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IBS, Migraine, and skin reactions due to nail reviver, milk, and wheat

Beverley was aged fifty when she was referred because of swelling of her eyelids, especially on the right, which was worse at weekends. She was using two types of finger-nail ‘revivers’, she was right-handed, and she tended to scratch her right eyebrow, explaining why the right eyelid was worse. It seemed probable that the nail-revivers were the cause, but why it was worse at weekends? Reading the labels revealed that the nail-reviver she used at the weekend contained toluene sulphonamide resin, a well-known sensitiser. The skin of the eyelids is very thin, explaining why there was no effect on the thick skin of the fingers, which may be frequently washed.

Since she was sixteen she had suffered about once a month from severe migraine, once requiring hospitalisation because of incessant vomiting,. Her warning of an impending attack was unique, as it consisted of uncontrollable burping!. She also had had irritable bowel syndrome for many years, improved since she had tried avoiding wheat.

Skin tests were definitely positive for milk and slightly positive for wheat. Although skin tests for these foods are not reliable it seemed worth while introducing a diet consisting of only foods which rarely cause problems. This was continued well past the time when she was due to have another migraine, and she had no attacks until she had cheese. Her “IBS” also vanished on the diet, but deliberate challenges with a glass of milk reproduced the wind, bloating, and diarrhoea on several occasions, leaving no doubt that milk was the major cause of her problems.

Flapjacks made using one make of margarine caused a gut upset, but not using another sort. Comparison of labels revealed that the colourings annatto and circumin were in the margarine which upset her, and this has been avoided. She now kept very detailed diaries of foods and symptoms, and established that any trace of any sort of milk could not be tolerated, and also the nitrite preservatives in corned beef.

Thus the causes of all three problems were identified as a result of her meticulous cooperation, as she has had no problems for the last five years except when she has had a trace of milk. One tummy upset was triggered by using a cream cheese substitute, and another by eating two Thorntons milk chocolates at Christmas.

Some time later she noticed patches of eczema under her collarbones and could not understand what was causing them until, when standing in the shower, she realised that she was folding her arms in such a way that the ends of her fingers were over the symmetrical patches of eczema. This cleared after she ceased to apply any hand creams at bedtime!!

Beverley is obviously very easily sensitised and will have to take great care, but her quality of life is much better than for many years as long as she avoids the known causes of her problems. However, if she had not cooperated to the full and been a willing partner in the investigation she would not have been helped.

A case of Multiple Inhalant and Food allergies

Joan had been on continuous oral steroids in quite high dosage for five years, and showed all the usual side-effects. The main cause was her cat, which was always sat on the end of the bed and glared at her GP when he called to see her. After the cat was banished and the house cleaned she was able to reduce the dose of steroids to a low level. She was then found to be allergic to pencillium mould which was coming from the dahlia bulbs in the cellar which had gone very mouldy. She improved even more when they were thrown out.

She was also sensitive to house dust, and was improved after desensitisation injections, but she still had chronic asthma. Attention was then directed to her diet, and she was found to be allergic to milk, all milk products, and plain chocolate. Stopping her bedtime cocoa stopped her attacks of asthma in the early hours. She had also been found to be allergic to wool, and improved with removal of woollen blankets, but it was only after a course of desensitisation to wool that she was finally able to stop her oral steroids altogether.

This case was investigated and treated before Becotide inhaled steroid became available, at a time when desensitising injections offered the only possibility of stopping oral steroids. Today nothing could have been done for her because this treatment is taboo for asthma in the UK.

It is interesting that her skin tests were positive for house dust but negative for mites, suggesting that something in the home environment other than mites, such as wool and cat, was responsible for her continuing problems.

The wool allergy was positively diagnosed by a nasal provocation test, because the skin test for wool is always negative, but this investigation would be unethical today because desensitisation is no longer available.

A Fishy Tale “Bloodworms” cause Swollen Face and Conjunctivitis !!

Grace was thirty-four years old, and had had six episodes when her face became very swollen, mainly round her right eye which was sometimes almost closed for up to a week, and with intense irritation of the eyes. These attacks occurred any time, but always started at home, and because she looked as if she had been beaten up she could not carry out her part-time job as barmaid at a local hotel. Skin tests were negative for a wide range of possibilities, including her son’s pet cat, rabbit, and hamster. Although no cause could be found the possibilities were discussed in general terms, and she was asked to get in touch at any time if she had any ideas regarding a possible cause.

