Case 1 Food Allergies What is the first medication you should give - PDF document

Case 1 Food Allergies • What is the first medication you should give this child? Peter Mustillo, MD 1) Benadryl Rebecca Scherzer, MD 2) Zantac Department of Pediatrics 3) IM Epinephrine Section of Allergy and Immunology 4) SC Epinephrine Children’s Hospital of Columbus 5) Steroids The Ohio State University Medical Center Case 1 Case 1 • What is the first medication you should give this child? • 15 month old male presents to the ER with an acute onset of urticaria/facial 1) Benadryl angioedema/and wheezing. Symptoms began 5 minutes after he started eating 2) Zantac scrambled egg. Family is unsure if he has ever been exposed to egg before. Physical 3) IM Epinephrine exam is noteable for generalized urticaria, 4) SC Epinephrine facial angioedema, mild wheezing and a BP of 65/35. 5) Steroids 1

Food Hypersensitivity Disorders Food Allergy IgE mediated Gastrointestinal Oral allergy syndrome, gastrointestinal anaphylaxis Cutaneous Urticaria, angioedema, morbilliform rashes and flushing Respiratory Acute rhinoconjunctivitis, bronchospasm (wheezing) Generalized Anaphylactic shock • Definition: Mixed IgE and cell mediated Gastrointestinal Eosinophilic esophagitis/ Gastroenteropathy � An adverse immune response to Cutaneous Atopic dermatitis Respiratory Asthma food proteins. Cell mediated Gastrointestinal Food protein -- induced enterocolitis Syndrome (FPIES) Food protein – induced proctocolitis (allergic colitis) Food protein – induced enteropathy syndromes Celiac disease Cutaneous Contact dermatitis, Dermatitis herpetiformis Respiratory Food-induced pulmonary hemosiderosis (Heiner syndrome) J Allergy Clin Immunol May 2004, 113:805-19 Causes of Adverse Food Allergy Reactions to Foods • More prevalent in westernized nations • Intolerance � Lactose intolerance, galactosemia • Incidence is increasing • Pharmacologic • Anaphylaxis (IgE mediated) related to food � Caffeine, tyramine in aged cheeses allergies accounts for at least ⅓ to ½ of • Toxins anaphylaxis cases seen in ED’s. � Food poisoning • Food Allergy J Allergy Clin Immunol 2001; 107:191-3, Clin Exp Allergy 2003; 33: 1033-40. • Food allergy is a major risk factor for � IgE mediated severe life-threatening asthma. � Mixed IgE mediated and non-IgE mediated J Allergy Clin Immunol 2003;112:168-174. � Non-IgE mediated 2

Symptoms: IgE Based Food Allergy Reactions • Affects 6% of children under 3 years of age. • Typically occur within 60-90 minutes • 73% caused by Milk, Egg, and Peanut • Urticaria Journal of Pediatrics 1990;4:561-567 • Angioedema (especially of face) • Up to 95% of reactions in children are caused by: Milk, Eggs, Peanut, Tree Nut, • Wheezing Soy, Wheat and Fish • Vomiting/Diarrhea • 20% of peanut allergic children eventually • Rhinoconjunctivitis develop clinical tolerance • Anaphylaxis Prevalence of Food Allergy in IgE Mediated Responses the United States Food Young Children Adults Mast cell IgE Inflammatory Allergen degran- Clinical symptoms synthesis mediators ulation Milk 2.5% 0.3% Allergic rhinitis Egg 1.3% 0.2% Mechanism Atopic Asthma eczema, Peanut 0.8%* 0.6% urticaria Tree Nuts 0.2% 0.5% Food allergy Fish 0.1% 0.4% Allergen Specific Mast-cell Mediator Late-phase Treatment avoidance Immunotherapy stabilization: antagonists: inhibitors: antihistamines, steroids Shellfish 0.1% 2% antileukotrienes OVERALL 6% 3.7% Adapted from Roitt J. Essential Immunology. 1994. J Allergy Clin Immunol 2004;113:805-19 3

Food Allergy Diagnosis • 32 fatal food-induced anaphylaxis cases • Skin Prick Testing � 94% due to peanut and tree nuts � Simple, generally safe � Majority are adolescents/young adults � Results in 10 -20 minutes � Good negative predictive value (> 95%) but � Virtually all had history of previous poor positive predictive value (< 50%) reaction to the implicated food � Examples when difficult to perform: � Majority had asthma dermographism, patient cannot stop antihistamines � Only 10% had epinephrine available � Age requirements J Allergy Clin Immunol 2001; 107: 191-3 Clinical Diagnosis • History Video • What food had been eaten? Demonstration • Time course of reaction • Symptoms and treatment of reaction of Allergy Skin Test • Previous exposure? • Other food allergies? • Other atopic disease? 4

