San Diego Dr. Milan Brandon is San Diego's longest-practicing allergist. Since leaving the Navy in 1959, he has treated more than 30,000 patients. His son, Donald, also a physician with an interest in allergies, practices with him at their Third Avenue office in Banker's Hill. Brandon has seen a good deal of innovation in treating allergies over the years, but he doesn't quite buy the popular belief that allergies are on the rise.
"There's not necessarily a rise in the instances of allergies, but there is more awareness. Because of the media, the public has learned a lot that they wouldn't have otherwise learned. The problem now is that we're emphasizing food allergies and not putting enough emphasis on toxic allergic reactions."
According to Brandon, toxic allergic reactions are commonly mistaken as food allergies. "Take shellfish, for instance," he explains. "They're a very common cause of hives and other allergic reactions, but a lot of times the reaction is not to the shellfish, but to the shellfish being tainted. So a person will come in with a severe hives reaction, and if you just treat that patient as an allergic problem, they will take a long time to get over it. If it were a true shellfish-allergy reaction, it would clear up in 24 hours. So if you get a reaction to food that hangs on, be suspicious. It's because it's been tainted with bacteria, or some kind of degradation has taken place."
Discerning true allergic reactions from toxic reactions is usually measured by the patient's response to treatment. "If you buy some peanuts and you get an acute allergic reaction with hives and it comes on very quickly and you treat it as an allergic reaction and the patient gets over it quickly -- that's an allergy. Now, let's pretend those peanuts had a lot of aspergillus mold on them. The mold is in the powder, and that mold causes a toxic allergic reaction, which takes longer to get over. When you go buy popcorn in a theater and you get a severe reaction, you might think you're reacting to the popcorn, when you're really reacting to whatever oil was used in popping it. Some of these oils are old, and you never know how long that popcorn has been sitting around before it was popped. Don't always think that every reaction is an allergy. When we skin-test these people to these things, very often the skin-test is negative because they have a toxic reaction to other things. So someone will have a reaction to shellfish, and we'll skin-test them, and if they break out, we know that they're allergic to it. But if they have that toxic-allergic reaction and we skin-test them and find out it's negative, you can be pretty sure that they were reacting to something else."
Mistaken reactions are not limited to toxic reactions. Allergies can easily be misidentified. "Soybeans are a common offender. Soybeans are in so many foods, and people will eat stuff that has soybean in it, and they'll think they're reacting to another ingredient, when, in fact, they are reacting to the soybean. When they go eat something else that doesn't have the ingredient they thought they were allergic to and break out in hives, they don't think of looking at the label and seeing what the ingredients are in that product. If soybeans are near the top, you should be very suspicious that it's the soybeans. The most common offender is milk and dairy products."
The problem children have with milk and dairy products is usually the development of antibodies that lead to an allergic reaction. "It's primarily a problem with children. Let's say a mother is unable to nurse right away, and cow's milk is given to the baby. So the baby has no antibodies, at the time, against the cow's milk and has no allergic reaction. Then the mother is able to produce and starts nursing the baby. After she stops nursing and gives the baby milk, the baby reacts immediately to the cow's milk because it's had this long interval to develop the antibodies to the cow's milk. So even though the cow's milk did not bother it in that first week of life, the antibodies have since been developing against that milk. So when the baby is exposed to the cow's milk later on, it immediately reacts. The longer the interval between exposures, the more time there is to develop antibodies and the more risk of allergy."
Allergic reactions are one of the ways the body has to get rid of a foreign "offender." The runny nose, sneezing, and watery eyes associated with breathing in pollen are just the body's way of trying to dispose of the pollen. The problem is, allergic reactions can get a lot stronger -- to the point where the body seems at war with itself. "A lot of patients notice that if they cough up mucus from their lungs, the asthma will go away. So maybe they got rid of the allergen by coughing it up. Some doctors feel that hives occur because you haven't had enough liquids, and you're trying to eliminate the allergen through the skin. But there's no proof -- that's a hypothesis. Or you get rid of it through the kidneys or digestive tract. So if a person has a gastrointestinal food allergy and consumes that food, if they feel a reaction in their mouth, the first thing they should do is to try to spit it out. That's particularly true with peanuts, because peanuts can cause reactions so quickly that you can feel it when it hits your tongue. If it does get as far as the stomach, you'd get a lot of gas cramps, digestive upset, and diarrhea. Whether it's through vomiting or diarrhea, the body's trying to get rid of it. The allergic mechanism is partly a disposal mechanism, even though you seldom hear that concept."
