give...

Winston Churchill

As I entered the exam room, Michelle looked up and smiled.  The despondent look of so many visits ago was gone.  In her hand was a card. Her eyes were bright and sparkled.   Before I could say anything, she handed it to me.

"Here, I want you to have this", she said.  

And she handed me a Christmas card.  

Michelle had started to see me a year and a half earlier, struggling with eosinophilic esophagitis, asthma, and hives.  Prior to seeing me, she had seen another allergist and had been unsuccessfully placed on an elimination diet without help in her symptoms.  In reality, she had a complex mixture of food AND inhalant sensitivities, and it was in June of 2008, at the height of the grass pollen season that she felt like she was chewing and swallowing glass, and the diagnosis of Eosinophilic Esophagitis was made.  We had placed her on sublingual immunotherapy (SLIT) for multiple severe inhalant and food sensitivities, modified her diet, and she was went into symptomatic remission.

And so she gave me a Christmas Card.   

The Christmas season is a wonderful time of the year in many ways, but as an allergist it is a very special time...

Because of Christmas gifts I receive from my patients.  I still don't believe it, but not only cards, but ornaments, plaques, and even Christmas stockings have graced my walls during the Holiday Season.  I am blessed.  

For those of you analytically inclined, please note that there is no medical literature or study on Christmas Cards.  A search of the PubMed data base shows only 4 articles on search, and none of these studies the phenomenon whereby doctors receive Christmas Cards.  What type of patient sends these cards? How often are they sent?  What message do they convey?   My impressions are anecdotal, but perhaps worth noting, since I have been their grateful recipient for  many years, and I can't find the least bit of discussion on the topic:  

As I study the cards I've received I've observed that most of them fall into two broad categories.  The first group are the patients that have received treatment and have felt remarkably better.  The name(s) at the bottom of the card are usually instantly recognizable to me--extremely challenging cases that have recovered sufficiently to have a quality of life they never had, or perhaps had in the distant past but never felt they could regain.  I'm not talking about people with variable asthma, or a few sinus infections--these are people who've had deep allergic disease--usually delayed onset food and inhalant allergies missed or ignored by other doctors.  The names on the cards conjure up a picture of people who were once terrified and felt helpless with their fatigue, fibromyalgia, irritable bowel syndrome, chronic severe sinusitis, etc. Their disease is better, a semblance of life has returned, and they want to share their joy with me, symbolically, 

With a Christmas Card.

But there is another group of people I have received cards from.  Once again, I usually immediately recognize the names.  But this group is particularly intriging  to me Because  in this group are people I don't feel I've helped enough. Or at all.   I haven't made their disease go away, or "cured" them in any sense of the word. In the strictest sense, I've totally failed them

So why in the world are they sending me a Christmas Card?  

Let's start with the obvious, and then hypothesize:  The suffering person wants his/her suffering to be alleviated.  Completely.  However, if the suffering can't be completely eliminated, but it can be transformed or refined by a companion in suffering they can absolutely trust,  then progress towards health can still be made.  The person may (with hard work) be able to transform themself from being "a disease", to a place where they feel they are a  "healthy person" with a bad illness. There is an enormous gulf between these two viewpoints, but with hard work and patience, a person can often achieve this state.    And if the allergist can partner with his/her patient, and be a companion on their journey, the patient can be extremely grateful.  They recognize they can talk to the doctor without fear of a "lecture", truly reveal their deepest worries and most intimate concerns, in an atmosphere of nonjudgement and true advocacy.  But please don't get me wrong.  I am no Mother Theresa.  I am just an allergist who is challenged and frustrated as any other doctor to care for somebody they don't see that they have helped. I sometimes get frustrated that I haven't helped someone more than I have.   But the rewards to companioning with a seriously ill patient seems sometimes to mean more to the patient than anything I can imagine.  So I try to do my best, even if I sometimes think I come up short.  

So, what was Michelle saying to me with her Christmas Card?  I think she was saying "Thanks for helping me live life to its fullest".  But, other cards I get from other patients in the second category seem to be saying "Thanks for Being There for me".  And I realize both messages are from the heart; I just hope my patients realize what these messages mean to me, and although I can often fail on both accounts, I (like my patients) keep on trying.  And that is the true spirit of Christmas.   