Approximate rate of clinical reactivity to at In Vitro IgE (Cap-System FEIA) least 1 other related food J Allergy Clin Immunol Volume 108, Number 6 Food Challenges Treatment • Open • Currently is avoidance � Easiest to perform • Early use of epinephrine � Child, parent, and health care team aware the • Future Possibilities patient is ingesting the possible allergen • Single-Blinded • Anti-IgE therapy • Desensitization � Possible allergen hidden in liquid such as grape juice • Genetic engineering � Health care team aware of when the patient is • Immunotherapy using CpG motifs ingesting the sample with the suspected allergen 5

Patient Education Case #2 • If allergic to peanut / tree nuts, avoid • A 12 y/o male is seen in your office for bakeries, ice cream parlors, and Asian complaint of certain foods getting stuck in restaurants esophagus during eating. Other than some • Demonstrate EpiPen using trainer seasonal allergic rhinitis and rare heartburn, • Identification bracelet / necklace he has been previously healthy. Physical exam is unremarkable. • Communication with other caretakers • Dietary consults • You start him on a proton pump inhibitor bid, recommend he avoids caffeine, and suggest • Suggested Resource: follow-up in 4 weeks. � Food Allergy and Anaphylaxis Network www.foodallergy.org Vaccine Use in Egg- …Case #2 Allergic Children • On follow-up, he tells you he is no better on • Avoid influenza and yellow fever vaccines the antacid, and twice in the past 2 weeks was • Red Book States that children with egg unable to swallow meat, until it was washed allergy may be given MMR without previous down with extra milk purchased in the school skin testing (vaccine derived from chicken lunch line. egg fibroblast tissue cultures, but does not • You subsequently refer him to GI, who contain significant amounts of egg cross- performs an upper endoscopy. reacting proteins) 6

…Case #2 Which of the following would be the most • likely diagnosis? A) Candida esophagitis B) Vocal cord dysfunction C) Gastroesophageal reflux disease D) Eosinophilic esophagitis …Case #2 Eosinophilic Esophagitis • An immune reaction due to an IgE Which of the following would be the most • mediated, non-IgE mediated or likely diagnosis? combined response A) Candida esophagitis • Characterized by infiltration of the B) Vocal cord dysfunction esophagus with eosinophils C) Gastroesophageal reflux disease • Seen most often during infancy through adolescence D) Eosinophilic esophagitis 7

Pathology and Diagnosis of Eosinophilic Esophagitis No. of eosinophils per HPF ≤ 15 >15 Consider Rx for Consider allergy or primary aggressive eosinophilic antireflux Rx esophagitis Eosinophilic GERD Esophagitis Clinical Features of Eosinophilic Esophagitis 8 ± 0.9 (range, 1-16) Mean age at presentation (yr) Sex (M/F) 14/5 Duration of symptoms before diagnosis (yr) 2.3 ± 0.6 Presenting complaints a (%) Dysphagia 58 Vomiting 42 Heartburn 37 Abdominal pain 32 Food impaction 11 Failure to thrive 11 Diarrhea 5 Family history of allergic disease (%) 58 Personal history of allergic disease (%) 84 Peripheral eosinophilia (%) 58 ------------------------------------------------------------------------------------------------------------------ a Some patients had more than 1 presenting symptom. Teitelebaum JE. Gastroenterology 2002; 122:1216-1225 8

Eosinophilic Esophagitis: Case #3 Clinical Features in INFANTS • A 12 month old girl with a history of eczema Symptoms may be more vague since age 4 months is brought into your office for her well visit. During the interview, you � Feeding refusal note she is continuously scratching her legs. Mom reports antihistamines and numerous � Early satiety topical creams, including steroids and � Failure to thrive emollients, have resulted in minimal improvement. � Poor weight gain Case #3 Eosinophilic Esophagitis • In reviewing her history: • Commonly, but not always attributed to food allergy (68% (+) Skin test +/- RAST). � On milk formula since shortly after birth. Started solids at 4-5 months J Allergy Clin Immunol 2002; 109:363-8. • Treatment options � On 3 courses of antibiotics for secondarily infected skin. • Food elimination or hypoallergenic formula � No history of urticaria, abscesses or pneumonia. • Swallowed topical steroid treatment � Exam is significant for generalized xerosis, • Long term prognosis unclear areas of erythema with some scaling on the trunk and extremities, and lichenification • Strictures in some with excoriation over the hands, wrists, and ankle areas. 9