A True Halloween Mystery Case: Tammy

Once a week, her mother told me.  Over the summer it had been less predictable.  Sometimes 2 or 3 times a week, then.  Now that she's in school, it's once a week.  Nearly always on Monday.

It usually starts to be visible in the morning.  In fact, when I ask 7-year-old Tammy, she's very clear on this, and disagrees with her mother.  She says that sometimes she knows it's coming on when she's in her bath the night before.  She starts getting itchy.  Mom remembered this, but said that she examined her and could find nothing.  Then the following morning Tammy is really itchy, and starts to get red around her lips.  By the end of the afternoon, her lips and face are red and swollen.  Her face is very itchy, and the painful to touch.  It looks like a swollen water balloon.  Mom says that she gave her an antihistamine and that helped a little with the itch but did nothing for the swelling.  Within a day or so, the swelling gradually diminishes, the skin on her face cracks and peels, and everything goes back to normal.

That's not the worst of it, her mother adds.  It's her privates, too.  The whole sequence is just the same:  itch, then swelling and redness and more itch and tenderness, and then it gradually goes back to normal.  It's never as bad as her face, she added.

The first time, Tammy was taken to the Emergency Room.  They gave her some steroid medicine and an antihistamine.  This seemed to help the itch, and the problem went away in a day or so.  The ER doctor told mom that it was poison oak [our West Coast relative of poison ivy].  She told me she knew that wasn't possible, but didn't say anything at the time.  A week later, it happened again, just the same way.  This time, her mother didn't take her to the ER, she just gave her some antihistamine and took her to her regular doctor.  The doctor focused on the first symptom, the redness around the lips and told the mother based on this that the child has a serious food allergy and should be tested right away.

At the allergist, Tammy was tested for sensitivity to:  milk (2 kinds), cheese (3 kinds), fish (4 kinds), shellfish (6 kinds), wheat, corn, oats, rice, rye, barley, walnuts, almonds, pistachio nuts, Brazil nuts, pecans, sunflower seeds, sesame seeds, hazelnuts, cottonseed, olives, chocolate, beef, pork, chicken, soybeans, tomatoes, cucumbers, squash, pumpkin, egg white, egg yolk, peanuts, strawberry, raspberry, blueberry, blackberry, carrots, lettuce, broccoli, melons, pears, apples, peaches, 4 different molds, 4 different dust mites and their droppings, 16 different inhaled pollens from grasses/trees/weeds/flowers, and dogs and cats.  The tests were negative.

Tammy's mom found her way to me.  Our first visit took 2 hours. 

I gave Tammy a quick exam, but since she wasn't having any symptoms, I didn't expect to find anything.  I didn't.

What took the time was my insistence on hearing about the most recent episode—just a few days ago—from beginning to end.  The first thing I caught was the lips.  Mom said red around the lips when she told me the first time.  Was it around them, or were the lips red?  Around, she said.  So did the lips get swollen?  Yes, but only after the whole face was swollen.  I asked Tammy if her lips got itchy or tingly.  They didn't, and neither did her tongue or throat. 

And what was she eating the day before this would happen?  All the usual stuff:  sometimes macaroni and cheese, sometimes a hot dog, sometimes a chicken nugget or salad or peanut butter sandwich.  The same stuff she ate on every day that it didn't happen.  Did she go anyplace different before it happened?  No, the same old places as always.  Home, play park, grandma's.  Does grandma have pets?  A dog, who plays with Tammy when they're in the vegetable garden helping grandma.

In fact, that's how mom knew that it couldn't be poison oak.  Grandma was a meticulous gardener, and started growing vegetables with Tammy so that they'd have a project together.  They grew the vegetables that Tammy picked out:  pumpkins, of course, both orange and green speckled ones and white ones, along with squash and cucumbers.  They have just harvested the last crop, and in the upcoming weeks, Tammy explained, she would help her grandmother chop up the vines and leaves for compost to help the soil and prepare for the winter.  Her grandma had bought her pink gardening gloves that matched her own.

I asked both Tammy and her mother about every possible body part.  Did her eyes itch?  How about her palms or feet or scalp?  And other symptoms:  coughing, wheezing, sneezing, runny nose, itchy nose, rash of any kind?

The ER doc was on the right track but didn't have the time to listen to the whole story from beginning to end.

The reaction that most people get to poison oak or poison ivy is intense itching, sometime with blisters.  It's from a plant resin that sinks into the skin and causes a big reaction from the immune system.  It often does take at least several hours, sometimes more than a day,  for a reaction to be noticed.  But the resin binds to the skin and the immune reaction takes weeks to resolve.  Besides, the mother knew that the grandmother's garden had no weeds.  Tammy didn't venture into unknown bushes.

