Source: Continuing Education, Sept. 1979, pp. 47-59.
Examples of enviornmentally triggered disease involving the respiratory system are multiple. Symptoms and signs can result from odor sensitivities (cigarette smoke, hair spray, or pesticide), and include post-nasal drip, hoarseness, cough, or wheezing, resulting in sinusitis, laryngitis, bronchitis, and asthma.
If the gastrointestinal system is involved, the patient might develop bad breath or eructations, abdominal pain, bloating, constipation, or diarrhea. Nonreflux esophagitis, gastritis, ileitis, or colitis may also occur. When the genitourinary system is involved, complaints include urinary frequency and urgency, back pain or vaginal discharge that might result in a diagnosis of nonspecific 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. Such complaints as fatigue, vascular and tension type headache, nosebleed, hemoptysis, spontaneous bruising, petechiae, peripheral and periorbital edema, cyanosis, Raynaud phenomena, and adult acne may occur. These can result from a type of small vessel vasculitis. 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.
Other Clinical Characteristics
Drug sensitivity often occurs. Usually one or more drugs bother the patients and often five or more different drugs cannot be tolerated. The patient is often odor sensitive and can detect the presence of natural gas when others cannot. Normal gas leakage in a home is approximately 10%, but the average person does not perceive this. Often perfumes will produce nausea and vomiting, and the use of aerosols or air fresheners often make the patient ill. Chemically susceptible patients may not be able to tolerate fabric stores because of the toxic fumes emanating from the fabrics, and they are frequently intolerant of synthetic clothing and bedding.
Anesthesia is often a problem, and many people with chemical sensitivity have complications after surgery. Some even want to leave the hospital in order to have a more benign post-operative course. Women often find that they become worse after each pregnancy. This occurs for unknown reasons.
Patients may say that they are not sensitive to foods, but careful histories indicate they are intolerant to one or two 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. Sometimes, patients are even intolerant to water.
The chemically sensitive patient also may be weather sensitive. On inclement, overcast days, when the pollution is being held in, symptoms worsen. When a cold front blows in, these patients often develop recurrent sore throats and upper respiratory infections. They are plagued by recurrent infections all winter, complaining of flu-like symptoms month after month. Cold susceptibility is a frequent complaint. They become much worse in the winter and sometimes cannot tolerate foods that give them no problem in the summer. They usually wear sweaters and several layers of clothes. Even in the summer they wear clothes to protect them from air conditioning.
Weakness is a prime complaint in chemically susceptible patients. Patients are unable to complete a day=s work and may develop severe weakness for no apparent reason. They become apathetic and listless, are often worked up for hypothyroidism and adrenal insufficiency, and may be told that they have borderline hypothyroidism. They are sometimes misdiagnosed as having myasthenia gravis.
A second parameter that is easily accessible to the clinician is the total eosinophil count. In over 300 patients with this problem studied at Brookhaven Environmental Unit, 90% had total eosinophil counts below 50/mm3; 10 above 400/mm3. It is well known that some environmentally triggered asthmatics have elevated eosinophils, but it appears that many more patients with environmentally triggered disease will present with few eosinophils in the peripheral blood smear. It has become quite clear that a stay in the Environmental Unit, away ffrom incitants, allows the eosinophils to return to normal. When an incitant challenge is done under these controlled conditions, the eosinophil count will become depressed paralleling 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 done.
IgG should also be studied in patients suspected of having food and chemical sensitivity; often this will be in the range from 90 mg/dl to 750 mg/dl (normal is 800 mg/dl to 1800 mg/dl). Once returned to normal, it will often become depressed after incitant challenge.
Total complement (CH50 and CH100) as well as C3 and C4 should be done. Frequently, total complement will be low in these patients, ranging from 20% to 80% of normal. Many patients with environmentally triggered disease will have marginally low complements, 60% to 80% of normal. Often the C3 complement will be low, staying around 50 to 70 mg/dl while C4 may be elevated above its 20 to 40 mg/dl range.
Occasionally, patients will present with normal laboratory
tests but still react severely to challenges. In this group of patients
there probably exists direct mediator triggering of symptoms, with kinin
and prostoglandin being examples.
An alert family doctor suspected food and chemical susceptibility and asked the patient to avoid the four most frequently eaten foods in her dietCcoffee, beef, eggs, and wheat. After four days of avoidance, 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 complaints worsened. The following day she ate eggs and developed a phlebitis-like syndrome, became extremely weak and fatigued, and could not function for several hours. She also noticed that each time she was around her gas cook stove she would start coughing, develop tightness in the chest, beame nauseous, and her nose would run. Biopsy of a petechia showed lymphoctyic infiltrate around the vessel.
Laboratory data showed zero total peripheral eosinophils, WBC 3,000, IgG 600 mg/dl, IgE 150, total complement 60%, and T lymphocytes 700. She was admitted to the Environmental Unit and all signs and symptoms cleared after five days of total food abstinence. She found that her city drinking water triggered fatigue and rhinorrhea and that chlorine, formaldehyde, and fumes from polyester clothes did the same. In all, nine foods triggered her symptoms.
Since returning 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. Only washable natural fiber clothes are worn in order to avoid the formaldehyde. For the last three years, the patient has been totally asymptomatic, without medication, leading a vigorous life. Laboratory tests have returned to normal, except the total completment remained 80% of normal.
Patients often can be helped by establishing simple cause and effect as was done in this woman. As a general rule, it is the substances to which the patients are exposed on a daily basis that are the offending agents, and the major offender often will be obvious in the uncomplicated patient if potential causes are methodically examined in the patient=s home and personal environment. When the physician suspects certain agents, the patient can do withdrawal and challenge tests at home until the offenders are clearly defined. If the practitioner finds a few triggering agents and the patient does not improve, further workup will be needed by an individual specializing in this area of treatment.
Avoidance of environmental incitants is by far the best treatment for environmentally triggered disease, but this may be impossible because of employment and financial situations. When this is the case, the total body load often can be lowered by removing all offending agents possible and creating one room at home as an oasis. The general reduction in incitant load seems to decrease the overall sensitivity to many substances and often will allow a person to continue to work at a job that formerly would have been intolerable because the major offenders could not be removed in the workplace. If the offending substances are natural, often hyposensitization and neutralization by injection can be accomplished. Neutralization of symptoms of food reactions often is quite successful by injecting small doses of the aggravating food subcutaneously every three or four days. Neutralization of odors can often be accomplished in a similar manner.
For examples of immune system changes during challenge
and in environmental control.
The most polluted place in the environment appears to be the average home. Homes being built air-tight will contain pollutant contaminants. They are full of high outgassing synthetics such as polyester, foam rubber in beds and chairs, and gas heat further complicates pollution. The summation of these facts plus a polluted work environment makes a massive increase in body load that the individual has to handle just to function daily. This often becomes too great in people with certain herediatry and acquired tendencies and results in individual susceptibility, allowing inflammatory diseases to occur.