food adverse reaction Flashcards
FOOD ALLERGY
• Food intolerance
o Adverse physiologic response
• Food allergy
o Adverse immunologic response and can be
immunoglobulin IgE mediated or non IgE mediated
• Prevalence 1-10%
• Up to 6% of children experience food allergy reaction in the
1st 3 years of life
• 2.5% cow’s milk allergy
• 1.5% egg allergy
• 1% peanut allergy
• 53% of children “outgrow” milk and egg allergy
• 80-90% of children with peanut, nut and seafood allergy
retain their allergy for life.
Adverse Food Reactions>FOOD INTOLERANCE (NON–IMMUNE SYSTEM-MEDIATED,
NONTOXIC, NONINFECTIOUS)
Host factor
Enzyme deficiencies—lactase (primary or secondary), sucrase/
isomaltase, hereditary fructose intolerance, galactosemia
Gastrointestinal disorders—inflammatory bowel disease, irritable
bowel syndrome, pseudoobstruction, colic
Idiosyncratic reactions—caffeine in soft drinks (“hyperactivity”)
Psychologic—food phobias, obsessive/compulsive disorder
Migraines (rare
Food factors (toxic or infectious or pharmacologic)
Infectious organisms—Escherichia coli, Staphylococcus aureus,
Clostridium perfringens, Shigella, botulism, Salmonella, Yersinia,
Campylobacter
Toxins—histamine (scombroid poisoning), saxitoxin (shellfish)
Pharmacologic agents—caffeine, theobromine (chocolate, tea),
tryptamine (tomatoes), tyramine (cheese), benzoic acid in citrus
fruits (perioral flare)
Contaminants—heavy metals, pesticides, antibiotics
FOOD ALLERGY
IgE-mediated
Cutaneous—urticaria, angioedema, morbilliform rashes, flushing,
contact urticarial
Gastrointestinal—oral allergy syndrome, gastrointestinal anaphylaxis
Respiratory—acute rhinoconjunctivitis, bronchospasm
Generalized—anaphylactic shock, exercise induced anaphylaxis
Mixed IgE- and non–IgE-mediated
Gastrointestinal—allergic eosinophilic esophagitis and
gastroenteritis
Respiratory—asthma
Non–IgE-mediated
Cutaneous—contact dermatitis, dermatitis herpetiformis (celiac
disease)
Gastrointestinal—food protein–induced enterocolitis, proctocolitis,
and enteropathy syndromes, celiac disease, food protein induced
enteropathy
Respiratory—food-induced pulmonary hemosiderosis (Heiner
syndrome)
Unclassified
Differential Diagnosis of Adverse Food
Reactions
GASTROINTESTINAL DISORDERS (WITH VOMITING AND/OR
DIARRHEA
Structural abnormalities (pyloric stenosis, Hirschsprung disease,
reflux
Differential Diagnosis of Adverse Food
Reactions>Enzyme deficiencies (primary or secondary):
Disaccharidase deficiency—lactase, fructase, sucrase-isomaltase
Galactosemia
Malignancy with obstruction
Other: pancreatic insufficiency (cystic fibrosis), peptic disease
CONTAMINANTS AND ADDITIVES
Flavorings and preservatives—rarely cause symptoms:
Sodium metabisulfite, monosodium glutamate, nitrites
Dyes and colorings—very rarely cause symptoms (urticaria, eczema):
Tartrazine
Toxins:
Bacterial, fungal (aflatoxin), fish-related (scombroid, ciguatera)
Infectious organisms:
Bacteria (Salmonella, Escherichia coli, Shigella)
Virus (rotavirus, enterovirus)
Parasites (Giardia, Akis simplex [in fish])
Accidental contaminants:
Heavy metals, pesticides
Pharmacologic agents:
Caffeine, glycosidal alkaloid solanine (potato spuds), histamine
(fish), serotonin (banana, tomato), tryptamine (tomato), tyramine
(cheese)
PSYCHOLOGIC REACTIONS
Food phobias
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Hen’s egg white 0-1 yr Other avian eggs 7 yr (75% of cases resolve)
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Cow’s milk 0-1 yr Goat’s milk, sheep’s milk, buffalo milk 5 yr (76% of cases resolve)*
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Peanuts 1-2 yr Other legumes, peas, lentils; coreactivity
with tree nuts
Persistent (20% of cases resolve)
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Tree nuts 1-2 yr; in adults, onset occurs after cross
reactivity to birch pollen
Other tree nuts; coreactivity with peanuts Persistent (9% of cases resolve)
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Fish Late childhood and adulthood Other fish (low cross-reactivity with tuna
and swordfish)
Persistent†
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Shellfish Adulthood (in 60% of patients with this
allergy)
Other shellfish Persistent
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Shellfish Adulthood (in 60% of patients with this
allergy)
Other shellfish Persistent
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Wheat* 6-24 mo Other grains containing gluten (rye, barley) 5 yr (80% of cases resolve)
151-3 Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Soybeans* 6-24 mo Other legumes 2 yr (67% of cases resolve)
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Kiwi Any age Banana, avocado, latex Unknown
Natural History of Food Allergy and Cross-Reactivity Between Common Food Allergies
Apples, carrots,
and peaches§
Late childhood and adulthood Birch pollen, other fruits, nuts Unknown
