SYSTEMIC
MANIFESTATIONS
DUE
TO
ALLERGY
790
PmAi-mcs, May 1961
Reporl
of
Fifty
Patients
and
a Review
of
the
Literature
on the
Subject
(Sometimes
Referred
to
as Allergic
Toxemia
and
the
Allergic
Tension-Fatigue
Syndrome)
William G. Crook, M.D., Walton W. Harrison, M.D., Stanley E. Crawford, M.D.,
and Blanche S. Emerson, M.D.
Tile Children’s Clinic, Jackson, Tennessee
T
HERE is a kind of allergy that is metwith in children of all ages, yet is easily overlooked if the physician is not aware that it exists. Signs of this disorder may be noted in the child’s facies as he walks fully clothed into the physician’s office. He ap-pears pale or sallow, although the blood
may later be found to be normal; his eyes have dark circles under them, and often there is an associated puffiness of the
pen-orbital areas. He looks listless and tired even
though lie has had a full night’s sleep. As the child’s examination proceeds, other
characteristic symptoms and signs are
un-covered. Almost without exception, he tends to have a stuffy nose, although this
symp-tom is rarely the presenting one.
Fatigue or the feeling that the child is
“rundown” is often the main complaint
\Vilich causes the parents to bring the child
to the physician. They are concerned about
his sluggishness, drowsiness and lack of
in-terest in both schoolwork and play. They
further comment on his general irritability,
peevishness and unpredictable behavior.
They are apt to say, “Jimmy just isn’t like himself.”
Sometimes the child shows more severe
neunologic and psychologic signs and
symp-toms, including panesthesias, facial ties, se-vere personality disturbances and even
psy-Cilotic behavior.
A detailed history often discloses a wide variety of symptoms referrable to different
systems of the body. Of these, abdominal
pain and headache are the most common.
Less frequently seen but not uncommon are
leg ache, backache, enuresis and excessive
ADDRESS: (W.G.C.) 648 West Forest, Jackson, Tennessee.
sweating. The latter symptom seems more
noticeable in infants and young children. In
spite of these many symptoms, the physical examination, except for the facies previously
noted, is often not remarkable.
The laboratory examinations also are
ally within norma! ranges, but on occasion
an increased number of eosinophils may be found in the peripheral blood smear or in the nasal secretions. Although allergy skin
tests are often positive in some children
with this kind of allergy, in others such
tests may be negative.
A careful examination of the medical lit-erature reveals that systemic manifestations due to allergy have been described by many
observers during the past several decades.
However, since these reports are scattered and terminology is often confusing, they have often been overlooked or given only brief coverage in most allergy textbooks. This report is presented to describe again
the systemic manifestations which can and
do occur due to allergy; to report the find-ings in 50 children with such
manifesta-tions; and to review the literature.
CLINICAL OBSERVATIONS
Fifty patients with systemic
manifesta-tions due to allergy were recognized in a
pediatric group practice in Jackson, Ten-nessee, between January, 1956, and May, 1960. The diagnosis was suspected because of the patients’ sugggestive clinical history and characteristic appearance. In patients with systemic symptoms due to pollen, the
diagnosis was made by correlating the
partie-TABLE I
SYMPTOMS AND SIGNS FOUND IN THE 50 PATIENTS
OF THE PRESENT SERIES
*Major symptoms were those volunteered by the
parent in relating the history. Often such symptoms
were the “chief complaint.” Minor symptoms were
those elicited by routine questioning of the parent. **Irritability, restlessness, inability to concentrate, anxiety, tearfulness, peevishness, perversity, paranoic
ideas, compulsiveness, etc.
***Oral temperature readings of 99 to 99.8#{176}F.
ural pollen season with a positive skin test
for the same pollen. In each of the four
pa-tients with systemic manifestations due to
inhalant allergy alone, the customary
respi-ratory symptoms of pollinosis were either absent or minimal, while the generalized
symptoms were severe and disabling.
A diagnosis of food sensitivity was made in the following manner: Symptoms and
signs were relieved by eliminating a
sus-pected food from the diet for 5 to 12 days
and then reproduced by giving the food
back to the child. This technique of food testing has been modified from that
de-senibed by Rinke!.1 The majority of patients
included in this report had symptoms
re-lieved and reproduced on at least three
oc-casions by this withdrawal and challenge technique.
