As allergists, we must not only be expert in our requisite field of technical immunological knowledge, but also in applying it in the context of the patient whom we carefully observe and listen to.   It is the fusion of expert technical knowledge and expert practical observational and listeniing skills that makes us expert allergy clinicians.  It's been my experience that certain signs seen in day-to-day allergy practice haven't been given enough emphasis, or reported in the literature.  It was in this spirit that (In my last post), I had discussed what I had termed "Eaton's Sign"--the curious phenomenon of "recall" activity at prior skin test sites  when an allergy patient subsequently is re-exposed to his/her allergen.  But wait!  There's more!  In a sense, Eaton's sign is part of a bigger picture--the allergic "target organ" phenomenon.  Here's the story:

When an allergy patient is exposed to an allergen (either by inhaling it or ingesting it), he/she may be principally/preferentially affected at a sight of prior trauma.  The site of prior trauma may be accidental (an injury or infection) or deliberate (a prior surgery).   Here are some examples:

  Case 1:  A patient comes to see me.  He was aware that previously he would ingest milk and have problems with immediate sinus congestion and posterior nasal drainage.  Then he had a car accident and suffered serious whiplash.  Now when he ingests milk, he develops not only sinus congestion and drainage, but his neck aches terribly...

Case 2:  A patient comes to see me with episodic urticaria and pruritis.  When she ingests the wrong food or breathes an allergen, the first site that reacts is a small area on her abdomen....on exam, this is the exact site of a surgical scar where she had a laparoscopy years earlier.

Case 3:  A patient comes to see me.  He states that he is seeing me for knee pain.  He has been scoped three times previously, and only old, degenerative knee disease is seen.  Nothing new.  His orthopedist is mystified that the patient has more kinee pain in the fall season, precisely when he has more sinus and mucous drainage.

Case 4: A patient comes to see me, with a history of a prior scabies episode adequately treated.  But she continues to suffer from periodic episodes of intense pruritis at former sites of infection.  When her corn allergy is diagnosed and treated, the residual pruritis resolves.   

As might be expected, the permutations on this principle are endless.  Among others, sites of prior herpes zoster are particularly vulnerable to subsequent allergic reactions. In short, sites of prior trauma--whether accidental, surgical, or infectious--are all fertile areas for subsequent allergic reactions.  Presumably, cytokine release during allergy reactions preferentially "targets" these vulnerable areas that have preexisting prior trauma, damage, and residual inflammation.  

In short, as good allergy clinicians, we must keep our "eye on the target" at all times.  

Later, Dude

 Clinical medicine--including the specialty of allergy-- is about sight, touch, smell, and hearing--not just about the latest medical article we've read in the Annals of Allergy or JACI.  One thing we've tended to underemphasize  in our profession is late-phase skin test reactions--something we can see and touch hours after the test has been applied--if we just look for them.  But there is another  item that I've never seen described or documented in the lilterature--and that is the curious phenomenon of intradermal skin test "recall" days or even months after intradermal skin testing was done.  Under certain occasions, it seems as if the site where a skin test was formerly applied  retains a "memory" for furher reaction  when a similar antigen is encountered in our environment many days later. 

What do I mean?  For example, I've seen patients receive intradermal skin tests for molds, and end up with strong delayed rections to them.  Upon getting a subsequent  airborne mold exposure many days later, (for example, mowing the lawn), the patient may note pruritis and swelling at the site of his former tests.  If you ask patients about this phenomenon, they will frequently volunteer that it does indeed occur.  Interestingly, I had a chance to examine this phenomenon first-hand in my office one day, in  a patient who I had previously tested for mold allergy.  She had had strong delayed reactions to mold when I initially tested her. .  When she saw me, she had just had a major symptomatic mold exposure the day before.  On her arm, there were faint areas of erythematous swelling and puriritis where I had previously tested her to mold on an earlier occasion.   

I'd like to call this phenomenon "Eaton's Sign", named in memory of the late Dr. Keith Eaton, M.D. 

I remember meeting Dr. Eaton in Manchester, England, when he excitedly came up to me and asked if I thought that heavy mold exposure could trigger depression in susceptible individuals.  He was one of the earliest members of the BSACI (British Society for Allergy and Clinical Immunology), and a student of Professor Jack Pepys. He was a prolific writer, publishing some 80 papers, and specifically wrote about the delayed reaction to molds on intradermal testing,  and described it thoroughly in his publications.  He felt the delayed mold reaction, although obscure in cause, was "not without biological significance".  In retrospect, his interest in mold was probably stimulated by his wife Susan's serious illness from mold, and a serious case of "dry rot" in his house!  He was a consumate clinician and researcher, who tragically passed away with pancreatic cancer.  Dr. David J Freed has this to say about him in his memorium:  

I love aphorisms...and those of you with keen clinical eyesight will now see that I have a list of personal allergy aphorisms listed in the rightside menu bar of my Blog....Aphorisms give us memorable insights into the minds of others, and ideas to mull over....and it was in that spirit that I provide them...Maybe my love for aphorisms is because I was academically raised on them...while I was at the University of Iowa one of my attending physicians was the late Dr. William Bean. 

