Food and Chemicals as Environmental Incitants
Susceptibility to environmental incitants such as air, food and water components is becoming an increasingly recognized health problem. These sensitivities and reactions can induce a spectrum of symptoms affecting smooth muscle mucous membranes and collagen in the respiratory, gastrointestinal, genitourinary and vascular systems. These reactions may be mistaken for hypochondriasis, but actually are due to reactions to foods and chemicals found in the patient's home and work environments. Careful clinical histories should alert the nurse and physician, who can confirm suspicions by eliminating and challenging the patient with potentially offending agents under controlled circumstances.
William J. Rea, M.D., F.A.C.S., F.A.A.E.M.
Gerald H. Ross, M.D., C.C.F.P.
The existence of clinical symptoms due to sensitivities to foods and chemicals has been poorly understood until recent developments in the fields of environmental sciences, toxicology, immunology and vascular diseases.1 Increasingly, practitioners are beginning to recognize that some individuals are particularly sensitive to components of air, food and inhalants, and that these incitants can produce significant illness in susceptible patients.2 Observation of changes in immunological parameters allows practitioners to correlate changes in the body's homeostatic immune mechanisms with the controlled introduction of environmental incitants. In addition, the development of the environmental control unit has facilitated more precise control of individual challenge tests and the accurate diagnosis of disease-producing incitants.
Most of the body's neutralizing mechanisms for toxic substances involve enzyme detoxification systems, primarily in the liver and lungs, and, to a lesser extent, the kidney.3 However, all cells in the body have these mechanisms to some extent if exposed to toxic chemical overload. With chemical overload, the body's detoxification pathways can become exhausted, permitting reactions to chemicals and foods. Better understanding of the pathophysiology of smooth muscle reactions to environmental incitants is evolving, particularly in relation to the cardiovascular system.4-5
Signs and Symptoms
The signs and symptoms of patients affected by environmental incitants can be myriad and complex. Frequently, patients' symptoms resulting from environmental triggers are confused with hypochondriasis, because they have such a wide variation.6-9 However, attention to the details of the symptoms allows the clinician to perceive that any part of the smooth muscle system, as well as responses in the mucosa and collagen system, can be involved. Most of the inflammatory diseases of unknown etiology affect smooth muscle, mucosa or the musculoskeletal system. It may well be that these inflammatory diseases are influenced by environmental factors, either as triggers or contributing factors.10
Examples of environmentally triggered disease involving the respiratory system are multiple, and include medications, foods, formaldehyde and other chemicals."11-13 Symptoms and signs can result from inhalant sensitivities (cigarette smoke, hair spray or pesticide), and include postnasal drip, hoarseness, cough or wheezing, sinusitis, laryngitis, bronchitis and asthma.
If the gastrointestinal system is involved, the patient might develop bad breath or belching, abdominal pain, bloating, constipation and/or diarrhea.14 Reflux esophagitis, gastritis, ileitis or colitis may also occur. When the genitourinary system is involved, complaints may include urinary frequency and urgency, back pain or vaginal discharge. This might lead to a diagnosis of non-specific cystitis (often requiring urethral dilatation), and vaginitis or back pain secondary to broad ligament swelling.
In the vascular system, symptoms often will be vague if the small arterioles, venules and capillaries are involved.5,15 Such complaints as fatigue, vascular and tension-type headache, nosebleed, hemoptysis, spontaneous bruising, petechiae, peripheral and periorbital edema, cyanosis, Raynaud's phenomenon and adult acne may occur in response to environmental sensitivities. The correlation between Raynaud's phenomenon (vascular spasm) and cigarette smoking is well-known. If the veins, larger arteries or heart are involved, recurrent phlebitis, Raynaud's disease, collagen-type vascular diseases, arthritis, and a variety of idiopathic cardiac arrhythmias may occur without an atherosclerotic basis.