Prevention of Food Allergy
Exclusive breast feeding for 4-6 mo
Introduce solid (complementary) foods after 4-6 mo of exclusive
breast feeding
Introduce low-risk complementary foods 1 at a time
Introduce potentially highly allergenic foods (fish, eggs, peanut
products, milk, wheat) soon after the lower-risk foods (no need to
avoid or delay)
Don’t avoid allergenic foods during pregnancy or nursing
Soy-based formulas do not prevent allergic disease
Symptoms of Food-Induced Allergic
Reactions
Cutaneous Erythema
Pruritus
Urticaria
Morbilliform eruption
Angioedema
Erythema
Flushing
Pruritus
Morbilliform
eruption
Angioedema
Eczematous rash
Symptoms of Food-Induced Allergic
Reactions
Ocular Pruritus
Conjunctival erythema
Tearing
Periorbital edema
Delayed
Pruritus
Conjunctival
erythema
Tearing
Periorbital edema
Symptoms of Food-Induced Allergic
Reactions
Upper respiratory Nasal congestion
Pruritus
Rhinorrhea
Sneezing
Laryngeal edema
Hoarseness
Dry staccato cough
Symptoms of Food-Induced Allergic
Reactions
Lower respiratory Cough
Chest tightness
Dyspnea
Wheezing
Intercostal retractions
Accessory muscle use
Cough, dyspnea,
and wheezing
Symptoms of Food-Induced Allergic
Reactions
GI (oral) Angioedema of the lips,
tongue, or palate
Oral pruritus
Tongue swelling
GI (lower
GI (lower) Nausea
Colicky abdominal pain
Reflux
Vomiting
Diarrhea
Nausea
Abdominal pain
Reflux
Vomiting
Diarrhea
Hematochezia
Irritability and food
refusal with weight
loss (young
children)
Cardiovascular
Tachycardia (occasionally
bradycardia in
anaphylaxis)
Hypotension
Dizziness
Fainting
Loss of consciousness
Miscellaneous
Uterine contractions
Sense of “impending
doom”
PATHOGENESIS
• Exposure to allergen → formation of food specific antibodies
→ bind to the Fc receptor of mast cells, basophils,
macrophage, & dendritic cells → penetrate mucosal barrier &
reach cell-bound IgE antibodies → mediators are released →
vasodilation, smooth muscle contraction, mucus secretion
→symptoms of immediate hypersensitivity (allergy)
• Skin: oral pruritus, angioedema, flushing
• GIT: oral pruritus, angioedema, nausea, abdominal pain,
vomiting, diarrhea
• Respiratory: nasal congestion, rhinorrhea, nasal pruritus,
sneezing, laryngeal, edema, wheezing
• Cardiovascular: dysrhythmia, hypotension, loss of
consciousness.
• Delayed type
o Activated macrophage and mast cells release cytokines
that attract and activate cells, cells like eosinophils and
lymphocytes → prolong/ chronic inflammatio
Class 1
Class 1 food allergen: allergens penetrating the GI barrier
o Cell mediated sensitivity
• 90% of food allergen occurring in children: egg, milk,
peanuts, treenuts, fish, soy and wheat
• All milk allergy occurs by 12 mos of age
• All egg allergy by 18 mos of age
• Median age of first peanut allergic reaction is 14 mos
• Current recommendation:
o Introduce egg peanut products, fish, wheat, and all allergic
food after 4-6 mos of exclusive breastfeeding
(gradually introduce these allergenic foods during
complimentary feeding to develop tolerance)
Class 2
• Class 2 food allergen: food allergen partially homologous to
plant pollens penetrating the respiratory tract
(Bigger table below)
CLINICAL MANIFESTATION
• Skin Manifestation:
1. AD – at least 30% of children with moderate to severe
AD has food allergy
2. Acute urticaria and angioedema
o Most common symptom of food allergic reactions
o Onset is rapid within minutes of ingestion
o Egg, milk, peanuts & nuts
3. Perioral dermatitis
o Contact dermatitis
o Toothpaste, gum, lipstick
4. Perioral flushing – noted in infants fed with citrus fruit
caused by benzoic acid (orange fruit)
• Respiratory Manifestation:
o Uncommon
o Wheezing occur in 25% of IgE allergic reaction
o 10% of asthmatic patients have food-induced
respiratory symptoms
DIAGNOSIS
•
DIAGNOSIS
• Thorough medical history (food eaten prior to the onset of
signs and symptoms)
• IgE mediated food reaction
o Skin prick test
o Serum specific IgE level
• Cell mediated
o Elimination diet followed by food challenges
o 10-14 days for IgE mediated for food allergy
TREATMENT
• Appropriate identification and elimination of food
• Children with asthma and IgE mediated food allergy, peanut,
or nut allergy or with history of previous severe reaction should
be given epinephrine and a written emergency plan (ideally,
they should have their EpiPen whenever they go outside their
house)
TREATMENT
• Appropriate identification and elimination of food
• Children with asthma and IgE mediated food allergy, peanut,
or nut allergy or with history of previous severe reaction should
be given epinephrine and a written emergency plan (ideally,
they should have their EpiPen whenever they go outside their
house)
PREVENTION
• No consensus as to whether food allergen can be prevented
• Exclusive breastfeeding
• Partially hydrolyzed whey food
• Probiotic supplementation
• Avoid peanut oil containing skin preparation
