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Argiz L, Valsami-Fokianos M, Arasi S, Barni S, Boscia S, Bracaglia G, Bracamonte T, Carballeira I, Dinardo G, Echeverria L, Garcia E, Garcia-Magan C, Gomez-Rial J, Gonzalez-Delgado P, Fiocchi A, Garriga T, Ibrahim T, Infante S, Machinena A, Mangone G, Mori F, Moure JD, O'Valle V, Pascal M, Pecora V, Prieto A, Quevedo S, Salas A, Vazquez-Cortes S, Vila L, Martinon-Torres F, Gomez-Carballa A, Boyle RJ, Vazquez-Ortiz M. Clinical-Hematological Changes and Predictors of Severity in Acute Food Protein-Induced Enterocolitis Syndrome Reactions at Oral Food Challenge: A Multicenter Observational Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:2454-2467.e8. [PMID: 38796100 DOI: 10.1016/j.jaip.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Oral food challenge (OFC) is the criterion standard for diagnosis of acute food protein-induced enterocolitis syndrome (FPIES). No diagnostic/prognostic biomarkers are available, and OFC assessment criteria are not validated. OBJECTIVE To assess clinical-hematological changes and predictors of severity of FPIES reactions at OFC. METHODS This was an observational multicenter prospective study. Children aged 0 to 18 years diagnosed with acute FPIES were recruited at follow-up OFC in 12 tertiary centers in Spain and Italy. OFC outcomes (as positive/negative/inconclusive and mild/moderate/severe) were assessed on the basis of published "2017 FPIES Consensus" criteria. Clinical characteristics were recorded, and full blood cell count was done at baseline, reaction onset, and 4 hours later. Regression analysis was performed to assess predictors of severe reactions at OFC. RESULTS A total of 81 children had positive OFC (mild in 11% [9 of 81], moderate in 61% [49 of 81], and severe in 28% [23 of 81]). Increase in neutrophils and reduction in eosinophils, basophils, and lymphocytes were observed (P < .05). OFC was inconclusive in 19 cases despite objective signs or neutrophilia. Regression analysis showed that a 2-day OFC protocol where only 25% of an age-appropriate portion is given on day 1 (not sex, age, culprit food, cumulative dose, and previous reaction severity) was associated with reduced odds of severe reaction compared with giving multiple doses in a single day. CONCLUSIONS Distinct hematological changes may help support FPIES diagnosis. Current OFC assessment criteria may not capture the broad spectrum of acute FPIES presentations. This 2-day protocol may be associated with a reduced risk of severe reactions. Future work should aim to develop safer OFC and non-OFC diagnostics for FPIES.
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Affiliation(s)
- L Argiz
- Department of Allergy, Clínica Universidad de Navarra, Pamplona, Spain; RICORS Red De Enfermedades Inflamatorias (REI) - RD21/0002/0028, Madrid, Spain
| | - M Valsami-Fokianos
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - S Arasi
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - S Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - S Boscia
- Division of Immunology, Meyer Children's Hospital IRCCS, Florence, Italy; Department of Health Sciences, University of Florence, Florence, Italy
| | - G Bracaglia
- Laboratory Medicine, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - T Bracamonte
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - I Carballeira
- Paediatric Allergy Section, Arquitecto Marcide Hospital, Coruña, Spain
| | - G Dinardo
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Echeverria
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - E Garcia
- Paediatric Allergy Section, Arquitecto Marcide Hospital, Coruña, Spain
| | - C Garcia-Magan
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain
| | - J Gomez-Rial
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - A Fiocchi
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - T Garriga
- Paediatric Allergy Section, Vall D'Hebron University Hospital, Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - T Ibrahim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Allergy and Immunology Division, Hamad Medical Corporation, Doha, Qatar
| | - S Infante
- Pediatric Allergy Unit, Hospital General Universitario Gregorio Marañón, Gregorio Marañón Health Research Institute, IiSGM, Madrid, Spain
| | - A Machinena
- Pediatric Allergy and Clinical Immunology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - G Mangone
- Division of Immunology, Meyer Children's Hospital IRCCS, Florence, Italy
| | - F Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - J D Moure
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain
| | - V O'Valle
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - M Pascal
- Immunology Department, CDB, Hospital Clínic de Barcelona, Barcelona, Spain; IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - V Pecora