The brain is a frequent target for environmentally susceptible patients, both in the cognitive and emotive aspects. Patients may experience severe unexplained anxiety, inability to concentrate or reason clearly, depression, hostility, mood swings, headaches, visual and balance disturbance, dizziness or tingling sensations.16 On occasion, adverse reactions to foods or chemicals can produce toxic psychosis7 and other neurological dysfunctions.17
If a mix of body systems is affected by environmental sensitivities, a confusing set of symptoms can develop. The simplest way to diagnose a patient with environmentally triggered disease is to take a meticulous history relating to these symptoms, with special attention given to whether the symptoms are triggered in certain circumstances such as after food consumption or chemical exposure. Examples might include the patient who develops a migraine headache only after eating chocolate, or who undergoes a personality change such as developing aggression or hostility after being exposed to traffic fumes.
Other Clinical Characteristics
Medication reactions often occur in environmentally sensitive patients. Frequently these people may be aware of five or more different drugs that they cannot tolerate. The patients are often odor sensitive and can detect the presence of natural gas or other chemicals when others cannot. Normal gas leakage in a home is approximately 10 percent, although the average person does not perceive this. Often perfumes will produce nausea and vomiting, and the use of aerosols or air fresheners often makes the patient ill. Chemically susceptible patients may not be able to tolerate fabric stores because of the toxic fumes emanating from the fabrics. They are frequently intolerant of synthetic clothing and bedding.
Anesthesia may often be a problem, and many people with chemical sensitivity have complications after surgery. Some even want to leave the hospital in order to enjoy a more benign postoperative course. Most hospitals, with liberal use of cleansers, disinfectants, floor waxes, air fresheners, etc., may be very toxic to chemically sensitive patients. Women often report that after each pregnancy their sensitivities increase, the cause of which is not yet known.
Many patients believe they are not generally sensitive to foods, but careful histories reveal they are intolerant to a few foods that they strictly avoid. They will often admit to feeling sluggish after eating and frequently will develop bloating that lasts for one to two hours.20
The chemically sensitive patient may also be weather sensitive. On inclement, overcast days when the pollution is held close to the ground, symptoms worsen. When a cold front blows in, these patients often develop recurrent sore throats and upper respiratory infections. They may be plagued by recurrent infections all winter, complaining of flu-like symptoms, month after month. The production of symptoms upon exposure to cold temperatures is a frequent complaint. They become much worse in the winter, when they may develop symptoms from eating foods that give them no problem in the summer. Frequently such patients wear sweaters and several layers of clothing when others are comfortable. Even in the summer they may wear extra clothing to protect them from the effects of air conditioning.
Weakness is a prime complaint in chemically susceptible patients. Patients are frequently unable to complete a day's work and may develop severe weakness for no apparent reason. They may become apathetic and listless, are often worked up for hypothyroidism and adrenal insufficiency, and may be told that they have borderline hypothyroidism. Sometimes they are misdiagnosed as having myasthenia gravis.
Patients with food and chemical susceptibility often have depressed white blood cell counts below 4,000/mm≥.21 Once malignancy and acute viral infections have been ruled out, a chronically low white blood count should cause suspicion of food and chemical susceptibility.
A second parameter, easily accessible to the clinician, is the total eosinophil count. In more than 300 patients studied at the authors' environmental control unit in Dallas, 90 percent had total eosinophil below 50/mm≥, 10 percent above 400/mm≥.21 It has become quite clear that a stay in an environmental control unit, away from incitants, allows the eosinophils to return to normal. When an incitant challenge is done under these controlled conditions, the eosinophil count will become depressed, coincident with the production of the patient's symptoms. Because steroids will alter these relationships, the physician must be sure the patient is not taking them while evaluation is being carried out. IgE, which is often increased in traditional allergy patients (asthma, hay fever), is elevated in only 10 percent of these environmentally sensitive patients.
