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Akashi M, Kaburagi S, Kajita N, Morita H. Heterogeneity of food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:196-205. [PMID: 38553113 DOI: 10.1016/j.alit.2024.02.001] [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: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 04/02/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy with gastrointestinal symptoms such as vomiting and diarrhea. The development of international consensus guidelines for the diagnosis and management of FPIES in 2017 enabled us to compare patients worldwide, regardless of geographic variation in disease features. As a result, it has become clear that there is heterogeneity among patients with FPIES or that there are cases that partly fit the diagnostic criteria for FPIES but have different characteristics. This review highlights the heterogeneity in FPIES characteristics in terms of trigger foods, the age of onset, differences in geographic regions, and symptoms; it further proposes four disease entities, including acute FPIES in children, acute FPIES in adults, chronic FPIES, and early-onset neonatal FPIES, depending on the age of onset and presumed pathophysiology. The major symptoms at onset and trigger foods differ in acute FPIES in children, acute FPIES in adults, and chronic FPIES, whereas the disease entities may share a similar pathophysiology. Early-onset neonatal FPIES may have a different pathophysiology than acute or chronic FPIES, and may not necessarily fulfil the full diagnostic criteria for acute or chronic FPIES described in the international consensus guidelines. Due to the similarity in symptoms, early-onset neonatal FPIES may sometimes be misdiagnosed as necrotizing enterocolitis. We aim to increase awareness of FPIES among medical staff in pediatrics, neonatology, and internal medicine and promote research, to gain a better understanding of the heterogeneity and pathophysiology of FPIES.
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Affiliation(s)
- Masayuki Akashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Sachiko Kaburagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Kajita
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, 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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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:S2213-2198(24)00278-2. [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] [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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Miceli Sopo S, Mastellone F, Bersani G, Gelsomino M. Personalization of Complementary Feeding in Children With Acute Food Protein-Induced Enterocolitis Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:620-623. [PMID: 37778631 DOI: 10.1016/j.jaip.2023.09.022] [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: 07/20/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a food allergy that results in repetitive vomiting, lethargy, and pallor within 1 to 4 hours of food ingestion. One of the issues in its management is the introduction of new foods. Over the past 25 years, suggestions have been made mainly based on the likelihood that a given food family could induce an episode of acute FPIES. Thus, foods have been categorized into low, moderate, and high risk. The suggestion was always to postpone the introduction of moderate- or high-risk foods, leaving the decision whether to introduce them at home or in hospital to the doctor. These suggestions were designed for all children with acute FPIES, regardless of their geographical area. However, it is true that these suggestions are the result of expert opinion. In recent years, studies have been published that have shown that the risk category of foods varies according to geographical area and so does the prevalence of single FPIES versus multiple FPIES. For this reason, we believe that the introduction of new foods in the child with acute FPIES can and should be tailored according to the geographical area.
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Affiliation(s)
- Stefano Miceli Sopo
- Department of Life Sciences and Public Health, Pediatric Allergy Unit, Pediatrics Section, Policlinico Gemelli Universitary Foundation IRCCS, Catholic University of Sacre Hearth, Rome, Italy.
| | - Francesco Mastellone
- Department of Life Sciences and Public Health, Post-Graduate School of Pediatrics, Policlinico Gemelli Universitary Foundation IRCCS, Catholic University of Sacre Hearth, Rome, Italy
| | - Giulia Bersani
- Department of Life Sciences and Public Health, Pediatric Allergy Unit, Pediatrics Section, Policlinico Gemelli Universitary Foundation IRCCS, Catholic University of Sacre Hearth, Rome, Italy
| | - Mariannita Gelsomino
- Department of Life Sciences and Public Health, Post-Graduate School of Pediatrics, Policlinico Gemelli Universitary Foundation IRCCS, Catholic University of Sacre Hearth, Rome, Italy
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Hayano S, Natsume O, Yasuoka R, Katoh Y, Koda M. Predictors of initial oral food challenge outcome in food protein-induced enterocolitis syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2022; 1:122-127. [PMID: 37781265 PMCID: PMC10509941 DOI: 10.1016/j.jacig.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/12/2022] [Accepted: 05/09/2022] [Indexed: 10/03/2023]
Abstract
Background There is a paucity of data on predictors of clinical history in oral food challenge (OFC) outcome for the initial diagnosis of food protein-induced enterocolitis syndrome (FPIES). Objective This study aimed to identify predictors for the diagnosis of FPIES. Methods The study included patients who underwent OFC to diagnose FPIES from 2010 to 2021. Patients with a positive OFC result were classified as belonging to the FPIES group, and those with negative OFC result within 120 days from the last symptomatic episode were classified as belonging to the no-allergy (NA) group. Background factors were analyzed in the groups. Results A total of 50 OFCs to 12 different foods were conducted in 50 patients. Of those 50 patients, 30 were classified as belonging to the FPIES group. No significant difference was observed between the FPIES and NA groups with respect to background factors, including the features of symptomatic episodes and examinations of immediate-type allergy. A history of asymptomatic ingestion was observed in 23 of 24 and 13 of 19 patients in the FPIES and NA groups, respectively; thus, it was significantly more common in patients with FPIES. The diagnostic rate of patients with fewer than 3 symptomatic episodes was 52%, and that of patients with 3 episodes or more was 75%, not considering a patient without available data. Conclusions A definite diagnosis of FPIES should be based on OFC, as there are no predictors for OFC positivity other than a history of asymptomatic ingestion. The absence of asymptomatic ingestion history was a negative predictor for the diagnosis of FPIES.
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Affiliation(s)
- Satoshi Hayano
- Allergic Disease Research Center, Chutoen General Medical Center, Kakegawa, Japan
- Department of Pediatrics, Chutoen General Medical Center, Kakegawa, Japan
| | - Osamu Natsume
- Department of Pediatrics, Chutoen General Medical Center, Kakegawa, Japan
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
- Department of Pediatrics, Public Morimachi Hospital, Morimachi, Japan
| | - Ryuhei Yasuoka
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
| | - Yukiko Katoh
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
| | - Masaki Koda
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu City, Japan
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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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