The first of this group of 50 patients was
recognized in January, 1956. Over half of
the group were patients who had been
fol-lowed for 5 years or longer. During this
pe-nod of time, the allergic nature of many of these children’s symptoms went unrecog-nized. It is of interest that no diagnosis had
been made for four of these children even
though they were intensively studied in
uni-versity medical centers.
In addition to the 50 patients discussed
here, a larger number of patients were
ob-served in whom generalized allergy was
suspected but in whom the specific
causa-tive agent could not be determined.
Symptoms and Signs (Table I)
The five signs and symptoms which were
present in all but 1 of this group of 50
pa-tients were fatigue, irritability and other
mental and emotional symptoms, pallor,
cir-des under the eyes and nasal congestion.
The fatigue varied from a mild morning
sluggishness in some children to
ineapaci-tating drowsiness in others. In several the
need for sleep was so great that they would be found sleeping on their desks in school in spite of an adequate night’s rest.
Irritability, unhappiness, unruliness,
emo-tional instability, rebellious behavior and even more serious emotional symptoms were
Symptoms and Signs Majors* Minor*
Fatigue 39 11
Mental and emotional symptonls** 26 23
Pallor 35 15
Circles under eyes 38 12
Stuffy nose 23 26
Headache 10 16
Stomach-ache 16 18
Leg ache 5 4
Excessive sweating 0 7
Low grade fever*** 3 3
Backache 0 3
Visual disturbances 3 0
Bladder symptoms 2 3
Swelling of abdomen 2 0
Numbness of hands or tingling
and swelling of hands 3 0
Pain in neck and/or shoulder 1 4
Tachycardia 1 0
Puffiness 1 0
Swelling of face or upper lip 1 2
present in all but one of this group of
pa-tients. Although symptoms of fatigue and
in-nitability were common in these patients, the
alternating type of symptom pattern in the
same patient was not as frequently observed
as has been described by Speer.24
The pallor and circles under the eyes in
combination with a stuffy nose are so
char-actenistic of this condition that the diagnosis in many of these children was suspected at
a glance even before the history was taken
and diagnostic studies performed. Certainly,
it has been our experience that when a
careful diagnostic examination shows no evidence of anemia, chronic infection or
other generalized body disease, that the child with such facies usually is allergic. In
our opinion, these five cardinal symptoms
allergy as fever, polyarthnitis and carditis
are of rheumatic fever.
In addition to the signs and symptoms which were present in almost all of this group of patients, an amazing variety of other symptoms were present in some of them. Among the more unusual of these were the following: The 7-year-old daugh-ter of a registered nurse for years had been noted to have a prominent abdomen, a!-though she was not obese and her posture was good. Furthermore, the size of the abdomen showed considerable variation. In addition, the child’s nose showed intermit-tent congestion; her complexion was pale, with associated infraorbital circles; her emo-tional stability was labile, and she was often tearful without apparent cause; she com-plained of intermittent abdominal pain. Re-cently, after much dietary experimentation, the mother has been able to demonstrate that she can precipitate these signs and symptoms by daily feeding of chocolate and relieve them by chocolate elimination. Among the most striking of these signs is a 4-in. variation in the circumference of the abdomen.
A 15-month-old child became drowsy, irritable and, on several occasions, stuporous within 30 minutes after eating an egg. Along
TABLE II
MISTAKEN DIAGNOSES5
Diagnosis Patients
Functional disorder, behavior prohlem,
psychoneurosis, anxiety state, etc. 9
Cerebral palsy 3
Hypothyroidism 2
Rheumatic fever 2
Peptic ulcer 2
Psychosis I
Abdominal epilepsy 1
Petit inal epilepsy 1
Rheumatoid arthritis I
Intestmal polyp 1
Cehiac disease 1
Mental retardation 1
Trichinosis 1
SMade in ,50 children whose clinical features were
subsequently found to he due to systemic
manifesta-lions of allergy.
with these generalized symptoms was an associated urticania. Two years later, this child’s tolerance to eggs had gradually in-creased so that infrequent ingestion of small amounts was possible without urticaria. However, ingestion of eggs on two succes-sive days resulted in pallor, infraorbital circles, sluggishness and irritability.