A common finding in chemically sensitive patients is immune suppression, whereby T-lymphocytes often are depressed below 1,000 (normal = 1,260 to 2,650).21 In the most severely affected patients, B-lymphocytes are also low.21 Chemically sensitive patients with vascular involvement have depressed levels of the suppressor T-lymphocytes by over four standard deviations when compared with controls.21
There are now analytical methods for determining levels of many toxic environmental chemicals.22 Environmentally sensitive patients have been found to have a significant body load of these toxic chemicals.23 Included are the organochlorine pesticides, general volatile organics, solvents, PCBs and herbicides.24 General volatile chemicals are frequently detected in nurses, presumably because of the exposure on the hospital ward.
When analyzing and considering whether environmentally triggered disease is a factor in a given patient's illness, the health professional must understand several clinical principles. First, it appears the ability to arrive at a medical diagnosis lags far behind environmental technology. Practitioners are often limited in their ability to diagnose and treat diseases caused by non-infectious processes because of a lack of awareness of other contributing mechanisms, such as environmental factors.
Our understanding of environmentally induced illness is comparable to medical practice 100 years ago, before the germ theory of disease became well-understood. At that time, people rubbed manure into wounds, and physicians performed pelvic exams after becoming contaminated at autopsies.
Up until recently, the public has been largely unaware of potential environmental triggering agents. This is changing rapidly as more people become concerned with environmental effects on health. Offending substances are readily found in homes, workplaces (and even hospitals) in such abundance as to sometimes negate all treatments and sabotage diagnosis and recovery in patients environmentally sensitive.
We are all biochemically and genetically unique, and show tremendous variation in our ability to tolerate infections, emotional stress and chemical exposures.25-26 This biochemical individuality will determine whether one person may be adversely affected by exposure to natural gas, for example, while the bulk of the population may adapt and tolerate such exposure quite well.
Such an individual may have symptoms induced by natural gas, but because the individual may be exposed to the gas up to 24 hours a day (since the home, water and food are heated by it) the cause-and-effect relationship between exposure and production of adverse symptoms may not be perceived. This may also be true in the individual who is sensitive to the chemicals in the water supply, who is exposed when cooking, drinking and bathing. The important concept to understand is that whenever a large number of people encounter the same incitant, sensitive people may react adversely while the large bulk of the population may not. This is due to our biochemical individuality.
Total Body Load
Another principle that should be understood is the concept of total body load, which is the sum total of all the pollutants taken into the body. These tend to distort many of the body's homeostatic mechanisms. The total load includes not only incitants that are components of air, water and food, but encompasses biological factors (viruses, molds, pollens) as well as emotional stress. One might initially assume that we are in danger of being "overloaded" until we consider the vast amount and scope of pollution that has crept into the environment. Most drinking water systems, for example, are overloaded with man-made contaminants that increase the exposure to these chemicals by 1,000 times to 10,000 times in comparison with spring water.20-27 Unfortunately, most public water supplies are rated safe by bacterial content only. EPA studies of large U.S. cities show water supplies to be severely chemically contaminated, and many of these organic solvents can be absorbed directly through the skin, by contact alone.23 Apparently waters are now as polluted with chemicals as they were with bacteria 50 years ago before chlorination.20 Virtually all commercially grown food has pesticide or herbicide in it, and a 1987 EPA report ranked pesticides in food as one of the nation's most serious health and environmental problems.29 In many cases, the patient may react to regular commercially available foods, but may tolerate the same food if organically grown. This suggests that it may actually be the food additives or pesticide residues that are causing the reaction.
