M.R.Fariborzi Assistant Professor of Pediatric Gastroenterologist - PowerPoint Presentation

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3. M.R.FariborziAssistant Professor of Pediatric GastroenterologistBoushehr medical universityClinical Manifestations of Food Allergy

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5. IgE-MEDIATED REACTIONSRapid in onset (typically beginning within minutes to two hours from the time of ingestion)Signs and symptoms can involveSkinRespiratory Gastrointestinal tractsCardiovascular systemTwo distinct presentationsOral allergy syndromeFood-dependent, exercise-induced anaphylaxis (FDEIAn)

6. IgE-MEDIATED REACTIONS:Urticaria and angioedema The most common cutaneous manifestations of food hypersensitivity reactionsUrticariaAcute (Food allergy may account for 20 percent of cases of acute urticaria )Chronic (food allergies are an uncommon underlying cause of chronic urticaria and angioedema)

7. IgE-MEDIATED REACTIONS:Oropharyngeal symptoms Oropharyngeal symptoms Isolation As part of a systemic reactionOral allergy syndrome, or pollen-food allergy syndrome:A form of contact allergy that is common in patients with allergic rhinitis to pollen. Immediate onset of (after ingestion of fresh, uncooked fruits and vegetables) :Pruritus IrritationMild swelling of the lips, tongue, palate, and throat uponSymptoms usually subside within minutes after ingestion ceases. Examples:Birch-allergicRagweed-allergicMugwort-allergic

8. IgE-MEDIATED REACTIONS:Respiratory tract symptoms Asthma, allergic rhinitis and conjunctivitis are more common in children with food allergy. However, isolated allergic rhinoconjunctivitis or asthma in response to foods is rareOccupational asthma & "Baker's asthma,"

9. IgE-MEDIATED REACTIONS:Gastrointestinal symptoms  IgE-mediated gastrointestinal symptoms (anaphylaxis due to ingestion of a food allergen)NauseaAbdominal painAbdominal crampingVomitingDiarrheaThe term "gastrointestinal anaphylaxis" is used when gastrointestinal symptoms occur in isolation. The onset of upper GI symptoms: minutes to two hours after ingestionThe onset of lower GI symptoms: two to six hours after ingestion.

10. IgE-MEDIATED REACTIONS:Anaphylaxis Anaphylactic reactions may culminate in hypotension, vascular collapse, cardiac dysrhythmias, or death. Skin symptoms may be absent. Common causative foods include wheat, celery, and seafood. Cofactors may increase the risk that a food allergen will elicit anaphylaxis:Exercise(FDEIAn)NSAIDs AlcoholElevated body temperatureAcute infectionsAntacids

11. NON-IgE-MEDIATED REACTIONS(subacute and/or chronic symptoms in GI tract and/or skin )The exclusive non-IgE-mediated food allergy disorders principally include:Food protein-induced enterocolitis syndrome (FPIES; entire gastrointestinal tract)Food protein-induced enteropathy (small bowel)Food protein-induced proctitis and proctocolitis (rectum and colon)Food-induced pulmonary hemosiderosis (Heiner syndrome)

12. NON-IgE-MEDIATED REACTIONS Gastrointestinal manifestations  Food protein-induced proctitis/proctocolitis Passage of blood-tinged stools and mucus in an otherwise healthy infant without an anal fissureThe most common trigger: cow's milk in the mother's diet (also occur in formula-fed infants)Typically presents between two and eight weeks of age and resolves in a few days with complete elimination of the offending protein.

13. NON-IgE-MEDIATED REACTIONS Gastrointestinal manifestations  Food protein-induced enterocolitis syndrome (FPIES) :Sicker in appearance (lethargy and pallor )Watery stools with occasional mucus (melena is possible)Intermittent vomiting in the chronic setting can be severe and can lead to dehydration. Malabsorption. Poor weight gain/failure to thrive is common. Laboratory abnormalities: hypoalbuminemia, anemia and leukocytosisFPIES is uncommon in exclusively breastfed infants. Cow's milk and soy are the most common triggers in infants and children, although many other food protein triggers have been reported.