A year later she phoned to ask if feeding tropical frogs and fish, which she had not mentioned previously because they were looked after by her small son, could be the cause, because her last attack began a few hours after she fed the frogs when he was away on a school trip. I asked her to come and bring the fish food, and to my surprise she brought samples of deep frozen, freeze dried, and gamma radiated fish food all labelled as “Bloodworms” Fortunately one sample was accurately labelled as mosquito larvae.

I skin tested her with all three by sticking the test needle into the fish food samples, and then pricking her arm with the same needle. All three produced very large wheals, the biggest nearly 2 inches in diameter, which lasted for two days. Questioning revealed that she only fed the frogs and fish when her son could not do so for some reason. She used her right hand, explaining why the right eye was most affected, and she admitted that she did not always wash her hands after feeding the frogs and fish. Blood tests (RAST) confirmed that she was very allergic to mosquito larvae by finding specific IgE against larvae. She was advised never to touch “bloodworms” again, and I put her samples in my freezer for future use.

She had no further attacks by avoiding the fish food, but she could not really accept the diagnosis until she had carried out a deliberate test (on her own initiative), by touching the fish food and then her eye. She provoked an attack lasting three days! The thick skin of the fingers would prevent a reaction on the hands, but traces of mosquito larvae carried on her hand would easily penetrate the very thin skin round the eye and cause the reaction.

Enquiries at the pet food shop revealed that the young man who sold the fish foods had noticed his hands itched for some time after handling ‘bloodworms’, and he had a very large positive skin test and also a positive blood test.

Three years later a thirty three year old taxi driver was referred from the eye department having had conjunctivitis so severe that he could not see to drive for six weeks. This problem was not responding to treatment, and he also had occasional lip swelling, sneezing attacks, and sometimes a severe attack of asthma. Again all the usual tests were negative, but because he had kept tropical fish for twenty years the first patient’s sample was taken out of the freezer and used for a skin test, producing a very large immediate and delayed skin reactions.

He was asked to bring samples of his fish food, and he brought samples labelled “Fish Flakes” and “Tubifex”. When these were used for tests, only the Tubifex produced a skin reaction. He admitted that he did not wash his hands after feeding the fish, so he stopped using “Tubifex” and has had no further problems.

With the increased popularity of aquaria allergic problems caused by food for fish or frogs may become a more common cause of severe allergies. However, as in the first case, an intelligent and observant patient can pin-point the cause, and avoidance can effect a complete cure.

Another case was reported recently where a fish fancier had been grinding up mosquito larvae (picture at left) to feed his exotic fish. He accidentally inhaled some of the powder, causing immediate swelling of the face and wheezing which soon subsided, but was followed two days later by severe inflammation of the kidneys. Skin tests using the powder he had inhaled caused a very large skin reaction, and IgE antibodies to mosquito larvae were found in the blood. This case illustrates how any part of the body can be affected by allergy. Rarely kidney problems recurring every summer can be caused by grass pollen, the clue being the seasonality of the complaint.

Sexercise asthma?

This dust allergic patient was given a peak flow meter for the first time, and told that he must always blow it if he had an asthma attack, and that it was very important to to make a note of what he was doing at the time.

He took these instructions absolutely literally, with the results shown.

I refrained from asking for further details, so it will never be known if it was the dust from the mattress or the exertion that triggered the attack, or for details regarding the even lower reading the next night.

Allergy to Alcoholic Drinks

 

Beer only	One Gin & Tonic

Alcoholic drinks quite often contain allergens which will affect allergic patients. Obviously yeast is one of the commonest, but there are also additives, preservatives such as sulphites, clearing agents like egg white and isinglass derived from fish and many others.Obviously if the subject is drinking every day he will always be in trouble, so the cause may not be obvious.

A local GP phoned one day to ask if I would see a patient of his “because he was sick and tired of getting up in the wee small hours of Sunday morning to deal with his asthma” Apparently this happened with remarkable regularity in the last six weeks, so there had to be an answer.

As usual the personal history provided the solution, which was that he only drank on Saturday nights, and that the asthma had only occurred since he had changed his club from one that served Home Ales to one that served Worthington E. I never found out whether the difference was in the yeast, or in an additive, but going back to his old club solved the problem.

I have seen only one case where pure alcohol produced an attack of asthma, as shown below. I tried to carry out a provocation test as often as possible, and the results I have obtained are shown here.