An 11-year-old girl gave a history of re-current generalized muscular and joint
sore-ness and aching, especially in her neck and
shoulders. This type of clinical picture has
been recognized and described by Rowe5 and Randolph.”7 In addition, the child had recurrent and frequent episodes of spas-modic torticoilis. She had been seen by many physicians, who llad given such tenta-tive diagnosis as arthritis, psychoneurosis and rheumatic fever. After repeated elimi-nation diet testing, it was determined that her symptoms could be relieved completely by eliminating corn from her diet and repro-duced by adding it back.
Mistaken Diagnoses (Table II)
The pattern of mistaken diagnoses is of interest. There vere 14 diagnoses of dis-orders of the nervous system. Nine of the disorders were functional and the five were organic. Actually, these diagnoses were not entirely incorrect, because these children did have disorders of the nervous system. Instead, tile error was that the allergic cause of tile nervous system disorder went
un-recogmzed.
Associated Allergies (Table Ill)
About three-fourths of these patients had, or had had, other allergies, Conversely, it is of interest that one-fourth of this group had no definite allergy other than a possible a!-hergic rhinitis.
Causes (Table IV)
TABLE IV
CAUSES OF ALLERGY IN TIlE PRESENT SERIES
ALLERGIC FAMILY HISTORY INTHE PRESENT SERIES
TABLE VI
RESULTS OF SKIN TE.STS IN THE PRESENT SERIES
Tested 19
Positive 12
Negative 7
Not tested 31
TABLE VII
RESPONSE TO TREATMENT IN TIlE PRESENT SERIES
than the cereal grains, which have been found3’ -‘#{176} to be such important causes of food allergy.
In analyzing this group of patients, it is of interest that 18 of the 24 milk-sensitive
patients over the age of 5 years gave a
his-tory suggestive of milk allergy during the
early months of life. In many of these ehil-dren this allergy had supposedly been out-grown. This phenomenon is well illustrated in Case I, presented below.
Allergic Family History (Table V)
Over tWO-tilirdS of these patients had
family histories of allergy, and in one-third
it was very strong. In several patients,
a!-lergy to the same food, especially cow’s
milk, had been noted in several generations of the patient’s family.
Allergy Skin Testing (Table VI)
Fewer than half of this group of patients reported were given allergy skin tests. How-ever, most of those who were tested showed positive tests to various allergens, usua!!y inhalants. In only two patients were there positive skin tests to the foods to which they were clinically proven to be sensitive. This finding agrees with that of others,5’ 8-15 who
stated that the only accurate means of
identifying clinical food sensitivity is by the use of trial elimination diets.
Response to Treatment (Table VII)
MOst of the patients had good, excellent or superior results iii that their syfliptolTiS
TABLE III
ASSOCIATED ALLERGIES (PAST AND PHESENT) IN THE PRESENT SEnIt:55
.4ssociated Allergic Syndrome Patients
Asthma or asthmatic bronchitis 13
Eczema 11
Intestinal allergy 11
Seasonal hayfever 6
Urticaria 5
S In 13 patients there was no associated allergy
other than a possible allergic rhinitis.
Causative Agent Patients
Foods alone 38
Inhalants alone 4
Foods and inhalants S
Milk 28
Chocolate 21
Egg Ii
Ragweed 6
Wheat, corn, peanuts 6
Pork, orange juice, vitamin
B1,horse dander, grass 55*
*Two *5One each.
TABLE V
Family History of Allergy Patients
Very strong (3 or more in
immedi-ate family with major allergy) 17
Strong (I parent and 1 sibling
with major allergy) 9
Moderate (1 parent or 1 sibling
with major allergy) 10
Unknown or negative 14
Results Patients
Results Patients
Superior (symptom free) 5
Excellent (occasional mild symptoms) 21
Good (occasional mild to moderate
symptoms) 16
Fair (improved but still have
mod-erate symptoms) 5
SYSTEMIC ALLERGY
were completely or substantially relieved.
However, it is pertinent to mention that there are many other patients in our prac-tice with symptoms and signs suggestive of generalized allergy who have not been helped significantly by allergy investigation and management.