- Allergy Unit, Department of Pediatric Medicine, Bambino Gesù Children's Research Hospital, IRCCS, Rome, Italy
| | - A Prieto
- Paediatric Allergy Section, General University Hospital, Malaga, Spain
| | - S Quevedo
- Paediatric Allergy Section, Severo Ochoa University Hospital, Madrid, Spain
| | - A Salas
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Unidade de Xenética, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPoB Research Group, Instituto de Investigación Sanitaria (IDIS), Hospital Clínico Universitario de Santiago de Compostela (SERGAS), Galicia, Spain
| | | | - L Vila
- Paediatric Allergy Section, Teresa Herrera Hospital, Coruña, Spain
| | - F Martinon-Torres
- Paediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Coruña, Spain; Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - A Gomez-Carballa
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago (IDIS), University of Santiago de Compostela, Santiago de Compostela, Spain; Unidade de Xenética, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPoB Research Group, Instituto de Investigación Sanitaria (IDIS), Hospital Clínico Universitario de Santiago de Compostela (SERGAS), Galicia, Spain
| | - R J Boyle
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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Hayashi D, Yoshida K, Akashi M, Kajita N, Tatsumoto C, Ishii T, Koike Y, Horimukai K, Kinoshita M, Hamahata Y, Nishimoto H, Sakihara T, Arakaki Y, Hara M, Noguchi E, Morita H. Differences in Characteristics Between Patients Who Met or Partly Met the Diagnostic Criteria for Food Protein-Induced Enterocolitis Syndrome (FPIES). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1831-1839.e1. [PMID: 38492664 DOI: 10.1016/j.jaip.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/24/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Some patients with food protein-induced enterocolitis (FPIES)-like allergy do not completely fulfill the diagnostic criteria of the international consensus guideline for FPIES. However, it is unclear whether such FPIES-like patients represent a completely different population from FPIES. OBJECTIVE This study aimed to clarify differences in characteristics between patients with FPIES who fully met diagnostic criteria and those who partly met them. METHODS This was a cross-sectional study using data at the time of registration in multicenter, prospective studies of patients with FPIES in Japan. Children who had delayed emesis within 1 to 4 hours and/or diarrhea within 5 to 10 hours after ingestion of food were recruited between March 2020 and February 2022. We examined their compatibility with the diagnostic criteria of the international consensus guideline and their detailed clinical characteristics, including trigger foods, the serving size that elicited symptoms, and antigen-specific IgE antibody titers. RESULTS Of the 225 patients with FPIES, 140 fully met the diagnostic criteria whereas 79 patients did not fully meet them but demonstrated reproducible symptoms. The frequencies of pallor, lethargy, and diarrhea were significantly higher in those who met the criteria fully, whereas the age at onset, trigger foods, comorbidity, and perinatal information were comparable. Analysis of patients with FPIES to hen's egg revealed significantly higher levels of egg white- and egg yolk-specific IgE in patients who partly met criteria, whereas the serving size eliciting symptoms was comparable. CONCLUSIONS Patients who partly met the diagnostic criteria may have a milder phenotype of FPIES, but this needs to be validated in further studies using biomarkers reflecting the pathophysiology.
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Affiliation(s)
- Daisuke Hayashi
- Department of Pediatrics, Tsukuba Medical Center Hospital, Ibaraki, Japan; Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Koichi Yoshida
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masayuki Akashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Kajita
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Tomo Ishii
- Department of Pediatrics, NHO Tochigi Medical Center, Tochigi, Japan
| | - Yumi Koike
- Department of Allergy, Nagano Children's Hospital, Nagano, Japan
| | - Kenta Horimukai
- Department of Pediatrics, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Misako Kinoshita
- Department of Pediatrics, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Yuko Hamahata
- Department of Pediatrics, Saitama City Hospital, Saitama, Japan
| | - Hajime Nishimoto
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | | | - Yohei Arakaki
- Department of Pediatrics, Naha City Hospital, Okinawa, Japan
| | - Monami Hara
- Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Emiko Noguchi
- Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Allergy Center, National Center for Child Health and Development, Tokyo, Japan.