 Dr. Bean interned on the Osler service at Johns Hopkins, and he was named Sir William Osler Professor of Medicine at the University of Iowa.  One of my most treasured medical posessions is a signed textbook I received from him, entitled "Sir William Osler:  Aphorisms from his bedside teachings and writings".  These aphorisms were collected by Dr. Bean's father (Robert Bennett Bean), who was a medical student under Osler, and my attending physician William Bean edited and published them. After 30 years, I still have the textbook.  Through Dr. Bean, I felt I had a direct connection to the life of Osler--Dr. Bean stated "my memory does not go back to the time when Osler was not a household word...almost even a household god..." Dr. Bean remembered how personally devastated his family was at Osler's son's death.  And the book of Osler's aphorisms I got from Dr. Bean?  You can only imagine how they influenced my own thinking as an embryonic physician entering the grand specialty of medicine....

  ...But what about allergy?  Do we have our "own" aphorisms, written and recorded by the giants of allergy?  In truth, hardly any.  Why?  Perhaps it's because allergy is seen nowindays as a technical/immunological field...after all, how many aphorisms can you write about dust mite exposure modifying the effect of functional Il10 polymorphisms on allergy and asthma exacerbations?  In this time and age, the patient may be seen more as a complex roadmap of cytokine interactions rather than a living, breathing organism. ...I am again reminded of one of Osler's aphorisms:  

               "The greatest art is the concealment of art, and I may say that we of the medical profession excel in this respect..."

There was, however, one article on the subject I found:  "Aphorisms and Facetiae of Bela Schick, written by I.J. Wolf M.D. and published in Clinical Pediatrics, pp 495-497, 1968, subsequently made into a book.  .   Some great aphorisms abound:

               "It is too bad we cannot cut the patient in Half to compare two regimens of therapy..."

              "You can always make a theory.  In making theories, always keep a window open so that you can   throw one out if   necessary.  Twenty theories can be made in five minutes"

              "There was no diagnosis--that's what makes the case interesting"  (in responding to someone who remarked that                   a case was interesting)

               "The human body is like a bakery with a thousand windows...We are looking into only one window of the bakery  when we are investigating only one particular aspect of a disease..."

Now think about this one:  Allergy as a profession is nearly 100 years old.  We have only one article and one textbook of aphorisms about only one allergist.   Aphorisms breathe "art" into the "science" of clinical medicine.  They help us to remember what's really important in our life as clinicians.  They are an endangered species.  We must preserve them.  

Later, Dude

Maybe it's just because some of my relatives have recently had "less than optimal" interactions with their health practitioners, or maybe it's because of some recent patients I've seen who have also had "less than optimal" interactions with their former allergists, but I've gotten to thinking...about compassion...Now, I realize that thinking is a very dangerous activity for the Angry Allergist.  But what the hey...I live on the edge.  

Now, I realize some of you are 5 sentences ahead of me already..."man, now he's accusing allergists of not being compassionate to patients--this time the Shock Jock of Allergy has gone too far."  Well, before you degranulate all your mast cells...hear me out...but I warn you, the Shock Jock will nevertheless send a few volts your way...

You see, after 26 years, I've had alot of contact with patients.  And also alot of contact with allergists.  And in general we are compassionate to our patients...with one teensie eensie caveat--

You see, we  allergists are compassionate to patients---on our own terms. 

Conditional compassion.  

Compassion on our terms.   For the diseases we like to treat.

And we've got a bad case.  And this, in my opinion is the real crisis in allergy, not the crisis I spoke about in my earlier blog entry "why we don't need more allergists".   

What is conditional compassion?  It simply means when we see patients who "fit into the box" of our easily treatable diseases--asthma, rhinitis, we like them and have compassion for their plight.  We feel comfortable being around them, teaching them inhaler use, monitoring peak flows, etc.  And it seems more and more allergists are making little asthma clinics and becoming little "asthma doctors", catering mainly to the asthmatic patient, to the exclusion of other patients. Certainly our major allergy societies are codependents in this regard, with their incessant litany of "asthma-this and asthma-that".  So we want asthma patients.  Nothing else, if you please.  But what about the patient who walks in our office with a question on food intolerance? A history of delayed reactions to skin tests or injection immunotherapy?  A history of hyperactivity that seems definitely food related?  Chronic fatigue?   Headaches from foods?  Be honest.  How many of us want to really be compassionate and listen to a patient presenting with multiple complex food and chemical sensitivities?  How truly compassionate are we?  Judging from what I've noticed:

not very.  