Representative Cases
CASE 1:M. L., male, was born in 1944. During the first year of life this child had moderate eczema wilich subsided when cow’s milk was eliminated from his diet.
Milk was reintroduced at 18 months
with-out recurrence of the eczema. During the
next eight or nine years, the child’s general
health was fairly good, although he had an
almost constant nasal congestion during the winter months. He also tended to have oe-easional bouts of gastrointestinal dysfunc-tion and recurrent episodes of fatigue and
listlessness.
In 1955, the child began to have frequent
headache and abdominal pain. He became
highly nervous, cross and irritable. He was
pale, and his lips were parched and swollen. He developed a facial twitching which was embarrassing to him and to his parents. He became increasingly irritable and began to complain of backache, leg ache and fa-tigue, worse each morning on arising. His disability was such that he was absent from school 17 days during one school semester.
Genera! physical and laboratory examina-tions showed no abnormality except for
slight facial pallor, infraorbital circles and
a slightly boggy nasal mucus membrane. A
tentative diagnosis of a psychosomatic dis-turbance was made. He was given sympto-matic treatment and an effort was made to determine possible underlying causes. Little progress was made and the child’s symp-toms became increasingly incapacitating.
Finally, at the mother’s suggestion, the
possibility of allergy was considered.
Al-though scratch tests showed no positive re-actions, cow’s milk and house dust gave positive reactions on intradermal testing. The child was then put on a diet eliminat-ing milk. Within a week his color became norma!, the morning complaints
disap-peared, his stomache and headache van-ished, and his disposition greatly improved. The facial twitching completely disap-peared. An almost miraculous change in the child’s genera! health occurred. His school performance showed a dramatic
improve-ment.
In the 3 years since finding milk
sensi-tivity in this child, he been repeatedly
tested with challenges of milk and
milk-containing foods. If he ingests milk-contain-ing foods in several consecutive meals, he
has mild abdominal distress and fatigue. If
he actually drinks milk for several
succes-sive days, he becomes irritable, nervous and
depressed and has severe headache and ab-dominal pain.
To confirm objectively this patient’s
sen-sitivity to cow’s milk, in 1958 a double-blind
study was performed. Some of 480 gelatin
capsules were filled with powdered skim
milk and others were filled with powdered sugar; 16 capsules were placed in each of 30 envelopes. Four capsules were taken by the patient at each mealtime and at bed-time. During the first three weeks of the month, only sugar capsules were given, ex-eept for a single day of milk capsules on the ninth day and two consecutive days of milk capsules on the fifteenth and sixteenth
days. Beginning with the twenty-first day, nothing but milk capsules were given each
day. Both the patient and his mother were unaware of which capsules contained milk and which contained sugar.
A record of symptoms was maintained during the entire period of the test. Slight irritability and fatigue were noted on the morning of the seventeenth day, but symp-toms were minimal. The child was asymp-tomatic on the eighteenth day. Beginning
insidiously on about the twenty-third day
child became completely asymptomatic. This child’s tendency to nasal congestion
and frequent wintertime colds has almost completely disappeared since a dust-free room was instituted. No injection therapy
has been administered.
CASE 2: V. F., a white female, was born in 1948. In 1954 and 1955, this child was seen twice in our clinic with complaints of
stomach-ache, nervousness and poor
appe-tite for vhich no cause could be found. Beginning early in 1956, her symptoms
became much worse. The mother described them as follows : “She stays tired a!! the time. She doesn’t want to play or to go to
school. When she is at home she sits in the corner sucking her thumb. She screams out
at her father or me if we try to talk to her and especially when we start to put her to bed.”
Meanwhile, the child became pale and developed prominent infraorbital circles. Her school work became poor and she was reported to be inattentive in class. In June, 1956, in addition to other symptoms, the child began to show obsessive, compulsive behavior. According to the mother’s deserip-tion-”She counts slippers, powder, per-fume, all the things in her bedroom. She counts herself into hysterics. She sits in her room with her hair tousled up. We can
hardly get her to notice us when she is
hay-ing a bad spell.”