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Anvari S, Ruffner MA, Nowak-Wegrzyn A. Current and future perspectives on the consensus guideline for food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:188-195. [PMID: 38326194 DOI: 10.1016/j.alit.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy presenting with delayed onset of projectile vomiting in the absence of cutaneous and respiratory symptoms. The pathophysiology of FPIES remains poorly characterized. The first international consensus guidelines for FPIES were published in 2017 and provided clinicians with parameters on the diagnosis and treatment of FPIES. The guidelines have served as a resource in the recognition and management of FPIES, contributing to an increased awareness of FPIES. Since then, new evidence has emerged, shedding light on adult-onset FPIES, the different phenotypes of FPIES, the recognition of new food triggers, center-specific food challenge protocols and management of acute FPIES. Emerging evidence indicates that FPIES impacts both pediatric and adult population. As a result, there is growing need to tailor the consensus guidelines to capture diagnoses in both patient groups. Furthermore, it is crucial to provide food challenge protocols that meet the needs of both pediatric and adult FPIES patients, as well as the subset of patients with atypical FPIES. This review highlights the evolving clinical evidence relating to FPIES diagnosis and management published since the 2017 International FPIES Guidelines. We will focus on areas where recent published evidence may support evolution or revision of the guidelines.
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Affiliation(s)
- Sara Anvari
- Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, USA
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anna Nowak-Wegrzyn
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, New York City, NY, USA; Department of Pediatrics Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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Vasconcelos PDSP, Andrade ALMB, Sandy NS, Barreto JCC, Gomez GS, Riccetto AGL, Lomazi EA, Bellomo-Brandão MÂ. Outcomes and factors associated with tolerance in infants with non-IgE-mediated cow's milk allergy with gastrointestinal manifestations. J Pediatr (Rio J) 2024; 100:40-45. [PMID: 37696495 PMCID: PMC10751709 DOI: 10.1016/j.jped.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVES To evaluate outcomes of oral food challenge (OFC) test to assess tolerance in infants with non-IgE-mediated cow's milk allergy (CMA) with gastrointestinal manifestations and explore clinical data predictive of these outcomes. METHODS Single-center retrospective study including infants (age < 12 months) who were referred for CMA between 2000 and 2018 and underwent OFC on follow-up. A univariate logistic regression test was performed to evaluate variables associated with the outcomes of the follow-up OFC test. RESULTS Eighty-two patients were included, 50% were male. Eighteen patients had a positive OFC test (22%). Most patients had presented with hematochezia (77%). The median age of symptom onset was 30 days. Two-thirds of the patients were on appropriate infant formula (extensively hydrolyzed or amino acid-based formula), exclusively or in association with breastfeeding. The median time on an elimination diet before the OFC test was 8 months (Q1 6 - Q3 11 months). All cases with positive follow-up OFC tests (n = 18) had been exposed to cow's milk-based formula before the first clinical manifestation of CMA. Five out of eight cases with Food Protein-Induced Enterocolitis Syndrome (FPIES) had positive OFC tests. Exposure to cow's milk-based formula before diagnosis, a history of other food allergies, hematochezia and diarrhea were predictors of a positive OFC test. CONCLUSIONS In infants with non-IgE-mediated CMPA with gastrointestinal manifestations, the use of cow's milk-based formula, a history of other food allergies, and hematochezia and diarrhea upon initial presentation were associated factors for the later achievement of tolerance.
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Affiliation(s)
- Príscila da Silva Pereira Vasconcelos
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | | | - Natascha Silva Sandy
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Juliana Corrêa Campos Barreto
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Gabriela Souza Gomez
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil
| | - Adriana Gut Lopes Riccetto
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil
| | - Elizete Aparecida Lomazi
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil
| | - Maria Ângela Bellomo-Brandão
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil; Centro de Investigação em Pediatria da Faculdade de Ciências Médicas de Campinas (CIPED), Campinas, SP, Brazil; Programa de Pós-graduação em Saúde da Criança e do Adolescente (PPG-SCA), São Paulo, SP, Brazil; Laboratório de Investigação Diagnóstica de Gastroenterologia e Hepatologia Pediátrica, Campinas, SP, Brazil.
