Patient is 41-year-old male who states that approximately four months ago he developed a significant tooth infection that caused severe pain. He did have to get a root canal performed and it was treated with antibiotics. Ever since then, he has had this tingling down his neck and pain in his lymph nodes along his anterior cervical chain. He has also had been developing some diffuse muscle pains particularly in his calves and biceps and the feeling of his hair standing up and sensitivity. He has seen his for this Dr. and they did test his blood for a complete blood cell count, TSH, and also ANA and some other autoimmune testing. All this came back normal except for a histone antibody that was double the normal amount. He was diagnosed with neuropathy and was referred over to a rheumatologist to evaluate for any possible drug-induced lupus or systemic lupus. He did also go to an acupuncturist. At that time, his acupuncturist told him that he should get his vitamin B12 checked and also check for food allergies. He has been taking vitamin B12 supplements, so it does not feel that is a problem. He is here today to check if food allergies may be playing a role in his condition. I did discuss with him that this is an atypical presentation for an allergy-mediated reaction to foods and it is most likely not due to food allergies, but it is something that we can rule out to ensure that he is not eating something that is causing his troubles. I did discuss limitations on his testing with him.
He does have occasional hoarseness, itching inside ears, and snoring. He denies other seasonal allergy troubles. He has never had troubles with allergic rhinitis or conjunctivitis in the past. He denies sinus infection, TMJ, aspirin-induced nasal symptoms, nasal surgery, frequent bad colds, or frequent tonsillitis. He does take grapeseed extract occasionally for some allergy symptoms. He has good relief.
He does have some eye itching occasionally. He denies redness, tearing, dryness, burning, light hurting his eyes, yellow discharge from eyes, eyelid swelling, eyelid irritation, or vision changes.
He denies any history of wheezing or lung troubles. He denies any frequent coughing spells or recurrent night coughs.
3. Positive histone antibodies for concern for autoimmune disorder or drug-induced lupus.
4. Concern for food allergies.
1. At this time, I discussed with that I do not feel that food allergies is playing a role in his unusual symptoms. He is referred over to rheumatology and should be hearing from them soon to get an evaluation. I do think this is the best thing for him and they can recheck his lab work and determine why he is having his neuropathy and myalgias that are going away.
2. If he has any concerns with allergies in the future, he will contact me and let me know.