By Henry Ehrlich
Dr. Scott Sicherer of Mount Sinai spoke at Beth Israel Medical Center in New York the other day. He is Chief of the Division of Allergy and Immunology in the Department of Pediatrics at Mount Sinai School of Medicine, and one of the premier pediatric allergists in the country, which is to say that New York Magazine named him one of the top pediatric allergists in New York City this year along with Dr. Hugh Sampson, also of Mount Sinai, and Dr. Paul Ehrlich. The audience at Beth Israel was mostly internists.
I was able to talk to Dr. Sicherer for a few minutes before the program began. He told me that the talk would mostly be on the basics. Because Sinai is a mecca for food allergies (pardon the mixed religious images), Dr. Sicherer said it was not uncommon for families to travel hundreds of miles by car to see him because they have been told by the family doctor that their child’s peanut IgE levels are so high that they are in danger going by plane. It often turns out that the child is not allergic at all.
Thus the subtext of the talk: doctors in general practice don’t know enough about allergies. They don’t understand the difference between allergy and intolerance. They certainly don’t understand the strengths and weaknesses of the tests. Sicherer pointed out that allergen-specific IgE tests—aka RAST tests—are an unreliable indicator, yet many doctors and patients regard them like “pregnancy tests”, i.e. a yes-or-no proposition. They are not. Used along with skin tests they have their uses, but without a good history, test results are not necessarily indicative of allergy.
Sicherer walked through two cases to describe how a food-allergy diagnosis is made. One was of a man in his twenties with a history of asthma who had a reaction after eating a bakery cookie that contained wheat flour, egg, peanut, and almond. He eats the first three all the time but not almonds because he has trouble with tree nuts, so it seemed logical that almond was the problem. Yet, the RAST showed IgE to the first three and not the almond. It turns out that the bakery where the cookie was made baked with other nuts without scrupulous cleaning between one batch and another, and the cookie-in-question was cross-contaminated. Without the full history, they wouldn’t know the truth.
Another case concerned a young woman who is a very healthy eater and a long-distance runner. Neither food nor exercise had ever given her trouble. However, she went running after eating a salad and went into anaphylaxis. It turned out she had a condition known as food-associated exercise-induced anaphylaxis. The solution? Never do these two things in sequence again.
Like any authoritative talk, this one was too varied to report comprehensively. A few little tidbits: 1) Some patients are so apprehensive about their allergies that after being given a placebo during a food challenge, they panic badly and the doctor will treat them for anaphylaxis. 2) Skin tests for sesame sometimes result in false negatives because the allergenic protein is oil-based and may not survive processing into saline extract with the allergenic components intact. 3) Jewish kids in the U.K. have about ten times the incidence of peanut allergies as their counterparts in Israel; it is believed that because a snack called Bamba, which contains peanuts, is a staple of infant diets in Israel, Israeli kids receive a form of oral immunotherapy.
Finally, Dr. Sicherer made an appeal for more patients to participate in clinical trials. The cure may be out there, but the search is proceeding slower than it should because it takes so much time to recruit subjects.
For more on Jaffe Institute trials go here.