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Shah S, Grohman R, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES): Beyond the guidelines. JOURNAL OF FOOD ALLERGY 2023; 5:55-64. [PMID: 39022754 PMCID: PMC11250192 DOI: 10.2500/jfa.2023.5.230014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Background Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) cell mediated food allergy that can cause severe symptoms and is considered an allergic emergency. Objective To describe FPIES epidemiology and appraise the approach to diagnosis and management. Methods A review of the relevant articles published in the peer-reviewed journals since the publication of the First International FPIES Consensus Guidelines in 2017. Results FPIES is estimated to affect 0.51-0.9% of children and 0.22% of adults in the United States. It typically presents with protracted, projectile vomiting, which occurs within 1-4 hours of ingesting culprit foods, sometimes followed by diarrhea within 24 hours of ingestion. In ∼15-20% of severe cases, patients go into hypovolemic or distributive shock. In chronic FPIES, infants may have failure to thrive and weight loss. The most common triggers include cow's milk, oat, rice, and avocado, with egg and peanut being more frequently reported. Examples of other common fruit and vegetable triggers include banana, apple, and sweet potato. FPIES can be classified into acute, chronic, adult-onset, or atypical subtypes. FPIES is associated with comorbid atopic conditions of IgE-mediated food allergy, atopic dermatitis, asthma, allergic rhinitis, and eosinophilic esophagitis. The natural history of infantile FPIES is generally favorable, with the exception of fish FPIES. Seafood FPIES in adults has low rates of resolution over 3-5 years. Correctly identifying FPIES can be challenging because there are no specific biomarkers for diagnosis and the constellation of symptoms may mimic those of infectious enteritis or sepsis. Management relies on dietary food avoidance, periodic re-evaluations for tolerance with oral food challenges, and management of acute reactions with rehydration and antiemetic ondansetron. Although the pathophysiology of FPIES remains poorly understood, underlying mechanisms such as cytokine release, leukocyte activation, and impaired gastrointestinal mucosal barrier function may act as cornerstones for further research. Conclusion Prevention, laboratory diagnostic testing, and strategies to accelerate tolerance development are urgent unmet needs in FPIES.
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Affiliation(s)
- Sohini Shah
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Rebecca Grohman
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, and
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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Mulé A, Prattico C, Al Ali A, Mulé P, Ben-Shoshan M. Diagnostic and Management Strategies of Food Protein-Induced Enterocolitis Syndrome: Current Perspectives. Pediatric Health Med Ther 2023; 14:337-345. [PMID: 37901587 PMCID: PMC10612481 DOI: 10.2147/phmt.s404779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/13/2023] [Indexed: 10/31/2023] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a form of non-IgE mediated food allergy that presents with delayed gastrointestinal symptoms after ingestion of the trigger food. The data regarding FPIES are sparse, despite being recognized as a distinct clinical entity. This narrative review presents the characteristics of this disorder in the pediatric population, as well-standard diagnostic and management protocols. FPIES can be classified into acute and chronic subtypes, and some cases may develop into an IgE-mediated allergy. Given that skin prick tests and specific IgE levels are negative in the majority of cases, diagnosis relies on clinical history and oral food challenges. Management involves elimination diets, assessment of tolerance through oral food challenges, and rehydration in the event of a reaction. Future research should focus on improving diagnostic methods, illustrating underlying pathogenesis and biomarkers, and assessing long-term natural history. Increased knowledge and awareness for FPIES are required.