The most polluted place commonly encountered in the environment appears to be the average home.30 Modern airtight, energy-efficient houses will contain many pollutant contaminants.31 These homes are full of high-outgassing (gas-emitting) synthetics such as polyesters, the foam rubber in beds and chairs, and the formaldehyde in fiberboard and plywood. Many homes are treated regularly with insecticides whether needed or not. Heating with natural gas further complicates indoor pollution.2,31
The combination of contaminated food and polluted work and home environments can produce significant increases in the body chemical load that an individual must cope with and detoxify. In people with certain hereditary and acquired tendencies, this often becomes too great and results in individual susceptibility, allowing inflammatory diseases to occur.26
Acute Toxicological Tolerance (Adaptation/Masking)
A third biochemical principle is that of masking or adaptation, essentially a changing of the body's homeostatic systems to a new set point.12 When a person comes into contact with a stimulus (for example, an odor of some kind), he or she gets used to it and perceives no harm, because there is no ongoing reaction. This adaptation response may occur continuously with prolonged exposure. If the substance is avoided for four days, a reaction may occur with re-exposure because the patient has then become "deadapted." In the unmasked or deadapted state, the patient may have an immediate and clearly definable reaction if the exposure is harmful to him or her. This process of withdrawal from a suspected allergen and re-exposure can make cause-and-effect relationships detectable. Likewise, food sensitivities often are missed because the individual eats the offending Food one or more times daily, a situation in which symptoms are masked, though the food is adversely affecting the body.
This principle of masking or adaptation is commonly understood in the individual who is addicted to drugs. This individual takes the addictive substance whenever withdrawal symptoms are experienced in order to feel better, but if the drug is omitted for a while and then reintroduced, the individual may have an exaggerated, acute reaction. People exposed to industrial fumes may not perceive the fumes as harmful except when they are re-exposed after having been away from them. Some painters and battery workers, for example, say that the substances they work around bother them after returning from vacation, until they get used to the offending chemicals again. Hospital personnel experience a similar situation since they are exposed to myriad floor washes, instrument sterilizers, airborne insecticides/toxic mediators, air-fresheners and plastics of all types. Once a patient has adapted, the effects of the exposures are unperceived but very real, and the patients may appear to be healthy until they eventually develop end-stage, fixed inflammatory disease.
When a pollutant enters the body, the immune and enzyme detoxification systems are induced. Parallel to this action, the sensitive individual may have a stimulatory brain reaction, whereby the substance is perceived not as harmful but as pleasurable.2 However, after a period of time - minutes, months or years - the body's defenses break down and harmful disabling symptoms occur, along with a depressed ability to adapt. Classically, this is a well-recognized principle in cigarette, narcotic or alcohol addicts, but is not as well-known (though just as prevalent) in plastics workers, painters, nurses, physicians, food addicts and any other individuals who constantly inhale or ingest a toxic substance.
Therapy for Environmentally SensitivePatients
The cornerstone of therapy for environmentally sensitive patients is the avoidance of adverse reaction triggers. When the total body load is reduced in this way, the person can then often tolerate small exposures of incitants that would otherwise make him or her ill.
Cleaning up the patient's environment with the introduction of clean air, food and water is an essential part of treatment. Contact with solvents, gasoline, cleansers, scented products and other triggers of reaction must be avoided. Sometimes special attention must be paid to the patient's home and work surroundings by making use of non-toxic and nonpolluting materials.1,33
Patients often can be helped by establishing a simple cause-and-effect relationship between the incitant and the symptom. As a general rule, it is the substances to which the patients are exposed on a daily basis that are the offending agents. Patients will often unknowingly react to their most frequently consumed foods. The major offender may frequently be obvious in the uncomplicated patient if potential causes are methodically examined in the patient's home and personal environment. When the practitioner suspects certain agents, the patient can carry out withdrawal and challenge tests at home until the offenders are clearly defined. This can easily be started by avoiding suspected foods or other agents for four or five days. Upon subsequent exposure, the patient may react vigorously and the relationship between the agent and its adverse effects may be demonstrated. If the practitioner finds a few triggering agents and the patient does not improve, further workup will be needed by an individual specializing in food and chemical sensitivities.
The practitioner can learn a great deal by asking specific questions about past work experiences, chemical or pesticide exposures, type of housing and heating, and other matters such as whether the patient has lived near an airport or factory that might have affected his or her health.25 For example, find out whether the patient has hobbies such as ceramics, woodworking, painting or others that involve working with paints, solvents, varnish or glue, etc. Has the patient had a significant or serious viral illness, such as hepatitis, cytomegalovirus infection, mononucleosis or post-viral fatigue syndrome? All of this information will give a better picture of the "total load," past and present.