Later, Dude

Posted on Sunday, December 18, 2011 at 05:32PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

The Uninvited Dinner Guest

The restaurant was perfect:  fine food, a delightful atmosphere, and the company of my wife and daughters celebrating a "back-to-school" final meal.  Lizzy & Kristi were soon leaving for college, and my wife and I wanted to give them a "going away" present of one memorable meal before they settled into the pitiful menu of dorm-food.  We were in a relaxed mood, talking and sipping a few drinks before dinner was served.  But I suddenly noticed a shadow had been cast over me and sensed someone standing behind me..My wife and daughters abruptly looked up, and focused on something over my shoulders.  I then heard a strange voice say

"Excuse me," she said, "are you Dr. Kroker?

"Yes, I am", I said.

"I want to thank you for saving my daughter's life", she said simply.  

For a moment, I said nothing.  As a physician, I have had the privilege and honor of having those words spoken to me in a variety of fashions over my 33 years of practice. And no matter how many times they are spoken--once or a thousand--they never ever become ordinary.  And my response to those words has never, in my opinion, been something I have been able to adequately handle.   It is absolutely impossible to convey the enormous surge of emotions they stir up in me when I hear them.  For these emotionally-charged words every physican--young and old--always dreams of hearing.  Hopes to hear. Wishes to hear.  And the hope to hear these words, or something like them, gets many of us through all of the tiresome days of filing out "prior authorizations", insurance forms, and fighting medicare bureaucracy.  Mostly, over the years I don't remember the exact words as much as the faces, and the eyes that spoke them.  The words, faces, and eyes are seared--burned--into my memory forever, with each encounter.  So when I heard those words, an enormous swell of joy, gratitude, coupled with some embarrassment and (yes) guilt (did I really deserve this accolade?) began to swirl in me.  Who was this person?  Who was their daughter?  As the woman spoke, it suddenly came back to me....

...Janice was a young woman from a large Midwestern City, several hours away from La Crosse.  She presented with a "mystery illness" of headaches, dizziness, fatigue, and aching.  Her illness had been going on for many months, and she had seen the finest doctors in the largest tertiary care centers in the area, and had a first-class internal medicine and neurological workup.  

Except for one thing.  

Although she had multiple illnesses ruled out, she still hadn't seen an allergist.  Fate intervened.   At a party her mother was confidentially discussing her case with one of her own friends.  Her friend suggested her daughter come to see me to find out "if she had any allergy".  And (true enough) although Janice seemed to have seen nearly every physician, she hadn't seen an allergist.  On the surface, it is logical her physicians hadn't entertained "allergy" in their differential diagnosis because she didn't have the usual "sneeze and wheeze" presentation that every physician recognizes as allergy.  But headaches, dizziness, fatigue, aching?  That's another story.  Surely, it can't be "allergy", right?  

Or could it?  

When I saw Janice, it was interesting to note that many of her symptoms had begun shortly after moving into an older apartment 2 years earlier.  The apartment had overt signs of mold, and everything from the refrigerator to the carpet seemed to bear signs of it.  

What was even more interesting was her skin test response.  When we had tested her, she had absolutely no reaction to any antigen at 10 minutes, even though her histamine control was appropriately positive.  However, since Janice was staying in town with her mother overnight, I suggested she come back the next day to our office and have a re-examination of her skin test sites.  So as I raised her sleeve up and examined her arm testing the next day, 

The diagnosis was made.

She had an enormous delayed reaction to several molds, including aspergillus sp. and penicillium.  Each site had swollen several centimeters in diameter, and was red and angry in appearance.  I explained delayed-onset mold allergy to Janice, and insisted she immediately leave her apartment.  Again, fate intervened.  Her lease was nearly up.  She promptly left the apartment on my strong encouragement, and began SLIT.  

And her recovery began.  

Thoughts from the story?  Several, in my opinion.  Here are a few:

1.  Thought 1:  I didn't save Janice's life--but I saved her quality of life--and for some patient's (and parents), they are nearly indistinguishable.  For a life with headaches, dizziness, aching, and fatigue is really no life at all.

