- Email: [email protected]
Use of Food Challenge to Distinguish Food Protein-Induced Enterocolitis Syndrome from Hereditary Fructose Intolerance
Abstracts AB181
J ALLERGY CLIN IMMUNOL VOLUME 127, NUMBER 2
Diagnosis and Management of Childhood Food Allergies at an Academic Medical Center S. H. Desai, T. D. Green; Children’s Hospital of Pittsburgh, Pittsburgh, PA. RATIONALE: There has been recent and growing interest in food allergies (FA), and ongoing professional discussions on diagnosis and management. We analyzed how FA are diagnosed and managed in the Allergy & Immunology clinic at the Children’s Hospital of Pittsburgh. METHODS: To date, a retrospective chart review has been performed on 150 children. We analyzed overall patterns at the institution and across different foods. RESULTS: Average age at first reaction was 2.5 years; 98% of patients had a personal or family atopic history. No correlation was found between season of birth and presence of FA. Most common allergens were peanut (31%)/tree nuts(28%), egg(15%) and milk(8%). Overall trend was to use history, skin prick and serum testing nearly equally at initial diagnosis. Overwhelming management preference was to follow serum specific IgE levels over time. Food challenges were used 0.66% of the time to diagnose, but were frequently used, after serum levels had declined, to determine whether clinical tolerance had been established. 37% of diagnoses were made without the child ever having a known ingestion; this occurred most commonly with shellfish (66% of diagnoses), soy and tree nuts (both 50%), but also in a significant proportion of others. CONCLUSIONS: Oral office challenges are rarely used to make a diagnosis of FA, while history, skin prick and serum tests are used equally. A large percentage of diagnoses are made without a history of known ingestion. Following serum specific IgE levels over time is the preferred method at this academic center for monitoring ongoing allergy.
Detection Of Milk-specific IgE And IgA In Stool Samples From Children With Food Allergy C. Berin, S. Wood, I. Lopez-Exposito, H. Sampson, A. Nowak-Wegrzyn; Mount Sinai School of Medicine, New York, NY. RATIONALE: Immunoglobulins in the intestine can facilitate (IgE, IgG) or inhibit (IgA) allergen uptake across the epithelium. Little is known about the role of gastrointestinal food-specific immunoglobulins in food allergy. Our goal was to determine levels of milk-specific IgE or IgA in stool samples of children with allergy or tolerance to milk. METHODS: Baseline stool samples were obtained from children enrolled in a trial to investigate the effects of ingesting heat-denatured milk on the development of tolerance. Challenges were performed with foods containing more milk protein in a progressively less heat-denatured form (muffin, pizza, rice pudding, milk). Casein-specific IgE and IgA, total IgE and IgA, a-1-antitrypsin and total protein were measured in stool extracts. RESULTS: Stool samples were obtained from 78 children; 22 children reacted to challenge with muffin, 16 to pizza, 6 to rice pudding, 23 to milk, and 11 were milk tolerant. Total IgE and IgA were detectable in 100% (median of 7.5 kU IgE/mg protein and 11.2 mg IgA/mg). Casein-IgE was detectable in 33% (median 0, range 0-1.4 kUA/mg), and casein-IgA in 57% (median 16.5, range 0-825 ng/mg). There was no correlation between clinical reactivity and stool casein- IgE or -IgA when levels were normalized to protein, total immunoglobulins, or a1-antitrypsin. CONCLUSIONS: Casein-specific IgE and IgA can be detected in stool samples of children with sensitization to milk, but levels are not predictive of clinical reactivity to milk. Children in the study were avoiding milk at baseline: follow-up studies will be performed after re-introduction of heat-denatured milk into the diet.
692
694
Use of Food Challenge to Distinguish Food Protein-Induced Enterocolitis Syndrome from Hereditary Fructose Intolerance M. A. Ruffner1, D. N. Finegold2, A. J. MacGinnitie2; 1University of Pittsburgh School of Medicine, Pittsburgh, PA, 2Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA. RATIONALE: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy characterized by vomiting, diarrhea, lethargy, and dehydration occurring within hours of the consumption of a triggering food protein. Hereditary fructose intolerance (HFI) is an autosomal recessive enzyme deficiency resulting in abnormal fructose metabolism which can present acutely as nausea, vomiting, abdominal pain and hypoglycemia following the ingestion of a fructose load but can progress to failure to thrive, liver failure, and renal dysfunction. We present the case of a 6-month old female who had tolerated breastmilk and rice cereal, yet presented with severe vomiting and lethargy approximately two hours after the first introduction of both bananas and squash. METHODS: She was otherwise healthy, without any significant family history, nor any developmental or growth concerns. She was felt to be clinically stable for a fructose challenge. Supervised measured apple juice challenge did not elicit symptoms, leading to the conclusion her symptoms had been FPIES triggered by banana and squash. RESULTS: The patient was maintained on a diet free of banana and squash, and at follow up has been asymptomatic and able to tolerate a wide variety of fructose containing foods into her diet without problem. CONCLUSIONS: The presentations of FPIES and HFI may overlap and food challenge may be required to establish the correct diagnosis. We believe this case is the first description of FPIES triggered by both bananas and squash in an individual.