There are many different kinds of allergies.  Some cause a sudden flood of signals into the bloodstream, setting off an unfortunate sequence of events which can include swelling of the airway, which can be lethal.  Others are slower or more superficial, with itchiness or redness the only symptoms.  Food allergies can be particularly worrisome because once you've eaten something, you're stuck with it until it breaks down into pieces of proteins too small to be recognized.  With the slower variety of food allergies, you might first feel a tingling or itchiness in you mouth, lips, or tongue.  It is a general principle that the parts most affected are usually the parts that got the most exposure to whatever it is that you're allergic to.  The pink moist skin of our lips, mouth, tongue, and a few other spots is particularly sensitive.  These tissues are often the first to sense and react to a problem.

But not in Tammy.  Her lips were not affected, it was the regular skin around them.  Then gradually, the rest of her face.  The fact that her body as a whole was unaffected is further reassurance that this signal, whatever it was, was not coming from the inside.  A reaction to a food would send its messages everywhere.  And what about the privates?

Some patterns ring familiar after years and years of experience.  If the ankles and hands and other areas of exposed skin are affected, it's likely something that brushed up against the person.  If it's the face and...then it's the places the person touches, and the offending agent was carried on the person's hands.  We all touch our faces unconsciously; we all must answer nature's occasional call. 

So I agreed with the ER doctor that this was a contact dermatitis.  But it wasn't poison oak.  I made the mother tediously recount the most recent episode from beginning to end.  When was the previous episode, and when the one before that?  Mom, as she tried to recollect, realized before I did that these episodes occurred the day after Tammy was with grandma.  We knew, however, that Tammy wasn't allergic to the dog or to any of the vegetables in grandma's garden.  We were almost there:  it was contact dermatitis, bad enough to make Tammy's skin swell but not getting into her system; she was contacting it at grandma's house but not at her own house or school or park.  What was different about grandma's house?

The garden. 

Mom pointed out that she had been tested for allergy to all of the garden plants. 

But this reaction wasn't from eating any of the vegetables.  There are many allergists and laboratories that can test for food allergies.  But how about the stems?  I checked the 3 different big commercial testing labs, but none of them offered such a test.

The family of plants that includes cucumbers, melons, gourds, and pumpkins are fun to grow because they grow so fast.  To support this rapid growth, they have thick stems with lots of sap.  This milky sap can cause severe skin irritation.  Most of these plants have bristly hairs which themselves—even without the sap—can cause a skin reaction.  A key clue in Tammy's story was the gardening gloves that prevented any symptoms on her hands.

When you take your kids to the pumpkin patch, feel free to pick a pumpkin from the ones that are waiting on the rack or in the bin.  But beware of the pumpkin patch itself.

Paradoxical Pathology

Every Thursday afternoon, I have been going to a diet program. It has helped me lose some weight, and that’s healthy for me. I feel good about it in general, despite my occasional lapses. The program involves weighing and testing every week, and I meet with the doctor. There’s also a nutrition class to help re-educate me, which is also a support group for the dieters. It’s been really, really, hard. I have often felt ravenously hungry and uncomfortable. I do the best I can. Apparently, however, I was the only one who was struggling. Everybody else in the support group would brag how this was the easiest diet they’ve ever tried, that they are never hungry, they love the protein shakes, they don’t miss eating, and they were losing weight like never before. I felt great about my weight loss, but felt like a complete failure after each support group. By the end of the second month of the program, I had lost about 20 pounds. After every Thursday support group meeting, I would drive directly to a local restaurant and have a huge plate of nachos, with guacamole and sour cream.

In my post Squirmy, some detective work and a lot of experience led me to the realization that the cream the parents were using to get rid of the baby’s rash was actually causing the rash it was supposed to treat. As the baby’s rash became more extensive, they put on more cream. As the baby’s skin became more inflamed, even more cream.

(By the way, that true story is a potent example of how valuable a house call can be. If I had not been there in person, to see the baby’s surroundings, to ask the parents to show me the actual container of every single thing that touched the baby’s skin, a different cascade of events would have happened. They would have taken the baby in to see me. I would have had to prescribe a very strong steroid medicine. It probably would not have worked, or not have worked well. Without progress, I would have done a bacterial skin culture and probably started the baby on antibiotics. I might have sent the baby to a dermatologist, who would have intervened even more. When would the parents have mentioned the ‘safe’ ‘natural’ ‘herbal’ skin cream?)