2.  Thought 2:  The lack of appreciating late-onset mold reactions is one of the great tragedies in modern medicine (not just allergy).  Recently I was attending a lecture by a well-respected allergist from another large midwestern city, and we were discussing late-phase skin test reactions.  His response?  "You know, I was trained that we really don't know what late-phase skin test reactions really mean".  Well, I'll tell you what they generally mean--serious illness.  To paraphrase the late Prof. Keith Eaton, Strong late-phase skin tests to molds are not without biological significance.

3.  Thought 3:  SLIT works like dynamite for late-onset mold reactions:  When I saw Janice back in followup recently, her strong delayed reactions were dramatically reduced.  This was probably a combination of reduced total load (from changing residences) as well as SLIT, but I have seen identical responses with just the use of SLIT alone.  Young allergists frequently want to know where to first incorporate SLIT into their practices.  The answer?  For troublesome late-onset mold allergy.    

4.  Thought 4: As a specialty we must evolve.   The allergist must be more than a "wheeze and sneeze" doctor.  Atopic disease is yesterday's story. Patients need--and demand--help with delayed-onset inhalant and food allergy.  Now.   If we are to adapt to the times, we must broaden our horizons.  I was pleased with Dr. Stanley Fineman's "President's Message" to ACAAI members, part of which I share below:

"In my Bella Schick lecture presented in Miami, I encouraged allergists to expand what we do in our practices.  Besides seeing a variety of patients with allergic sensitivities and continuing to manage asthma and allergic rhinitis, we also must make clear that the scope of practice includes helping patients with food allergies, skin diseases, chronic rhinosinusitis and immune deficiency problems."  

Darwin's theory of natural selection is relevant for us allergists:  Adapt and evolve with changes in the environment...

As allergists we must broaden our horizon.   Quickly.  Changes at a "glacial pace" are not fast enough for people like Janice, who are sick today.   And the payoff for the allergy profession? Simple.  A single phrase:

"Thank you for saving my daughter's life".

Later, Dude

 

 

 

Posted on Friday, November 25, 2011 at 03:47PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

When Worlds Collide

"I just don't understand it", Tim said.  "And I'm absolutely miserable."  

Tim was a staff physician at our hospital, and was coming in with a new problem.  He had a strong dust allergy which I had treated successfully with SLIT, and I had not seen him in several years.

Until now.

"I've been having these painful sores in my mouth for months", he said.  "And no one can find the cause.  I've checked in with an oral surgeon, and he assures me I don't have some terrible disease.  But no one can find the cause."  

"Was anything--anything at all--going on at the time you developed these sores?" I said.

"Well, yes", Tim said.  "But it really doesn't have anything to do with allergy.  I was diagnosed as having a high cholesterol."

"And what did you do for that?"  I said.  

"Well for one thing, I changed my diet."  I stopped having eggs every morning for breakfast" he said.  

"Well, what did you eat instead for breakfast?" I queried.

"Grapefruit.  Lots of them.  I figured they are healthy for me.  And you know what?  My cholesterol is coming down!" he said.  Tim smiled for the first time during our meeting.  

Tim's problem immediately became obvious to me.  He was having allergic stomatitis from citrus fruits, something I have seen before. This isn't something new, and others have reported on it:  Ettelson and Tuft, writing in the J Allergy 536-43, 1956 reported on "Canker sores from allergy to weak organic acids (citric and acetic).  Also, Kutscher, AH et al reported in the J Allergy 438-41, 1958 on "Citric Acid Sensitivity in Recurrent Ulcerative (aphthous) stomatitis.  

But is "the moral of the story" that excessive dietary intake of citric acid can trigger allergic aphthous stomatitis?  

Hardly.

You see, time and again, I see situations where the worlds of allergy and medicine collide.  Often with disastrous results.  The world of medicine often "prescribes" dietary intervention with the intent of utilizing something repeatedly to aid a condition.  But dietary repetition is something that isn't necessarily good for the allergy patient.  One of my allergy aphorisms is that "Repetition  may be the best thing for an aspiring musician, but it is the worst thing for an allergy patient aspiring to get well.

Worlds collide.