Nurses in particular should be alert to the patient who demonstrates intolerance to many medications, odors, foods or other possible environmental toxins. Listening to the patient's ideas and problems may avert a lot of distress, and prevent very serious reactions in the sensitive patient.
There are many sources of educational materials that are available to patients containing practical instructions on organic food sources and preparation, safe water sources, clothing and furniture advice, information about safe soaps, toiletries and shampoo, household cleaning products, etc. A great deal or valuable insight and information can be gained from some excellent publications feared for the general public; a sampling of such titles is included in Table 1.
Educational Resources for Environmentally
Dadd, D.L.: Nontoxic and Natural -A Guide for Consumers, Los Angeles, Jeremy Tarcher, 1984.
Golos, N. and Golbitz, F.G.: Coping with Your Allergies, New York, Simon & Schuster, 1986.
Golos, N. and Golbitz, F.G.: If This Is Tuesday, It Must Be Chicken, or, How To Rotate Your Food for Better Health. ,New Canaan, Conn., Keats Publishing, 1979.
Ludeman, K. and Henderson, L.: Do-It-Yourself Allergy Analysis Handbook. ,New Canaan, Conn., Keats Publishing, 1979.
Mandeil, M. and Scanlon, L.W.: Dr. Mandell's 5-Day Allergy Relief System, New York, Simon & Schuster, 1979.
.Rapp, D.J.: Allergies and the Hyperactive Child, New York, Simon & Schuster, 1979.
Rousseau, D. et al.: Your Home, Your Health, Your Well-being, Vancouver, Hartley and Marks, 1988.
Treatment with the Environmental Control Unit
An environmental control unit (ECU) is a facility that strictly controls the usual pollutants and contaminants of indoor air.31,34 The ECU is specially constructed of inert materials, with the walls and ceilings made of porcelain on steel panels. The floors are terrazzo or hard tile. The air is highly filtered to remove virtually all particulates and odors. The water used is also highly filtered. Generally, such a facility provides testing and treatment services "or allergies and environmental hypersensitivities, dietary consultation, laboratory analysis and other services; most of these services are covered by health insurance. In an ECU, sensitive patients almost always improve, since their total load is significantly reduced (see case reports). There are only a few such Facilities in operation in the United States. (For more information on these centers, contact the Dallas Environmental Health Center,  368-4132.)
To assess chemical sensitivities, double-blind chemical challenges are performed in a booth that is constructed of inert materials, usually stainless steel and glass. A patient being tested is then exposed to very low concentrations of chemical vapors in a double-blind fashion, while the symptoms and signs are carefully recorded. A heart monitor is in place, and other vital signs are taken periodically. This technique, if properly performed under environmentally controlled conditions, can demonstrate reactivity to substances that are frequently encountered, such as chlorine, alcohol, phenol, pesticide, formaldehyde and others.
Because many patients are reactive to a variety of foods, a rotary diversified diet frequently is recommended.45 Essentially, this program is not for weight reduction but for the avoidance of the frequent ingestion of a food to which a person may be sensitive. In a monorotational diet of this type, only one food is eaten at one meal, in any amount that makes the patient feel comfortable. In the most common rotational diet, the same food is not eaten again for four days, and any closely related foods are avoided for at least two days. The daily diet pattern repeats itself starting on the fifth day.
Eating only one pure food per meal greatly reduces the total contact with potential allergens, and allows food reactions to settle down. An example of a monorotational diet is shown in Table 2.