14. NON-IgE-MEDIATED REACTIONS Gastrointestinal manifestations  FPIES (cont) :FPIES in older children and adults is rare and typically presents a milder syndrome of nausea, protracted vomiting, and cramping several hours after ingestion.There are several reports of shellfish as a causative food in adults.Food Protein-induced enteropathy :findings similar to patients with FPIES

15. NON-IgE-MEDIATED REACTIONS Gastrointestinal manifestations  Celiac diseaseChronic diarrhea, anorexia, abdominal distension and pain, failure to thrive or weight loss, and sometimes also vomitingOlder children and adults: steatorrhea, weight loss, and other signs of nutrient or vitamin deficiency due to malabsorption. Flatulence and steatorrhea are suggestive of celiac disease rather than other forms of food-protein-induced enteropathy or FPIES

16. NON-IgE-MEDIATED REACTIONS: Skin manifestationsDermatitis herpetiformisItchy papular vesicular eruption located symmetrically on the extensor surfaces of the elbows, knees, buttocks, sacrum, face, neck, trunk, and occasionally within the mouth.The predominant symptoms are itching and burning that are rapidly relieved with rupture of the blisters.

17. NON-IgE-MEDIATED REACTIONS:Pulmonary manifestations  Food-induced pulmonary hemosiderosis (Heiner syndrome):Rare syndrome in infants that consists of recurrent pneumonia with pulmonary infiltrates, hemosiderosis, iron deficiency anemia, and failure to thrive. Cow's milk is the most common causative food, with pork and egg also being reported Elimination of the offending food results in resolution. Coexistence of celiac disease and idiopathic pulmonary hemosiderosis, also known as Lane-Hamilton syndrome, has been reported in a number of cases. Idiopathic pulmonary hemosiderosis :Rare disease found primarily in children that causes recurrent episodes of diffuse alveolar hemorrhage that may eventually produce pulmonary hemosiderosis and fibrosis. Diffuse alveolar hemorrhage is characterized by hemoptysis, dyspnea, alveolar opacities on chest radiographs, and anemia. Introduction of a gluten-free diet has been associated with remission of pulmonary symptoms in several patients.

18. MIXED IgE AND NON-IgE-MEDIATED REACTIONS  Atopic dermatitis (eczema) Food allergies may exacerbate atopic dermatitis, especially in young children with more severe eczema. The flare occurs within minutes to a few hours if the reaction is IgE mediated but may take hours to days if the reaction is non-IgE mediated. The patient has persistent lesions if the food is eaten chronically.

19. MIXED IgE AND NON-IgE-MEDIATED REACTIONS   Eosinophilic gastrointestinal disorders EGIDs are characterized by symptoms of postprandial gastrointestinal dysfunction accompanied by eosinophilic infiltration of various segments of the intestinal tract on biopsy. Symptoms are intermittent but can be delayed by hours to days if the food trigger is eaten infrequently. Many patients have evidence of allergic sensitivities to food and/or environmental allergens, but the causal role of these sensitivities is unclear.

20. MIXED IgE AND NON-IgE-MEDIATED REACTIONS    Eosinophilic esophagitis EoE should be suspected in patients of any age presenting with esophageal symptoms. Infants and young children may present with feeding disorders and failure to thrive Older children and adults typically present with dysphagia, vomiting, and abdominal pain A history of food impaction is common, particularly in adolescents and adults. Failure to respond to antacids and antireflux therapies is an important aspect of the history. Many patients with EoE have other atopic diseases. The most commonly implicated foods in children are cow's milk, egg, soy, corn, wheat, and beef, and most patients with evidence of food sensitivity tested positive for multiple foods. Elimination or elemental diets result in clinical and histologic improvement in most.

21. MIXED IgE AND NON-IgE-MEDIATED REACTIONS   Eosinophilic gastroenteritis Eosinophilic gastroenteritis can present at any age with abdominal pain, nausea, diarrhea, malabsorption, and weight loss. In infants, it may present as outlet obstruction with postprandial projectile vomiting that can mimic pyloric stenosis In adolescents and adults, it can mimic irritable bowel syndrome.Symptoms vary depending on the layer and portion of the gastrointestinal tract that is involved. Approximately one-half of patients have allergic disease, such as defined food sensitivities, asthma, eczema, or rhinitis. An empiric elimination diet or elemental diet may improve symptoms and histologic findings in up to half of patients.

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