I have seen this problem played out in various scenarios over the last 30 years.  Consider these few examples taken from my practice:

--The pregnant mildly dairy-allergic pregnant woman who is "encouraged" by her obstetrician to drink plenty of milk during her pregnancy.  Even though she really doesn't feel well ingesting it.

--The heart patient who is egg allergic who starts a "healthier" diet and consumes poultry (instead of red meat) with every evening meal.  With disastrous results.  

--The patient with irritable bowel disease who is told to eat several cups of yogurt daily, and begins to have sinus congestion and more irritable bowel disease.  

--The allergy patient with hypoglycemia who is encouraged to frequently eat nuts between meals to stabilize her blood sugar, who then develops headaches and urticaria within six months.

Dietary diversification--not repetition--is essential for the allergic patient.  When a diet becomes "lop-sided"--even for the best of medical reasons--problems can ensue.

And Tim?  He came back to my office a few weeks later with a smile on his face.  His mouth sores were gone.  "I've learned my lesson", he said.  "The old saying--'practice makes perfect'--may be true, but it also makes allergies"

Well said.

Later, Dude

 

Posted on Sunday, October 16, 2011 at 06:34PM by Registered CommenterGeorge F Kroker MD FACAAI | CommentsPost a Comment

Disjointed Allergists

It's funny how things can happen in a busy allergy clinic...sometimes you see a confluence of patients that drives a particular clinical point home...Such was the case last week.

Cindy came into my office, delighted that the severe facial eczema she had struggled with for 6 years had gone into remission.  We had found the triggers--dairy and mold--that had precipitated her problem, and treating her had resulted in dramatic improvement.  

"I want to introduce you to a new patient today", she said.  "My sister".  Cindy's sister Joan was the only member of their family who didn't have "traditional" allergy symptoms.  Having 6 siblings, Cindy had related that 4 of them had hayfever, rashes, and "allergies" like she did.  

But Joan was different.  

Joan had arthralgia. No other "traditional" allergy symptoms... And, taking a cue from her sister Cindy, she decided to remove dairy from her diet, and her arthralgias were markedly better.  Simply put, Joan wanted validation that food sensitivity could be related to her joint pain.  

Switch scenes:  That same day, a younger partner of mine, another allergist in the clinic, came in to my office later in the day to consult with me on a curious case he had seen of a lady with springtime hayfever...

...and migratory arthralgias.

As I had blogged about earlier, Warren T. Vaughn had written about palindromic rheumatism related to allergic disease.   Furthermore, D.N. Golding, writing in the Journal of the Royal Society of Medicine, wrote an interesting article entitled "Is there an allergic synovitis?"  In this article he presents 9 patients with episodic allergic rheumatism, related to a variety of precipitating factors--dairy, streptococcal infections, Hayfever, etc.  His conclusion?

It seems that allergy is an occasional cause of episodic rheumatic pain or synovitis in certain atopic patients, whether or not they have an underlying arthritis.  

 In fact, idiopathic eosinophilic synovitis with Charcot-Leyden crystals in joint fluid has been reported by Antes, et. al in the Scan J Rheumatology in 1996 in their article "Idiopathic Eosinophilic Synovitis.  Case Report and Review of the Literature.  

Rheumatic complaints from food sensitivity is not new stuff.  H. Berger, wrote about "Intermittent hydroarthrosis with an allergic basis" in JAMA 112:2402, 1931.  There are others.  

So where does this information put us in 2011? Simply put, allergically-induced rheumatic complaints are an "orphan illness" that no single specialty  is willing to adopt.  Today's allergist has made an a priori decision to limit his/her specialty largely to the respiratory tract, and skin.  Today's rheumatologist is so caught up in autoimmune phenomenon that exogenous triggers are simply overlooked.

And this is a tragedy.  We "dis" joints.  In a word, we're disjointed.  

Allergy should be (and really is) the true Queen of Specialties.  It cuts across multiple organ systems, including the synovial membrane.  To "be all that we can be", to be a Renaissance Allergist, we need to take rheumatic histories on all of our allergy patients.  We might be surprised at what we learn.  

Later, Dude 

 

 

Posted on Tuesday, August 9, 2011 at 02:37PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments1 Comment