Example of Monorotational Diet
Breakfast Lunch Dinner Snack
Day I Cantaloupe Lentils Halibut Peaches
Day 2 Eggs Rice Beef Oranges
Day 3 Apples Green peas Pork Cashews
Day 4 Wheat Carrots Chicken Goatís milk
Susceptibility to environmental incitants such as air, food and water components is becoming an increasingly recognized health problem. These sensitivities and reactions can induce a spectrum of symptoms affecting smooth muscle, mucous membranes and collagen in the respiratory, gastrointestinal, genitourinary and vascular systems. Most patients can be successfully helped without the necessity of a sophisticated environmental control unit. The diagnosis is made on the basis of a thorough history and a trial of dietary or environmental modifications. The use of a food/symptom diary may help show patients a relationship between certain foods and subsequent reactions.
1.Rea, W.J. and Mitchell, M.J.: "Chemical Sensitivity and the Environment," Immun Allerg Prac, September/October l982, pp. 21-31.
2. Randolph, T.G.: Human Ecology and Susceptibility to the Chemical Environment. Springfield, Ill., Charles C. Thomas, 1978.
3. Makoby, W.B.: (Ed.): Enzymatic Basis of Detoxification, Vol. 1, New York, Academic Press, 1983.
4. Rea, W.J. and Suns, C.W.: "Cardiovascular Disease Triggered by Foods and Chemicals," in Gerrard, J.W. (Ed.), Food Allergy: New Perspectives, Springfield, Ill., Charles C. Thomas, 1980.
5. Rea, W.J.: "Environmentally Triggered Small Vessel Vasculitis," Annals of Allergy, 1977, 38, pp. 245-51.
6. King, D.S.: "Can Allergic Exposure Provoke Psychological Symptoms? A Double-B1ind Test." Biol Psychiat, 1981, 16, pp. 3-19.
7. Potkin, S.G. et al.: "Wheat Gluten Challenge in Schizophrenic Patients." Amer J Psychiat, 1981, 138, pp. 1208-11.
8. Randolph, T.G.: "The History of Ecologic Mental Illness," in C.A. Frazier (Ed.), Annual Rev Allergy 1973, Flushing, N.Y., Medical Examination Publishing Co., 1974.
9. King, D.S.: "Can Allergic Exposure Provoke Psychological Symptoms? A Double Blind Test." Biol Psychiat, 1981, 16:1, pp. 3-19.
10. Marshall, R. et al.: "Food Challenge Effects on Fasted Rheumatoid Arthritis Patients: A Multicenter Study," Clinical Ecology, 1984, 2:4, pp. 181-90.
11. Schlueter, L.E. et al.: "Airway Response to Air Spray in Normal Subjects and Subjects with Hyperreactive Airways," Chest, May 1979, 75:5, pp. 544-8.
12. Frigas, E. et al.: "Asthma Induced by Dust from Urea-Formaldehyde Foam Insulating Material," Chest, June 1981, 79:6, pp. 706-7.
13. Wuthrich, B. and Fabro, L.: "Acetylsalicylic Acid and Food Additive Intolerance in Urticaria, Bronchial Asthma and Rhinapathy," Schweiz Med Wochenchr, Sept. 26, 1981, 111:39, pp. 1445-50.
14. Jones, A. and Hunter, J.O.: "Irritable Bowel Syndrome and Crohn's Disease," in Brostoff, J. and Challacombe, S. (Eds.), Food Allergy and Intolerance, London, Bailliere Tindall/W.B. Saunders, 1987, pp. 555-69.
15. Rea, W.J.: "Recurrent Environmentally-Triggered Thrombophlebitis," Ann Allergy, 1981, 47:5, pp. 338-44.
16. Rea, W.J. et al.: "Pesticides and Brain-Function Changes in a Controlled Environment," Clinical Ecology, 1984, 2:3, pp. 145-50.
17. Shields, M.: "Subtle Effects of Toxics," Foundation for Advancements in Science and Education Reports, Spring 1988, 7:1, p. 1.
18. National Research Council: "Water Hardness and Health in Drinking Water." in Drinking Water and Health, Washington, D.C., National Academy of Sciences, 1977, pp. 439-47.
19.Wilson, C.W.M.: "Hyperactivity to Maine Tap Water in Children: Its Clinical Features and Treatment," Nutrition and Health, 1983, 2, pp. 51-63.