A complete history, physical and
labora-tory examination disclosed no detectable organic or psychologic clue as to the na-ture of this child’s disorder. Temporarily,
psychotherapeutic medications were
pre-scribed and psyciliatric referral was initi-ated. In spite of the medication and treat-ment measures, her symptoms continued.
In August, 1956, the child was seen
casu-ally in the clinic at the time of an
immuni-zation. Due to her peculiar pallor and the deep circles under her eyes, plus the pres-enee of allergy in a younger sibling, an elimination diet was suggested to the mother. Two days after chocolate was eliminated, the child began to improve
rapidly. Within seven days, the mother
stated the child seemed “perfectly normal,”
with no headache, abdominal pain, com-pulsive behavior or nervousness. Her pallor became less and she was reported to have shown a complete personality change. This improvement was maintained completely
during a 6-week period of chocolate
elimi-nation. Subsequent ingestion of chocolate resulted in symptoms of vomiting, ab-dominal pain and headache.
Interestingly enough, on reviewing this child’s history, it was noted that the child’s severe symptoms developed about 2 to 3 weeks after the family obtained a television set. Apparently influenced by repeated tele-vision advertisements of a chocolate syrup manufacturer, the child increased her con-sumption of chocolate milk to approxi-mately a quart a day. A daily ingestion of approximately the same amount or more of this beverage continued during the 8-month period of progressively increasing symptoms.
CASE 3: M. U., a white female, was born in 1944. This child was seen regularly at the Children’s Clinic from 1950 to 1956. During this period, she was seen several times a year with complaints of headache, stomach-ache, irritability and nervousness. In addi-tion, the mother repeatedly stated that the child was “puffy,” and had intermittent swelling of her hands and feet.
Furthermore, the child was said to have an excessive need for sleep. On at least two occasions, the child’s teacher suggested that the mother bring the child in for examina-tion because of excessive drowsiness at school. The mother stated that the
child
usually retired immediately after the eve-ning meal, and although she slept 13 hours at night, she was difficult to arouse in the morning. History, physical and laboratory examinations were repeatedly nonreward-ing in determining the cause of this child’s symptoms.
becom-196 SYSTEMIC ALLERGY
ing severe only two or three times a year; during the summer months she was essen-tial!y asymptomatie. No satisfactory diag-nosis was made and a functional problem was suspected.
In 1956, when this child returned again with these same complaints, her entire his-tory was reviewed. Recognition of similar symptoms due to allergy in other children and the presence of severe allergy with milk intolerance, intestinal allergy and asthma in a 2-year-old sibling led to the institution of trial elimination diets. Follow-ing repeated experimentation, she was found to be exquisitely sensitive to choco-late and moderately sensitive to egg and milk. Symptoms were completely relieved on an elimination diet. Symptoms of fatigue, drowsiness and irritability could be repro-duced at anytime by introducing small amounts of chocolate into the diet or by giving milk or eggs daily. The child had no associated allergies other than a tendency to nasal congestion during the winter months, which was accentuated at the same time her fatigue symptoms were most prominent.
CASE 4:
C. A.
WI., a white female, wasborn in 1952. This 6-year-old child was first seen at the Children’s Clinic in the fall of 1958 with a chief complaint of “fatigue and low blood.” The child gave a history of easy fatiguability since infancy. This fatigue had become much worse in the preceeding 2 years. The mother stated, “She can’t stay up al! day at a time. She gives out about
11 o’clock in the morning. She just can’t get enough sleep.” In addition, the child had periodic stomach-aches and headaches. She had a history of relatively few colds. There was also a history of aching in the feet, legs and shoulders.
Family history showed “sinus trouble” in mother and one sibling. Both the patient and her father were subject to recurrent urticaria. There was no history of asthma, hayfever or eczema in the child or her par-ents. A complete hemogram and urinalysis were normal. The physical examination was not remarkable except for pallor and infra-orbital circles.
A diet eliminating milk, eggs and ehoco-late was prescribed. In 7 days the mother reported that “the child did not seem like the same child.” Her teacher suspected that she had been given “pep pills.” The child’s genera! feeling of well being continued to be excellent for 5 more days, at which time she was challenged with milk, eggs and chocolate. These were fed to the patient at the evening meal and again the following morning. By midmorning, she was noted by her teacher to be so fatigued, sluggish and
drowsy that she was unable to sit at her
desk.