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Affiliation(s)
- Angela Mulé
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Catherine Prattico
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Adnan Al Ali
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Pasquale Mulé
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Moshe Ben-Shoshan
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children’s Hospital, McGill University Health Centre, Montreal, QC, Canada
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Ye L, Wong T, Lavine E, Cook VE, Erdle SC. Using the canadian egg ladder in children with food protein-induced enterocolitis syndrome: a case series. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:87. [PMID: 37803461 PMCID: PMC10557249 DOI: 10.1186/s13223-023-00843-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/15/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Current management of food protein-induced enterocolitis syndrome (FPIES) involves strict avoidance of the offending food for 12-18 months, followed by oral food challenge (OFC) under physician supervision. OFCs are resource-intensive and there is a lack of a universal standardized protocol for FPIES. Prolonged avoidance may increase the risk of IgE-mediated allergy, particularly in atopic patients. Food ladders have shown success in promoting accelerated tolerance in patients with IgE-mediated allergy. Our case series evaluated the safety of use of the Canadian Egg Ladder in patients with mild-to-moderate FPIES to egg. METHODS From May 2020 to November 2021, patients with mild-to-moderate FPIES to egg, defined as no history of lethargy or intravenous fluid administration, were started on the Canadian Egg Ladder. Instructions for advancing up the ladder were identical to using the Canadian Egg Ladder in patients with IgE-mediated allergy. Patients were followed every 3-6 months, at which time information was collected regarding progression up the ladder, symptoms while on treatment and interventions required. Treating allergists completed a survey to capture baseline demographic characteristics and prior tolerance to egg. Descriptive statistics were analyzed using MS Excel. RESULTS Twenty-one patients with mild-to-moderate FPIES were started on the Canadian Egg Ladder. Median age at initiation of the ladder was 10 months (IQR, 9-11). Nineteen (90.5%) patients completed the ladder, tolerating a serving size amount of cooked egg, over a median duration of 7 month (IQR, 4-9 months). Four patients (19.0%) had mild symptoms including vomiting (9.5%), pallor (9.5%), belching (4.8%), irritability (4.8%) and small spit up (4.8%). In three of the four patients, symptoms were the result of accidental exposure to a higher step of the ladder. There were no reports of lethargy. No patients required health care presentation or intravenous fluid administration. No patients discontinued the ladder. CONCLUSIONS The Canadian Egg Ladder can safely guide the dietary advancement of egg-containing foods in patients with mild-to-moderate FPIES to egg, without the need for prolonged avoidance and resource-intensive OFCs.
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Affiliation(s)
- Linlei Ye
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada.
| | - Tiffany Wong
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
| | - Elana Lavine
- Department of Pediatrics, University of Toronto, Humber River Hospital, Toronto, ON, Canada
| | - Victoria E Cook
- Division of Allergy, BC Children's Hospital, Vancouver, BC, Canada
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Patel N, Shreffler WG, Custovic A, Santos AF. Will Oral Food Challenges Still Be Part of Allergy Care in 10 Years' Time? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:988-996. [PMID: 36822320 PMCID: PMC10698627 DOI: 10.1016/j.jaip.2023.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/05/2023] [Accepted: 02/05/2023] [Indexed: 02/24/2023]
Abstract
Oral food challenges (OFCs) are currently the definitive diagnostic procedure in food allergy. Their design has evolved over the decades to maximize safety, optimize convenience, and address several specific clinical questions. However, they are a resource-intensive investigation that carry a risk for severe allergic reaction in which fatal outcomes, although rare, have been reported. In this review, we explore the many roles that OFC fulfil in the clinical and research settings. We also discuss progress that has been made in developing alternative diagnostic tools and how far these have reached in offering a viable replacement to OFC in clinical practice. Finally, we discuss the ongoing importance of research OFC to improve the future diagnostic capabilities of novel diagnostic tools.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Wayne G Shreffler
- Food Allergy Center and Center for Immunology and Inflammatory Disease, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London, Guy's and St Thomas' Hospital, London, United Kingdom.