20. Cherry, R. and Cherry, F.: "What's in the Water We Drink?" The New York Times Magazine, Dec. 3, 1974.
21. Rea, W.J. et al.: T and B Lymphocyte Parameters Measured in Chemically Sensitive Patients and Controls," Clinical Ecology, 1987, 4:1, pp. 11-14.
22. Laseter, J.L. et al.: "Chlorinated Hydrocarbon Pesticides in Environmentally Sensitive Patients," Clinical Ecology, 1983, 2:1, pp. 3-12.
23. Rea, W.J. et al.: "Toxic Volatile Organic Hydrocarbons in Chemically Sensitive Patients," Clinical Ecology, 1987, 5:1.
24. Accu-Chem Laboratories: Physician's Clinical Guide, Richardson, Texas, Enviro-Health Systems Inc., 1986.
25. Calabrese, E.J.: "Pollutants and High-Risk Groups," The Biological Basis of Increased Human Susceptibility to Environmental and Occupational Pollutants, New York, Wiley-Interscience, 1977.
26. Calabrese, E.J.: Genetic Variation in Susceptibility to Environmental Agents, New York, Wiley, 1984.
27. Spalding, R.F. et al.: "Water: Pesticides in Ground Water Beneath Irrigated Farmland in Nebraska," Pesticides Monitoring Journal, 1980, 1:2, pp. 70-3.
28. Brown, H.S. et al.: "The Role of Skin Absorption as a Route of Exposure for Volatile Organic Compounds in Drinking Water," Amer Jour Public Health, 1984, 74, pp. 479-84.
29. U.S. Environmental Protection Agency: Unfinished Business: A Comparative Assessment of Environmental Problems, Washington, D.C., 1987.
30. National Research Council: Indoor Pollutants, Washington, D.C., National Academy Press, 1981.
31. Nero, Anthony V.: "Controlling Indoor Air Pollution," Scientific American, May 1988, 258:5, pp. 42-8.
32. Randolph, T.G.: "Specific Adaptation," Ann Allergy, 1978, 40, pp. 333-45.
33. Rousseau, D. et al.: Your Home, Your Health, Your Well-Being, Vancouver, Hartley and Marks, 1988.
34. Sprague, D.E. and Millam, M.J.: "The Concept of an Environmental Unit," in Brostoff, J. and Challacombe, S. (Eds.), Food Allergy and Intolerance, London, Bailliere Tindall/W.B. Saunders, 1987, pp. 949-60.
35. Radcliff, M.J.: "Diagnostic Use of Dietary Regimes," in Brostoff, J. and Challacombe, S. (Eds.), Food Allergy and Intolerance, London, Bailliere Tindall/W.B. Saunders, 1987, pp. 800-22.
About the authors: William J. Rea., M.D., F.A.C.S., F.A.A.E.M., is director of the Environmental Health Center in Dallas, Texas. Gerald H. Ross, M.D., C.C.F.P., is a fellow in environmental medicine at the Environmental Health Center in Dallas.
CASE REPORT ONE
A 33-year-old woman presented with profound fatigue and weakness, reporting that all foods made her bloated and sluggish. A careful chronological history revealed tonsillitis in childhood, eventually resulting in a tonsillectomy. At age 15, she experiences abdominal pain bloating and mild intermittent diarrhea that was felt at the time to be from a nervous or irritable bowl. At age 17, recurrent posterior headaches occurred that were diagnosed as tension. These headaches seemed to follow exposure to the odor of eggs and cooking. At age 23, thrombophlebitis occurred and was thought to be caused by birth control pills. During a pregnancy at age 26, she had severe vomiting and felt tired and listless for months after delivery.