693
Allergen Patch Test In Children With Food Allergy-related Gastrointestinal Symptoms N. Visitsunthorn, O. Boonyaviwat, P. Pacharn, O. Piboonpocanun, P. Vichyanond; Siriraj Hospital, Mahidol University, Bangkok, Thailand. BACKGROUND: Skin prick test (SPT) or specific IgE to food allergens have very few benefits in evaluation of patients suspected food allergyrelated gastrointestinal symptoms. The objective of this study was to evaluate predictive value of allergen patch test (APT) in children suspected food allergy-related gastrointestinal symptoms. METHODS: A prospective self-controlled study was carried out in children with history of suspected food allergy-related gastrointestinal symptoms. SPT and APT using lyophilized and commercial allergens for cow’s milk, egg, wheat, soy and shrimp were performed. RESULTS: Twenty-one patients (14 boys, median age 1.5 years) with 38 events of suspected food allergy-related gastrointestinal symptoms were enrolled into the study. Cow’s milk was the most common suspected food allergens. The most common initial manifestations were diarrhea (63.6%). SPT was positive in 7/38 events (18.4%). APT using lyophilized and commercial allergens were positively correlated with history in 24/38 (63.15%) and 13/38 (34.2%) respectively. Twenty-three oral challenge tests were done. Positive challenge response was found in 6/6 (100%) if APT using lyophilized and commercial allergens were both positive, 6/7 (85.7%) if only lyophilized allergens were positive and none if only commercial allergens were positive. Agreement between APT and food challenge was significantly higher (P 5 0.01) in APT with cow’s milk lyophilized allergen than in commercial allergens, 0.8 and 0.4 respectively. CONCLUSION: APT using lyophilized allergens was more sensitive and predictive than SPT in diagnosing food allergy-related gastrointestinal symptoms in children, especially in those who were allergic to cow’s milk.
MONDAY
691
J ALLERGY CLIN IMMUNOL VOLUME 127, NUMBER 2
Diagnosis and Management of Childhood Food Allergies at an Academic Medical Center S. H. Desai, T. D. Green; Children’s Hospital of Pittsburgh, Pittsburgh, PA. RATIONALE: There has been recent and growing interest in food allergies (FA), and ongoing professional discussions on diagnosis and management. We analyzed how FA are diagnosed and managed in the Allergy & Immunology clinic at the Children’s Hospital of Pittsburgh. METHODS: To date, a retrospective chart review has been performed on 150 children. We analyzed overall patterns at the institution and across different foods. RESULTS: Average age at first reaction was 2.5 years; 98% of patients had a personal or family atopic history. No correlation was found between season of birth and presence of FA. Most common allergens were peanut (31%)/tree nuts(28%), egg(15%) and milk(8%). Overall trend was to use history, skin prick and serum testing nearly equally at initial diagnosis. Overwhelming management preference was to follow serum specific IgE levels over time. Food challenges were used 0.66% of the time to diagnose, but were frequently used, after serum levels had declined, to determine whether clinical tolerance had been established. 37% of diagnoses were made without the child ever having a known ingestion; this occurred most commonly with shellfish (66% of diagnoses), soy and tree nuts (both 50%), but also in a significant proportion of others. CONCLUSIONS: Oral office challenges are rarely used to make a diagnosis of FA, while history, skin prick and serum tests are used equally. A large percentage of diagnoses are made without a history of known ingestion. Following serum specific IgE levels over time is the preferred method at this academic center for monitoring ongoing allergy.