The suspected foods were removed from the child’s diet and again the symptoms of
fatigue, headache and irritability subsided
in 2 to 3 days.
Subsequently the mother reported that on
at least six occasions, when the child in-gested milk and eggs, she became droopy and irritable. Without these foods in her
diet, she felt well and
did
well at school. In addition, the mother insisted that thechilds stammering disappeared and that her
use of words improved. Also, before milk and eggs were eliminated, she would
fre-quently have periods when “she just
couldn’t think.” These have not recurred since she has been on her diet.
REVIEW OF THE LITERATURE
Hoobler’6 described this clinical picture quite clearly. He noted especially, the dis-turbanee of the nervous system in allergic infants and young children. He commented upon “their restlessness, fretfulness, and
sleeplessness” and their tendency to
irrita-bility. Shannon17 reported seven patients. with generalized symptoms due to allergy. He especially emphasized the involvement of the nervous system. Although the pa-tients he described had such allergies as eczema and asthma, they were also de-seribed as being unusually irritable, peevish and out of sorts. He further noted that the nervous manifestations were out of propor-tion to the primary allergy and were not
al-ways caused by the same allergen.
drowsiness which could be precipitated by
eating a particular food. Duke192#{176} called
at-tentioll to the occurrence of fatigue and other generalized symptoms in allergic
pa-tients. In his experience, these symptoms were usually caused by foods. Piness and
Miller21 suggested that symptoms of
nerv-ousness and irritability in allergic children
could be due to allergic sensitization of the
tissues of the nervous system. Kahn22 de-scribed children with severe systemic and
psyehologic symptoms due to po!linosis. These symptoms included fatigue alter-nating with intense irritability.
In 1930, Rowe8 published the first of his series of descriptions of the systemic,
psy-chological and neurological symptoms
which occur in some patients with food
allergy. Among the symptoms he noted
were drowsiness, irritability, fatigue,
weak-ness and slowness of thought. In other pa-tients, especially in children, he noted
irri-tability and incorrigibility. Rowe used the term food toxemia for this condition.
Winkelman and More23 partially
re-viewed the literature of allergy of the
nerv-ous system. They emphasized the
im-portanee of “giving due consideration to
allergy in the etiology of many baffling
neurological problems.”
Sternberg2 reported a patient with an incapacitating somnolence and associated
hypotension occurring each year during ragweed pollen season. This observer felt that these cerebra! symptoms were due to a sensitization reaction to the pollen, and he felt that this hypothesis was confirmed
when these symptoms subsided following
pollen vaccine therapy. It was of interest that there were no associated nasal or
bron-ehial symptoms.
Karnosh2 emphasized the ability of a!-lergic reactions to occur “at every level of the nervous system from the highest and
most elaborate centers in the cortex to the humblest, sympathetic terminal in the capillary loop of the skin.” Clarke,26 in the same year, stressed the importance of con-sidering allergy in searching for the cause of neurologic and psychologie problems.
Schneider27 commented on the possible role
of allergy in causing emotional problems, abdominal pain, headache, tension and un-ruliness in elementary school children.
Randolph124 published the first of his series of observations on the patient with fatigue, irritability and other systemic re-actions of allergic origin. Like other oh-servers, he noted the occurrence of bouts of abnormal behavior in otherwise vell-adjusted children. This author described for the first time the facial pallor, eyelid edema and infraorhital circles often seen in children with allergy.
Alvarez28 reported on “nervous storms” due to food allergy.
Clarke29 reported the results of a survey
made for allergy and its possible
relation-ship to “character problems in children.”
Replies were received from 171 practicing allergists. Ninety-five of those who replied stated that they had noticed personality changes due to allergy which corrected themselves when the allergic element was eliminated. Clarke, in analyzing the results of his survey, commented on the selective nature of allergy. He specifically hypothe-sized that, in many allergic individuals, altered behavior may be due to the direct involvement of the brain cells or other parts of the nervous system in the allergic reaction.