As I thought about the unsupportive support group, I realized that this was a phenomenon that occurs from time to time, and is often extremely difficult to diagnose if the problem is a medical one. I have coined the term Paradoxical Pathology because the resulting problem is contrary to what might be expected.

A couple of years ago, an adorable little girl came to the office with hives. She was itchy almost all over. Her mother said that this started last night, but it was very slight and didn’t bother her too much. Her mother gave her a Benadryl. She didn’t have any trouble sleeping. When she awoke early in the morning, she was covered in hives and was very uncomfortable, so the mother called me right away. I met them in the office about 7:30. By that time, the Benadryl had long worn off and I gave her another dose. Her mother and I reviewed absolutely everything that had gone in or on her body in the previous 48 hours. She hadn’t had new foods, been to new places, worn new clothes, or had any medications. I told both mother and child that I wasn’t sure what caused this, but told them to continue the antihistamine medication and stay as cool as possible.


By itself, this story wasn’t particularly concerning to me. The child was breathing comfortably, without wheezing or coughing, and could speak a whole sentence. She was itchy, but not in any danger. I sent them home.

Hives is the term we use for a medical condition called urticaria. Basically, when the body senses the right trigger—such as a protein from a certain food—it sends out messengers that cause certain cells to release a chemical called histamine. Histamine makes tiny capillary blood vessels leak, which causes swelling and redness. It also is extremely itchy. Naturally, the medicines we use to help with this are anti-histamines. Most of the available ones work pretty well, though some make you sleepy. Because urticaria causes swelling and redness, we can usually counter this directly, with a cool shower. When kids (or grown-ups) are itchy, warmth will worsen the itch and keeping cool will often help it. Nearly half the time, we never figure out what causes hives.

The girl’s mother was frantic when she called that afternoon. So a few hours later, they returned to my office and the child was much worse. She really looked miserable, but now her whole face was puffy, her eyes were red, and the serpentine red marks of the hives had joined into a giant red ocean on her skin. I gave her a shot of steroids in her behind, and made them wait in my office. In 5 minutes she started to feel better, and in 30 minutes most of the redness was gone. She felt great.

I sent them to the lab for allergy testing. In general, there are two types of allergy testing: skin tests and blood tests. In skin testing, each substance being tested is scratched into your skin. Then we see if you get red, itchy, and swollen. The problem with this in children is that in order to test a large number of things, the kid has to be scratched a large number of times. Each scratch can cover just one thing. With a blood test, the child’s blood is sent to a lab where it is exposed to as many possible culprits as I request. It’s still just the one poke. The downside here is that they usually need to draw quite a lot of blood. Sometimes one kind of test will show a reaction but the other kind won’t, which confuses things. The bottom line is that these are just tests. There’s only one lab that gets absolutely accurate results every time—the child herself. I have often had an allergy test say that a patient isn’t allergic to something. But when they eat it, their tongue tingles, their lips swell up and get itchy, and they say they don’t feel right in their throat. Whatever the lab said just doesn’t matter. The only thing that matters is what’s going on in my patient.

Even so, the lab test said (and her mom confirmed by experience) that she probably wasn’t allergic to wheat, corn, milk, eggs, nuts, peanuts, seafood, shellfish, chocolate, melon, strawberries, blueberries, kiwi, tomatoes, cocoanut, banana, soybeans, cheddar cheese, 3 different varieties of mold, 2 different species of dust mite, cats, dogs, 12 different local varieties of pollen, 4 different grasses, and chicken feathers. I sent her to an allergist. There, he repeated many of the blood tests with skin tests and got the same result, with a much less happy little girl.

They returned to my office, and her mother and I started over. This time, I read every ingredient on every label. I sent the poor girl back to the lab with a long list of exotic tests. I even tested for some of the ingredients in the diphenhydramine (Benadryl) that she had been taking. She wasn’t allergic to any of the ingredients of anything she had eaten.

She was, however, highly allergic to Red Dye #40, a food coloring used to make the coating of her pink pills pink. Every time she took one to help with her itching (sometimes at my instruction), she would get worse.


As I think about it more, I think there are many cases of paradoxical pathology. The support group story applies to a lot of social situations. For people with anxiety, for example, forcing them into anxiety-provoking situations often just makes them more anxious.

Do you have a story of being given a treatment for some problem that ended up causing that very problem? Please share it as a comment.

Epilogue: I stopped going to the support group. I felt better and ate better.