Detection Of Milk-specific IgE And IgA In Stool Samples From Children With Food Allergy C. Berin, S. Wood, I. Lopez-Exposito, H. Sampson, A. Nowak-Wegrzyn; Mount Sinai School of Medicine, New York, NY. RATIONALE: Immunoglobulins in the intestine can facilitate (IgE, IgG) or inhibit (IgA) allergen uptake across the epithelium. Little is known about the role of gastrointestinal food-specific immunoglobulins in food allergy. Our goal was to determine levels of milk-specific IgE or IgA in stool samples of children with allergy or tolerance to milk. METHODS: Baseline stool samples were obtained from children enrolled in a trial to investigate the effects of ingesting heat-denatured milk on the development of tolerance. Challenges were performed with foods containing more milk protein in a progressively less heat-denatured form (muffin, pizza, rice pudding, milk). Casein-specific IgE and IgA, total IgE and IgA, a-1-antitrypsin and total protein were measured in stool extracts. RESULTS: Stool samples were obtained from 78 children; 22 children reacted to challenge with muffin, 16 to pizza, 6 to rice pudding, 23 to milk, and 11 were milk tolerant. Total IgE and IgA were detectable in 100% (median of 7.5 kU IgE/mg protein and 11.2 mg IgA/mg). Casein-IgE was detectable in 33% (median 0, range 0-1.4 kUA/mg), and casein-IgA in 57% (median 16.5, range 0-825 ng/mg). There was no correlation between clinical reactivity and stool casein- IgE or -IgA when levels were normalized to protein, total immunoglobulins, or a1-antitrypsin. CONCLUSIONS: Casein-specific IgE and IgA can be detected in stool samples of children with sensitization to milk, but levels are not predictive of clinical reactivity to milk. Children in the study were avoiding milk at baseline: follow-up studies will be performed after re-introduction of heat-denatured milk into the diet.
692
694
Use of Food Challenge to Distinguish Food Protein-Induced Enterocolitis Syndrome from Hereditary Fructose Intolerance M. A. Ruffner1, D. N. Finegold2, A. J. MacGinnitie2; 1University of Pittsburgh School of Medicine, Pittsburgh, PA, 2Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA. RATIONALE: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy characterized by vomiting, diarrhea, lethargy, and dehydration occurring within hours of the consumption of a triggering food protein. Hereditary fructose intolerance (HFI) is an autosomal recessive enzyme deficiency resulting in abnormal fructose metabolism which can present acutely as nausea, vomiting, abdominal pain and hypoglycemia following the ingestion of a fructose load but can progress to failure to thrive, liver failure, and renal dysfunction. We present the case of a 6-month old female who had tolerated breastmilk and rice cereal, yet presented with severe vomiting and lethargy approximately two hours after the first introduction of both bananas and squash. METHODS: She was otherwise healthy, without any significant family history, nor any developmental or growth concerns. She was felt to be clinically stable for a fructose challenge. Supervised measured apple juice challenge did not elicit symptoms, leading to the conclusion her symptoms had been FPIES triggered by banana and squash. RESULTS: The patient was maintained on a diet free of banana and squash, and at follow up has been asymptomatic and able to tolerate a wide variety of fructose containing foods into her diet without problem. CONCLUSIONS: The presentations of FPIES and HFI may overlap and food challenge may be required to establish the correct diagnosis. We believe this case is the first description of FPIES triggered by both bananas and squash in an individual.
693
Allergen Patch Test In Children With Food Allergy-related Gastrointestinal Symptoms N. Visitsunthorn, O. Boonyaviwat, P. Pacharn, O. Piboonpocanun, P. Vichyanond; Siriraj Hospital, Mahidol University, Bangkok, Thailand. BACKGROUND: Skin prick test (SPT) or specific IgE to food allergens have very few benefits in evaluation of patients suspected food allergyrelated gastrointestinal symptoms. The objective of this study was to evaluate predictive value of allergen patch test (APT) in children suspected food allergy-related gastrointestinal symptoms. METHODS: A prospective self-controlled study was carried out in children with history of suspected food allergy-related gastrointestinal symptoms. SPT and APT using lyophilized and commercial allergens for cow’s milk, egg, wheat, soy and shrimp were performed. RESULTS: Twenty-one patients (14 boys, median age 1.5 years) with 38 events of suspected food allergy-related gastrointestinal symptoms were enrolled into the study. Cow’s milk was the most common suspected food allergens. The most common initial manifestations were diarrhea (63.6%). SPT was positive in 7/38 events (18.4%). APT using lyophilized and commercial allergens were positively correlated with history in 24/38 (63.15%) and 13/38 (34.2%) respectively. Twenty-three oral challenge tests were done. Positive challenge response was found in 6/6 (100%) if APT using lyophilized and commercial allergens were both positive, 6/7 (85.7%) if only lyophilized allergens were positive and none if only commercial allergens were positive. Agreement between APT and food challenge was significantly higher (P 5 0.01) in APT with cow’s milk lyophilized allergen than in commercial allergens, 0.8 and 0.4 respectively. CONCLUSION: APT using lyophilized allergens was more sensitive and predictive than SPT in diagnosing food allergy-related gastrointestinal symptoms in children, especially in those who were allergic to cow’s milk.
MONDAY
691