Davison,30 in discussing this paper, stated, “Dr. Clarke’s paper removes any possible doubt that these symptoms (that is, mental and emotional symptoms) must be con-sidered the direct results of allergic reaction in the nervous system.” He further com-mented that certain children without aller-genie foods in their diet are like Dr. Jekyll;
when those foods are added back to the
diet, tiley are almost demons like Mr. Hyde. 332 described his own observa-tions on allergy of the brain and nervous
system. In addition, he reviewed the litera-ture in detail. Like other observers before him, he commented on the alternating type of symptoms seen in many patients. These included “sleepiness on the one hand and
SYSTEMIC ALLERGY
Rinkel et al.” described in detail many of the generalized manifestations of food allergy. They hypothesized that symptoms of fatigue, aching and irritability may occur at a level of sensitization usually below that which is associated with such localized a!-lergic manifestations such as asthma, hay-fever and eczema.
Pounders33 described many of the sys-temic symptoms occurring in allergic chi!-dren. These included pallor in the absence of anemia, puffiness or discoloration under the eyes and unnatural tiredness. He also mentioned the uncooperative and antisocial behavior of children in allergic imbalance as well as abdominal pain, leg ache and ex-cessive sweating.
Clein34 reported on 204 infants with cow’s milk allergy. Although he emphasized skin, respiratory and gastrointestinal manifesta-tions, he also recognized and described in-fants with severe generalized reactions due to milk. These included unhappiness, list-lessness, apathy and toxemia.
Among the most recent descriptions of the systemic manifestations of allergy have been those of Speer.24 This observer, like others cited above, commented especially on the occurrence of symptoms of fatigue and irritability. He stated that these symp-toms occur in the same child at different times. He felt that these symptoms are due to a primary allergic disorder of the nervous system. In support of this hypothesis is his observation and the observation of others that “the degree to which the patient is disturbed has no predictible relation to other allergic disease or its severity.” For this general syndrome, he suggested the name “allergic tension-fatigue syndrome.”
Another recent contribution to the litera-ture is the report by Moore35 on symptoms of po!!inosis occurring in parts of the body other than the respiratory tract. He espe-cially commented on the psyehologic and neurologic manifestations. The symptoms in many of his patients, including fatigue, fretfulness and irritability, are similar to those described by others. He also observed that in some of these patients, “the classic
symptoms of hayfever have been at a
mini-mum, and the extra respiratory tract symp-toms have been the most pronounced and
troublesome as far as the patient [was] concerned.
COMMENT
This report on the varied systemic mani-festations due to allergy presents nothing which has not been previously reported. However, since many of these reports have been buried in the literature, it seemed pertinent to review them and to add to them our own experiences. It also would appear that the relatively large number of patients with this syndrome seen in our practice in a 4-year-period would indicate that systemic or generalized illness due to allergy is much more common than is usually recognized.
In our opinion it is especially important to emphasize that the clinical picture pres-ent in these children is so characteristic that it can be suspected at a glance by the
inter-ested
physician who is aware of it.It is only fair to state that, although we are convinced that a variety of symptoms can be due to generalized allergy, that often such a diagnosis is a presumptive one and based on clinical and subjective data alone. Absolute proof of these observations by im-munologie or other objective testing meth-ods would do much to clarify the whole sub-jeet. Perhaps it is not too much to hope that this clarification may come in the near fu-ture.
In conclusion, it is suggested that allergy be included in the differential diagnosis of illness in any child with generalized body symptoms of an obscure nature. It would seem especially pertinent that allergy be ruled out before a diagnosis of a functional disorder is made.
SUMMARY
Uniformly, the symptoms and signs in these children were fatigue, irritability, pallor in the absence of anemia, and infra-orbital circles. Most of them also had nasal congestion, abdominal pain and headache.
A variety of other signs and symptoms, in-eluding those of nervous system involve-ment, may also be present.
The literature on this condition is re-viewed in detail showing that this condition
has been described under several different
names by many observers during the past
40 years. In spite of these descriptions, few
physicians are aware that allergy causes
such systemic manifestations.
In conclusion, it is suggested that allergy be included in the differential diagnosis of
any child with generalized body symptoms
of undetermined cause.
REFERENCES
1. Rinkel, H.
J.,
Randolph, T. C., and Zeller,M.: Food Allergy. Springfield, Illinois,
Thomas, 1951, p. 120.
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