Emotional Asthma

When I was a student I was taught that asthma was often emotional, and even after the war that was a common opinion in teaching hospitals in London. For example when patient I knew well was admitted to a famous hospital in the sixties with asthma, arrangements for a consultation with a psychiatrist were routine. In my experience emotion as a significant trigger for asthma has usually been due to complete frustration with their medical advisers but two instances where there was a dominant emotional factor are memorable.

The first was when a boy aged 13 was referred with asthma which got worse through the week, but improved dramatically at weekends. All sorts of treatment, including oral steroids and tranquillisers, had been ineffectual. It transpired that he was very bad at maths, the first lesson every morning, and the teacher made a fool of him. The GP was a school governor, and when the teacher, who should have known better, was removed his asthma vanished immediately.

A young Asian girl had well controlled asthma while at University which became difficult to control after she got her degree and returned home. All summer she had severe attacks requiring treatment at the Emergency department, and was admitted several times for a few days. She was no sooner discharged than she developed another attack, but if she went to her grandmother’s house she was well. The home environment was considered as a significant factor as she was very sensitive to dust mites, and a visit to the home was arranged. The home was very clean indeed, but her father, an impressive Sikh gentleman, appeared on the scene and it became obvious that he was the trigger for her asthma. The background was that she wanted to marry someone who was not considered suitable.

A Complex case of Asthma and Dyslexia due to Milk and Moulds

Bruce was 12 years old, with a family history very suggestive of milk sensitivity in no fewer than five generations and extending as far as cousins. His mother was also a patient and was found to be allergic to milk and the moulds aspergillus and penicillium which were prevalent in her house. Even 1% milk solids in margarine would provoke intense rhinitis for a week. She also improved with desensitisation to moulds and was able to tolerate the house after an old well was found under the kitchen floor and was filled in.

He was at the bottom of the class at school, and had been diagnosed as dyslexic, but with avoidance of milk and desensitisation against aspergillus there was a vast improvement in his general condition and attitude. Before long he was at the top of the class and the reading difficulties had disappeared.

Yeast Allergy and Intolerance

Yeast is ubiquitous, and it is seldom realised that it can be a potent allergen. The following anecdotes may help in recognition, the skin test being always negative.

Eustace was 48, with a positive family history for allergies. His complaint was that for some months if he had a few drinks in the evening he would wake with abdominal pains, followed by a widespread urticarial rash. All sorts of tests had been done, all with negative results, and had dental abscesses removed without benefit. Avoidance of beer and yeast containing foods brought about so much improvement that he did not require any treatment. Pints of beer caused a rash in a few hours, ordinary bread caused slight urticaria, but soda bread had no effect. The answer was there in his story, but nobody had asked the right questions.

Susan was 39, with a family history of allergy on father’s side. She had had perennial asthma for 16 years, better in frost and snow suggesting moulds. Beer, shandy, sherry, and yeast tablets brought on worsening asthma in half an hour. She was also allergic to house dust and penicillin. Avoidance of yeasty foods was very helpful.

Beryl was 49, with family history of asthma. She had had asthma for 16 years, and rhinitis and polyps which recurred several times, over 26 years. She had noted that milk ”clogs me up doc” ( as so many say ) Sherry, whisky, and wine cause sneezing and wheezing but not gin. She had worked in the Marmite factory as a teenager and had been having Bovril for her morning break for years, both made from yeast. A short steroid course followed by Becotide and avoidance of milk and yeasty foods and drinks resulted in regression and finally disappearance of the polyps. Stopped all medication without relapse of the asthma or the polyps. Took 100 mls of milk and peak flow dropped from 420 to 220 just 7 hours after.

Edward was 65, with history of asthma in mother and an uncle who died of asthma. He was well until age 62, when he had sudden asthma after drinking three pints of bitter, and found that if he had a pint of beer each evening he would have severe asthma by the third day. Then found that sherry caused wheezing, and even a little whisky or brandy would cause confusion and dizziness lasting 12 hours, but gin had no effect. Discovered that in France wine had no effect at all. Avoidance brought about complete remission of the asthma, but a test with a little beer caused wheezing. It is curious that yeast in foods did not have any effect. All tests were negative.

Kay was 13, and had had chronic rhinitis and mild asthma since infancy. There were no clues from skin testing, but a nasal provocation test with yeast caused a positive reaction. Further enquiry revealed that father was a very enthusiastic home brewer. After this was closed down and yeast removed from her diet her asthma and rhinitis ceased within a week. An unexpected bonus was that her personality changed to being more extrovert and lively, and her school performance improved beyond recognition. She had been so difficult at school that when aged 7 she had been assessed by a child psychologist as backward. Two years later got good maths and English A levels. Accidental exposure to yeast caused irritability and bad temper as well as wheezing. One such occasion was when exposed to an in-store bakery in a supermarket, and another being near a room at school where baking was being carried out.