If milk is one of the most common allergies for children, the myth of breast-milk safety is one of the most common misconceptions. "People have always talked about how breast milk is much safer than cow milk. Now, finally, La Leche League [an organization dedicated to promoting breast feeding] is not working as hard as it used to. After all this time, people are coming out with evidence that shows cow's milk is better than breast milk. Of course, the reason is that with breast milk, your diet changes. If mom is eating a lot of corn, then doesn't have any corn for a number of weeks, then goes on another corn binge, the baby's had time to build antibodies against the corn. So now, when the baby starts drinking mom's milk, the baby starts reacting to corn. A skin-test would be positive for corn. There are a lot of misconceptions that we've passed on because of our bias and trying to look for facts and scientific explanations."
Further complicating the allergy picture are the different kinds of antibodies. "The IGE is the one that gets the most publicity, because it is involved in true, immediate allergic reactions like your immediate reactions to peanuts, shellfish, and so forth. Reactions that occur within 15 minutes after exposure are related primarily to IGE. They are what are called cytotoxic antibodies. Hemolitic anemia, for instance, is one of them, where certain substances will cause that anemia. It's called cytotoxic because it attacks the red blood cells and makes them burst. Then there's the Type III antibodies, which have to do with the immune-complex disorders, like serum sickness. For instance, if you take penicillin today, and you don't get a reaction in 15 or 20 minutes, that means you don't have the IGE antibodies, but, if in a week, you start breaking out in hives and getting aches and pains and joint swelling, that's an immune-complex reaction. That's a very complicated reaction, and it's one of those self-perpetuating actions that can go on for weeks or months and be very prolonged. Then there's the Type IV reaction, which is a delayed reaction in which the lymphocytes [cells in lymphatic tissue] and cytokines [extracellular factors that alter and affect other cells] are involved. It's also called a tuberculine reaction. For instance, if a person was exposed to tuberculosis, and you test him with the skin-test, you don't see a reaction in 15 minutes. You'll see it in 24 to 72 hours. Those are the different types of reactions."
Some people suffer from allergies in reverse. "That's called 'anergy.' That's where you don't react. Let's say you had tuberculosis years ago, and I skin-tested you, and you don't react. That means you have anergy. Very commonly AIDS patients will have that. They have such severe immune deficiency that when you skin-test them for TB, not only is the skin-test negative, but their delayed reactivity to a lot of other things is also negative. That person may have tuberculosis throughout his lungs and his brain and still have a negative skin test because he has anergy. Of course, that's why he dies, because he has no immune system to fight back. That's one of the problems we have with transplant patients. We interfere with normal immune mechanisms so much in trying to help the patient tolerate the organ, and that's one of the risks. This applies to treating several forms of cancer and how far we can go with chemotherapy too."