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9
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Oriel RC, Shah A, Anagnostou A, Greenhawt M, Khan F, Leeds S, Ravindran M, Stoffels G, Vickery BP, Virkud YV, Sicherer SH. Food Allergy Management Practices Utilizing Individual Patient Thresholds: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1083-1086.e1. [PMID: 36773718 DOI: 10.1016/j.jaip.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023]
Abstract
The paradigm for food allergy management has been strict avoidance of the food allergen. There is literature supporting a "high-threshold" phenotype, those who tolerate a small-to-modest amount of allergen but react to larger amounts. There is no consensus for best practice for these "high-threshold" individuals. We sought to understand management practices of "high-threshold" reactors using a survey that was distributed to a random sample of fellows and members of the American Academy of Allergy, Asthma, and Immunology. There were 89 respondents from the United States and Canada (11% response rate), with 64 (72%) answering all questions. Participants worked in private (52%) and academic practice (38%) and saw a median of 30 food allergic patients monthly. Eighty-one percent of respondents reported management strategies other than strict avoidance. When threshold was known, strategies ranged from allowing ingestion up to a specified amount (57%), proactively advising ingestion to a certain amount (56%), or oral immunotherapy (47%). Participants were more likely to choose a permissive approach for a mild reaction in a high-threshold milk-allergic patient compared with a peanut-allergic patient (83% vs 71%, p=.01). Important factors that influenced the approach included severity of reaction (52%), comfort with family/patient using emergency medications (42%), and family/patient preferences (41%). These survey results suggest that food allergy management recommendations are no longer binary in nature, with clinicians solely recommending avoidance for those who are allergic and ingestion for those who may not be.
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Affiliation(s)
- Roxanne C Oriel
- Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ami Shah
- Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aikaterini Anagnostou
- Division of Allergy, Immunology and Retrovirology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Fatima Khan
- Department of Pediatrics, Division of Allergy and Immunology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Stephanie Leeds
- Department of Pediatrics, Yale School of Medicine, New Haven, Conn
| | - Mayuran Ravindran
- Department of Medicine, Emory University School of Medicine, Atlanta, Ga
| | - Guillaume Stoffels
- Division of Biostatistics, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian P Vickery
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Yamini V Virkud
- Department of Pediatrics, University of North Carolina - Chapel Hill, Chapel Hill, NC
| | - Scott H Sicherer
- Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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10
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Jacobs S, Trogen B, Nowak-Wegrzyn A. Recurrence of Food Protein-Induced Enterocolitis Syndrome (FPIES) Following a Food Challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:326-328. [PMID: 36610758 DOI: 10.1016/j.jaip.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Samantha Jacobs
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY
| | - Brit Trogen
- Allergy and Immunology, Department of Medicine, Icahn School of Medicine, New York, NY
| | - Anna Nowak-Wegrzyn
- Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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11
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Diagnosis of Food Protein-Induced Enteropathy Based on Gastrointestinal Mucosal Pathology before and after Elimination Diet Therapy: A Case Report. Pediatr Rep 2022; 14:380-385. [PMID: 36136084 PMCID: PMC9503454 DOI: 10.3390/pediatric14030045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
We describe the case of a 1-year-old girl with food protein-induced enteropathy (FPE) that was difficult to diagnose. She was referred to our hospital with a 3-month history of diarrhea, vomiting, and weight loss. Although her diarrhea improved after a few days of fasting, oral intake of elemental diets, formula milk, or rice porridge resulted in repeated relapses. The serum IgE level was 1028 IU/mL, and radioallergosorbent tests were positive for milk, casein, alpha-lactalbumin, and other allergens. A histopathology of the duodenal mucosa revealed loss of mucosal villous structure, crypt hyperplasia, crypt apoptosis, and lymphocyte and eosinophil infiltration (<20 eos/hpf) into the lamina propria. After prednisolone (PSL) therapy and the complete removal of cows’ milk and chicken eggs from her diet, the patient’s diarrhea disappeared. Five months after discontinuing oral PSL and complete removal of cows’ milk and chicken eggs, the duodenum exhibited normal mucosal villous structure and well-differentiated ducts. No abnormalities were observed in the egg rechallenge; however, diarrhea recurred after the cows’ milk rechallenge. Thus, histopathologic examination of the gastrointestinal mucosa is useful for diagnosing FPE similar to oral food challenges, and re-evaluation after elimination diet therapy may be beneficial to rule out other diseases.