Blair was 6 when first seen, with a family history of allergies and eczema. Infant feeding had been very difficult, with projectile vomiting and suspected pyloric stenosis, followed by chronic indigestion, abdominal pains, large floating stools, chronic cough and rhinitis. He was almost impossible to examine, with temper tantrums and stamping his feet. There were no skin test reactions to a wide range of allergens, but on the basis of the history milk was removed from his diet. Within a month the cough, and the rhinitis had disappeared, and his stools and behaviour became normal. To me he seemed to have been transformed from a little horror to a lovely cheerful child who would not stop talking. His mother commented that after he had had some milk in a pudding his behaviour had become as foul as his stools. It was found that trace of milk, a small quantity of bread, or egg would produce severe abdominal pains in half an hour, with misbehaviour and heavy shadows under the eyes which would be red-rimmed. He resented very much having his bread stopped, as he had a positive craving for it. On one occasion he took a piece of stale bread from the bird table in the garden, and one mouthful produced an episode of dreadful behaviour. Seen aged 16 the situation was unchanged, and having spaghetti in defiance would still produce misbehaviour, misery, and shiners. His mother became very reluctant to introduce any foods to find out if his intolerance had subsided, but when seen aged 23 he could eat anything without problems

Inger had escaped from Norway by boat at the beginning of the war, got married, and established a business in Burton on Trent making hats. She noticed that whenever a brewery nearby was brewing a new batch of beer and the smell of yeast was strong she began to wheeze, but not at home in the countryside unless she went to the local pub and drank beer, On stopping her beer the asthma disappeared, but when she went on holiday in late August to the east coast in the autumn she found that if the weather was damp she had asthma. The only way she could get relief was to hire a rowing boat and row about a mile off shore, where the asthma vanished, only to return when she rowed back again. This was almost certainly due to allergy to the very high counts of yeast spores at that time of year, probably Sporobolomyces.

The next year she went back to Norway on holiday for the first time since 1940, and had no trouble whatever when there, as her relatives were total abstainers. On arriving back in Newcastle on the boat she took the train to Derby, and asthma returned in full force on the journey. I doubted if yeast spores could account for this, and asked her if she had had anything on the train. She confessed that she had gone to the bar and had a “Double Diamond,” which was a popular brand of beer at the time. She took to gin and tonic and had no trouble except when the smell of yeast was in the air in Burton was strong.

 

A Reaction to a Herbicide used round the School

Richard was a fifteen in 1985, and was a very allergic subject already well known to me because when he was changed from breast to bottle he became seriously constipated, which ceased when I advised avoidance.

Aged four I found that he was sensitive to dust feathers and wool, and it was repeatedly established that if he was exposed closely to wool he reacted by aggression and misbehaviour.

This remarkable effect of wool was firmly established, and persisted, so that being in a small car with people in thick sweaters would cause misbehaviour. His mother was a tireless and intelligent investigator, and was quite objective. Aged ten he reacted to coloured foods and drinks with headaches and tummy aches.

Repeated milk challenges resulted in eczema within a few days, but this time the eczema persisted after avoiding milk again, so he was seen for reassessment.

He had ++ skin tests for mites, housedust, and wool, a total IgE of 127 units which is about three times normal, but had no asthma.

The rash was associated by his mother with the fact that the school authorities had been treating the playing fields with Atrazine, a herbicide which has since been found to have many possible side-effects.

It was difficult to be sure that the herbicide had anything to do with the skin rash, which subsided on school holidays.

I instructed that some treated grass should be obtained from the playing field, and noted that so much Atrazine had been used that white powder was easily seen on the grass.

Rubbing one forearm with this grass and the other with grass from my garden produced no immediate results, but after an hour and a half the appearances were as shown ion the photographs.

Unfortunately it was not possible to follow up this preliminary investigation, but Atrazine was not used again at the school. Obviously much more intensive investigation would be desirable.

Allergy to Legumes in a small boy

George was three, and he was having attacks of abdominal pain and diarrhoea which were clearly associated with eating a remarkably wide variety of foods. He was very fond of tomato sauce, and spaghetti with tomato sauce. Prick Skin testing using the soups indicated clearly confirmed his specific allergies, as shown below