During the 1960s the majority of Brandon's patients were children, but with the growth of pediatrics, almost none of his patients are children anymore. Treating kids forced him to change his methods of testing -- a precursor to the more advanced methods now available. "When it comes to small children, you have to be very careful about skin-testing them. When I did skin-test little children -- like one-year-olds -- I had enough trouble with severe allergic reactions that I immediately abandoned it. I skin-tested a baby about a year old and got an anaphylactic [extreme shock] reaction to milk. We treated it and everything went fine. I still take care of people in that family, so I know they don't hold it against me, but I learned that wasn't the right thing to do. I decided it would be better to work with elimination measures and diet. In those days, we did tests by way of 'passive transfer.' That's where you take blood from the allergic individual, separate the serum, and inject it under the skin to a nonallergic patient and mark the spots where you injected the person. Then you skin-test into the spots with dog hairs, dust, feathers, and so forth. The reason we abandoned the passive-transfer test was the worry about transferring diseases like hepatitis or, nowadays, HIV and so forth. We always tried to find a family member to be the nonallergic individual. Nobody does that today except in research at universities. Nowadays we have the RAST test, in which we measure the allergy antibodies through the blood. Now we measure the antibodies directly in the serum of the blood. This is very, very good and very safe. The disadvantage is that you get more 'false negatives' with it. A person may be allergic to something, but the RAST test may come out negative. On the other hand, the disadvantage of the skin test is that you have more 'false positives.' I personally think the RAST test is a great thing. It's finally coming to the fore, even though it's been out for 30 years now!
"What's bothering me now is that there is a new treatment coming out called 'anti-IGE.' It's a shot you would take every two to four weeks that blocks the allergic antibodies, which sounds fantastic. So no matter what you're allergic to, it's blocking the allergic reaction. But what I think is going to happen is that doctors will draw blood on their patients, RAST test it, find out what the patient is allergic to, tell them to avoid this, that, and the other thing. But instead of giving them allergy shots to build up their immunity to what they're allergic to, it'll be 'Oh, I'll just give you anti-IGE shots, because that'll cover the waterfront.' So you won't have to have allergy shots. The public needs to know that anti-IGE does not stimulate immunity against the things to which you're allergic. It's simply keeping your IGE antibodies from reacting. I don't think we have any evidence to show that the risk of allergic reaction to it is any smaller than the risk of taking allergy shots. In other words, you can get anaphylactic reactions to anti-IGE as well as allergy shots. You're not doing anything to stimulate the normal immune system to stimulate what we call 'blocking antibodies,' which block the allergy. That's where the allergist comes into the picture, because he can prescribe the appropriate solutions so the patient can build up his immunities to whatever he's allergic to. I can just visualize the drug salesmen telling doctors, 'You don't have to send patients to an allergist anymore, just give them anti-IGE shots.' Then I can see doctors saying, 'Gee, if it's that good, I don't have to do any allergy tests! I'll just give them anti-IGE shots!' We've got to work on things that stimulate the immune system and stimulate anti-allergy antibodies. The antihistamines and all the other medications we take, the anti-IGE are all what I call 'symptomatic treatment' or 'passive treatment.' God has a reason for each of the immune processes in our body, so that when we suppress IGE, we're allowing something else to flare up."
One of Dr. Brandon's most enduring lessons in treating reactions came during his days at USC Medical School, when he worked at Claremont Community Hospital. "I was driving to the hospital to do rounds on my patients, and these men were working on the road with tractors. When I arrived, the intercom announced that there was an emergency, and they needed a doctor right away. So I responded, and it turned out to be one of the workers on a tractor. He had gone through a beehive and over 100 bees had stung him. He was literally dead. He was completely profuse with perspiration and completely white. He was as wet as you could be with perspiration. His blood pressure and pulse were zero. I got adrenaline right away, and I shot it into his heart. His heart started going right away -- in the old days resuscitating was different. He responded nicely to the adrenaline, and we were able to get his blood pressure up, and in a few hours he was greatly improved.
"Now you would ask, 'Was that an allergic reaction or was it not?' Well, there's two or three things involved. Number one, he was swarmed by bees with bee venom. But there also had to be a toxic component. I've always thought that with every bee sting, there's not just an allergic reaction involved, but a toxic factor. Now you hear all this publicity about 'killer bees' and much more about their toxic effect. I think that the real problem is that the nice bees that are producing honey for us aren't interested in stinging us, whereas the killer bee is much more interested in stinging us. His occupation is different -- I'm not an etymologist. But I'm not sure that they're any more dangerous than any other bee; they're just more likely to sting you and more likely to swarm on you. I think toxic reactions are just as important as allergic reactions. We shouldn't assume that everything we see is allergic or that everything we see is toxic. Very often, it's a combination of the two."