Point-in-fact:  , we can't wait to get this type of  patient out of our office.  We find these patients distasteful.  A few perfunctory skin pricks,  a quick pat on the back telling them that they're "not allergic" and whoof!--out the door.  We just don't care. Don't believe me?  Then you're not living in the real world I live in.  I see it all the time as a consulting allergist. Compassion.  Conditional compassion. 

It wasn't always like this.  In the Golden Age of Allergy, allergists were interested in symptoms on all mucosal surfaces and involving multiple body organs--not just the lungs. Allergists really listened to their patients....And when Dr. Francis W. Peabody, on October 25, 1925, ended his lecture to Harvard Medical Students on "The Care of the Patient" he closed with the now classic dictum "the secret of the care of the patient is caring for the patient".  I don't recall he said anything about "caring for the patient with asthma exclusively".  Don't recall that at all.  (But then, again, I wasn't at that lecture in 1925 either...)      

But with conditional compassion the real tragedy is ours.  Not the patients.   Because when we don't care about the patient (except on our terms) , we don't really seek to find out what's really wrong with them if our perfunctory prick tests are negative.  But with compassion comes a sense of urgency--curiosity--in finding out what's really wrong with our patient.  And to seek--and find--what's really wrong with them--allergy or no allergy--, adds to our knowledge.  And with accumulated knowledge and experience comes wisdom. 

So the Spiritual Trinity of the Superior Allergist is compassion--knowledge--wisdom.  But the greatest of these is compassion...and we need more...unconditionally

Later, Dude  

Want a scary thought? How about this one: How do Allergists think?...now THAT's a scary thought...be scared...be very scared....Actually, this question came to me while I was reading Jerome Groopman's excellent new book, How Doctor's Think. Basically, Dr. Groopman tackles a taboo subject--misdiagnosis--by discussing how clinical errors are made by even the most experienced and clinically astute physicians. In truth, multiple studies confirm that very few clinical errors in diagnosis are made because of lack of proper data.  They are made by misjudgement.  And I can relate--although I've made a few brilliant diagnoses, I can also look back on prior cases where I misinterpreted clinical findings and came up with the wrong answer. The very idea of a misdiagnosis is hateful to me, but we all have to face the fact that no clinician, no matter how good he/she is, can bat 100% all of the time. And of course, I am always better at "seeing the speck in my brother's eye than the log in my own." And with that humble and sheepish admission, I have the following ruminations:

As a consulting allergist who sees patients for a second or third opinion, I often see situations where patients have already seen one, two, or even three allergists without satisfactory results. Some of these patients, of course, never had an allergy condition to begin with. However, more often than not, in my experience there was an underlying allergy-related condition that was missed. What gives? To a large extent, I believe as physicians, we "do what we're told" by Conventional Wisdom--i.e., our medical organizations, societies, and peers. And so it happens:

1. We do what we're told--and we're told that we should emphasize asthma control--with symptomatic medication adjustment. Finding the causes of the asthmatic problem seems to be a secondary issue for us...If anything, we do a perfunctory group of prick tests and they're negative, and we stop looking for triggers.

2. We do what we're told--we're told that food allergy is IgE mediated and if it isn't IgE mediated, it isn't a food allergy, and therefore we stop looking...non-IgE mediated food sensitivity triggers be damned.

3. We do what we're told--we limit immunotherapy to the elite 15% of patients, and we're told that SLIT is still experimental. So we cautiously use SCIT on a few patients, and treat the other 80% with medications. And we give "lip service" to investigating a new form of immunotherapy...and immunotherapy, after all, is the ONLY disease modifying agent we have...but we don't really care about that do we? 

4.  We do what we're told--we're told that IgE mediated food allergies can't "be treated", so we practice avoidance with our patients, hand them an epi-pen, and hope the child or adult doesn't die from an accidental exposure to the food in the meantime.   

5.  We do what we're told--our major allergy societies both have inserted the word "asthma" into their titles--as if this is the only thing we should treat. Proverbially, we've peed on the tree and declared that this is OUR territory...and by implication we really aren't THAT interested in seeing ANYTHING else in allergy--just wheeze and sneeze, if you please (pardon the rhyme). No urticaria, food intolerances puhleeeeeease. "Good morning, Mrs. Smith--how are your lungs today?" "Need a new inhaler?"

6. We do what we're told--because we're not curious enough--and creative enough--with our allergy patients. Period.

Let's get busy THINKING about our patients, being CURIOUS about such things as late phase cutaneous reactions, allergy in parts of our body OTHER than the respiratory tract, delayed-onset food sensitivities...and new ways to treat allergy conditions safely and effectively (could that possibly be SLIT?) in short, let's  not "do what we're told"--sometimes we need to creatively think for ourselves--and our patients--and then our field can progress from its current stagnant  "siege mentality" and really move forward.  Then we'll be proud to answer the question "How do Allergists Think?"

Later Dude