At age 30, she had an n increase in postnasal drip and frequent episodes of sinusitis. She also notice that she had become very sensitive to the odors of cigarette smoke, perfume and pesticides, and that exposure to these made her cough and feel nauseated, jittery and very tense. At age 32, she developed recurrent cystitis and was treated with frequent urethral dilations. By age 33, she became incapacitated by fatigue and weakness and noticed that all foods gave her bloating and sluggishness. She also experienced peripheral cyanosis and swelling after being out shopping, especially in malls. She began to develop spontaneous bruising and petechiae and her teenage acne was reactivated. Symptomatic treatment with Benadryl®, codeine and Valium® caused adverse effects.
An alert family doctor suspected food and chemical susceptibility and asked the patient to avoid the four most frequently eaten foods in her diet Ė coffee, beef, eggs and wheat. (It has frequently been seen that patents will unknowingly react to their most frequently consumed foods.) After four days of avoidance, she began feeling better. On a trial of re-exposure, she drank only coffee for a couple of hours and became violently ill with headache, fatigue and nasal symptoms. After eating wheat the next day, diarrhea and urinary complains worsened. The following day she ate eggs and developed a phlebitis-like syndrome, became extremely weak and fatigued, and was incapacitated for several hours. She also noticed that each time she was around her gas cooking stove she started developing a cough, tightness in the chest and nausea, and her nose would run. Biopsy of a skin petechia showed perivascular lymphocytic infiltrate around the blood vessels.
Laboratory data showed zero total peripheral eosinophils (normal = 0 to 350/mm≥); WBCís were depressed to 3,300 (normal = 4,800 to 10,000); lgG was low at 600 mg/dl (normal = 600 to 1,600 mg/dl); and was admitted to the authors environmental control unit in Dallas, and all signs and symptoms cleared after five days of total food abstinence. In the ECU, she found that her city drinking water triggered fatigue and rhinorrhea and that chlorine, formaldehyde and fumes from polyester clothing did the same. After oral and intradermal testing, she learned that nine different foods triggered her symptoms.
Since returned home the patient has removed all gas appliances, drinks only spring water, and maintains a rotary diversified diet, never eating the same foods more than one time in four days. This type of diet minimizes the chances of food reaction, since the body is not challenged as frequently by the same food. Only washable natural fiber clothes are worn, since all synthetic materials such as nylon, orion and polyesters will "outgas" and release chemicals to which some patients are very sensitive. For the last three years, the patent has been totally asymptomatic, medication-free, and is leading a vigorous life.
This case is typical of the patient with environmentally triggered disease who rather frequently presents to a health care facility. A 20-year history of symptoms was overlooked, probably because the symptoms were so commonplace, and because several physicians called many of the complaints "functional" or felt that the cause could not be determined. Many people with recurrent tonsillitis (at any age) develop other problems related to environmentally triggering even though their throat infections are cleared after tonsillectomy. Frequently, these problems are in other smooth muscle systems of the body, resulting in inflammatory disease such as phlebitis, cystitis, colitis or bronchitis. Perhaps if the early signs had been recognized, this patient would not have developed such a widespread and chronic problem. Other patients may present with more life-threatening complications.
CASE REPORT TWO
A 30-year-old woman presented with Raynaudís syndrome with an area of gangrene induced on the right index finger. She also had recurrent headaches and was obese. Pain was excruciating and vasodilators were ineffective. Her past history was significant in that her father and grandmother died around age 40 from inflammatory vascular disease. Laboratory data showed a depressed immune status as measured by a WBC count depressed to 3,500 (normal = 4,800 to 10,000), total eosinophil count of zero (normal = 50 to 350/mm≥) and T-lymphocytes depressed to 800 mm≥ (normal = 1,260 to 2,650/mm≥). The patient was taken off all foods and medications after admission to the authorsí environmental control unit. Within 10 days the gangrene and pain had disappeared. Ten different foods, including formaldehyde, phenol alcohol and gas and several inhaled molds were found to trigger this arterial spasm. Since discharge, the patent has been able to work for the past 10 years without vasodilators or other medications. There has been no recurrence of the disease, although if the patient becomes chemically overloaded her finger turns blue for a short period of time.
CASE REPORT THREE