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12
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Baker MG, Cecilia Berin M, Sicherer S. Update on Food Protein-Induced Enterocolitis Syndrome (FPIES). Curr Allergy Asthma Rep 2022; 22:113-122. [PMID: 35522370 DOI: 10.1007/s11882-022-01037-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy characterized by delayed, and potentially severe, gastrointestinal symptoms. Since the advent of a specific diagnostic code and establishment of diagnostic guidelines, our understanding of this condition has grown. RECENT FINDINGS FPIES affects patients from early infancy into adulthood. Any food can be a trigger, and common culprit foods vary geographically and by age. An understanding of the complex underlying immune mechanisms remains elusive, although studies show pan-leukocyte activation, cytokine release, and increased gastrointestinal permeability. Management involves trigger avoidance, and patients may benefit from the support of a dietitian to ensure adequate nutrient intake. Tolerance develops over time for most children, but due to the risk of severe symptoms, re-introduction of a suspected FPIES trigger is recommended only under supervision at an oral food challenge. Studies continue to evaluate the optimal challenge protocol. Caregivers of children with FPIES report high levels of anxiety and stress, which is attributed to the dramatic symptomatology, dietary restrictions, nutritional concerns, lack of confirmatory diagnostic tests, and limited tools for management of reactions. Our understanding of the FPIES diagnosis has improved over the last few decades, but there remain opportunities, particularly regarding discerning the pathophysiology and best management practices.
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Affiliation(s)
- Mary Grace Baker
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA.
| | - M Cecilia Berin
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
| | - Scott Sicherer
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, Division of Allergy and Immunology, Kravis Children's Hospital, The Elliot and Roslyn Jaffe Food Allergy Institute, One Gustave L. Levy Place, Box 1198, New York, NY, 10029, USA
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13
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Feketea G, Vassilopoulou E, Geropanta F, Berghea EC, Bocsan IC. Alternative Fish Species for Nutritional Management of Children with Fish-FPIES—A Clinical Approach. Nutrients 2021; 14:nu14010019. [PMID: 35010894 PMCID: PMC8746553 DOI: 10.3390/nu14010019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
In the Mediterranean region, fish is a common cause of food protein-induced enterocolitis syndrome (FPIES) in children. No laboratory tests specific to FPIES are available, and oral food challenge (OFC) is the gold standard for its diagnosis and testing for achievement of tolerance. Children with FPIES to fish are usually advised to avoid all fish, regardless of the species. Fish are typically classified into bony and cartilaginous, which are phylogenetically distant species and therefore contain less cross-reacting allergens. The protein β-parvalbumin, considered a pan-allergenic, is found in bony fish, while the non-allergenic α-parvalbumin is commonly found in cartilaginous fish. Based on this difference, as a first step in the therapeutic process of children with FPIES caused by a certain fish in the bony fish category (i.e., hake, cod, perch, sardine, gilthead sea bream, red mullet, sole, megrim, sea bass, anchovy, tuna, swordfish, trout, etc.), an OFC to an alternative from the category of cartilaginous fish is suggested (i.e., blue shark, tope shark, dogfish, monkfish, skate, and ray) and vice versa. Regarding the increased mercury content in some sharks and other large species, the maximum limit imposed by the European Food Safety Authority (EFSA) for weekly mercury intake must be considered. An algorithm for the management of fish-FPIES, including alternative fish species, is proposed.
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Affiliation(s)
- Gavriela Feketea
- PhD School, Iuliu Hatieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
- Department of Pediatrics, Amaliada Hospital, 27200 Amaliada, Greece
- Department of Pediatrics, Karamandaneio Children’s Hospital, 26331 Patras, Greece
| | - Emilia Vassilopoulou
- Department of Nutritional Sciences and Dietetics, International Hellenic University, 57400 Thessaloniki, Greece;
| | | | - Elena Camelia Berghea
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pediatrics, “Marie S. Curie” Emergency Children’s Clinical Hospital, 041451 Bucharest, Romania
- Correspondence:
| | - Ioana Corina Bocsan
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Iuliu Haţieganu University of Medicine and Pharmacy, 400337 Cluj-Napoca, Romania;
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