Lec 06: Adverse Food Reactions Flashcards
True or False:
Adverse food reaction = Food allergy
False.
ADVERSE FOOD REACTIONS can be any abnormal clinical response attributed to ingestion, contact, or inhalation of any food, food derivative, or food additive. FOOD ALLERGY, on the other hand is limited to the immunologic type of adverse food reactions.
Scombroid fishes, a known toxic cause of non-immune adverse food reactions are rich in:
a. dinoflagellates
b. staphylococcus sp.
c. histidine
d. theobromine
c. histidine
scombroid fish poisoning – scombroid fishes (tuna, mackerel, bonito, tulingan, galunggong) are rich in histidine. Bacterial decarboxylase converts histidine to histamine.
- a. dinoflagellates - in ciguatera fishes
b. staphylococcus sp. - most common food contaminant
d. theobromine: pharmacologic component of chocolate that can cause non-immune adverse food reaction.
Determine type of food allergy: Acute urticaria
a. IgE-mediated
b. Mixed IgE and non-IgE-mediated
c. Non-IgE-mediated
d. Cell-mediated
a. IgE-mediated
Other IgE-mediated
Oral allergy syndrome Angioedema Food-associated anaphylaxis Bronchospasm Allergic rhinitis
Determine type of food allergy: Food protein-induced enteropathy.
a. IgE-mediated
b. Mixed IgE and non-IgE-mediated
c. Non-IgE-mediated
d. Cell-mediated
c. Non-IgE-mediated
other Non-IgE-mediated types:
Celiac disease
Dermatitis herpetiformis
Heiner’s syndrome
allergic proctocolitis
- Celiac disease - an autoimmune disorder of the small intestine that occurs in genetically predisposed people of all ages from middle infancy onward. Symptoms include pain and discomfort in the digestive tract, chronic constipation and diarrhoea, failure to thrive (in children), anaemia and fatigue,
Determine type of food allergy: Most common
a. IgE-mediated
b. Mixed IgE and non-IgE-mediated
c. Non-IgE-mediated
d. Cell-mediated
d. Cell-mediated
Determine type of food allergy: Allergic contact dermatitis
a. IgE-mediated
b. Mixed IgE and non-IgE-mediated
c. Non-IgE-mediated
d. Cell-mediated
d. Cell-mediated
Determine type of food allergy: Eosinophilic gastroenteritis
a. IgE-mediated
b. Mixed IgE and non-IgE-mediated
c. Non-IgE-mediated
d. Cell-mediated
b. Mixed IgE and non-IgE-mediated
Other mixed types:
Atopic dermatitis
asthma
The TYPICAL evolution of allergic diseases (Atopic march):
a. Gastrointestinal -> Asthma -> Allergic rhinitis -> Atopic dermatitis
b. Gastrointestinal -> Atopic dermatitis -> Asthma -> Allergic rhinitis
c. Gastrointestinal -> Allergic rhinitis -> Atopic dermatitis -> Asthma
d. Gastrointestinal -> Asthma -> Atopic dermatitis -> Chancroid
G.E.A.R
b. [G]astrointestinal -> Atopic Dermatitis ([E]czemas) -> [A]sthma -> Allergic [R]hinitis
True or False: Acute Urticaria as an adverse food reaction is rare in children.
True.
US population-based estimates show that the Food allergy prevalence of acute Urticaria is 20% in adults and rare in children.
- Atopic dermatitis is more common in children (37%) and rare in adults.
Identify the theory on Induction of Oral Tolerance described:
Intestinal epithelial cells function as nonprofessional antigen presenting cells. The lack of a co-stimulatory signal during T cell activation results in non-progression.
a. Clonal Anergy
b. Tolerogenic Cytokines
c. Priming Location
d. Commensal Gut Flora
a. Clonal Anergy
Identify the theory on Induction of Oral Tolerance described:
T cells primed in the local mucosal environment (e.g. Peyer’s patches) lead to tolerance while T cells primed in mesenteric lymph nodes lead to immune response.
a. Clonal Anergy
b. Tolerogenic Cytokines
c. Priming Location
d. Commensal Gut Flora
c. Priming Location
Identify the theory on Induction of Oral Tolerance described:
Activated T cells release tolerogenic and antiinflammatory cytokines IL-10 and TGF-β instead
of IL-4 and IL-5.
a. Clonal Anergy
b. Tolerogenic Cytokines
c. Priming Location
d. Commensal Gut Flora
b. