By Dr. Larry Chiaramonte
Erika Von Mutius MD, whose research lies at the heart of the idea of the “hygiene hypothesis” and Jeffrey Drazen MD, editor of the New England Journal of Medicine, recently had in that august publication an article called “A Patient with Asthma Seeks Medical Advice in 1828, 1928, and 2012.” As the name implies, it creates three typical interactions between patient and doctor, complete with symptoms, analysis, and treatments in the vocabulary of the times.
1828--Boston housewife “Mrs. A. Smith” age 35 is examined by a consultant at home where she lives “her husband of 17 years, four children, a cook, two maids, a stable boy, and a footman.”
Her attacks of “dyspnea” accompanied by a musical noise in her chest are treated by inhaling steam from a kettle kept boiling by the cook, and while she usually recovers within a day or two, she is confined to bed for up to a week once or twice a year. She also suffers from what we now recognize as seasonal and environmental allergies.
“I think that she may benefit from smoking the leaf of Datura stramonium, also known as the thorn-apple plant.”
1928’s version of Mrs. Smith has been referred to a specialist, and the write-up takes the form of a letter to her GP, who has been treating her attacks “subcutaneous injection of adrenaline…she often has relief from acute symptoms, and the attack may or may not recur.”
The diagnostic technology has taken a big leap forward:
“I examined the radiograph of the chest that she brought with her, which was taken within the last month. It showed hyperinflation of the lungs, but there were no abnormal shadows; there were no findings that would suggest tuberculosis. Her cardiac silhouette did not show any abnormalities.
“A blood smear was made, showing 14 per cent eosinophils; in a normal person this is most often less than 5 per cent. A sputum sample was also examined, and all the polymorphonuclear leukocytes observed were eosinophils. Specialized skin testing was performed. She had positive reactions to extracts of ragweed and horse dander.”
Treatment? Continued use of adrenaline injections when attacks are severe, along with possible use of oral ephedrine and avoiding pollens and other triggers, or as a last resort moving to a new location where they are not present.
The current Ms. Smith is contacted via email by a sub-subspecialty physician who only cares for patients with asthma whom she has found on the Internet search and is consulting him for a second opinion. He reviews her history—including allergy tests–and treatments going back many years and after a physical exam, he suggests some modifications to her regimen. These might include, oral theophylline, replacing Singulair with Zyflo CR (zileuton, controlled release), which prevents the synthesis of both cysteinyl leukotrienes and dihydroxy leukotrienes, and possibly Xolair (omalizumab). Each drug is presented with a very tempered description of possible effectiveness and statement of possible side effects—clearly her consultant has listened to his lawyer.
In the Year 2028
So what might the consultation look like in 15 more years when today’s bright middle-school students are practicing medicine? Ms. Smith might look into her sunglasses and an allergist will appear. The good doctor will say:
Ms. Smith, I am afraid you are paying the price for your grandmother’s smoking habit and perhaps for the years your mother spent in the Bronx going to medical school and then treating disadvantaged patients in an area where there was a lot of diesel traffic. We screened your umbilical cord blood, which was kept frozen all these years, and found high levels of IgE for a newborn. Your parents strived to prevent allergic disease by reducing your childhood exposure to common allergens as house dust mite, cow’s milk, peanuts, cockroaches, pets and diesel-exhaust fumes, which possibly delayed the onset of your allergy, but now you have fully developed asthma. We will send our environmental assessment team to do antibody evaluation for allergen levels in your home and workplace.
Many immunologically based therapies have been recently added to the old stand-bys of Subcutenous Immunotherapy [SCIT], Sublingual Immunotherapy [SLIT], and anti-IgE [Xolair]. There is an anti-IL-4 antiserum, as IL-4 is responsible for the induction of IgE synthesis. Also interferon gamma (IFN-gamma), interferon alpha (IFN-alpha), and prostaglandin E2 can be used to block IL-4-induced IgE production. So you see we have many choices. We will tailor your therapy with a consideration of the cost/ benefit to fit your asthma severity.
Of course you will need medication until the effects of the immunologically based therapy take place. We now have long-term inhaled medication. The combination LABA and ICS need to be taken only once a week. Your exhaled nitric oxide levels will determine the weekly dose. I will put our asthma tracking application on your smart cell phone as well as devices like your glasses, wrist watch, and running shoes. It will serve as an early warning of an asthma episode and reminder to maintain your therapeutic measures. With all this in place, by the time you start college, your asthma will be thoroughly under control.
{Note–if you have a vision of how asthma will be treated in the future, please feel free to comment.}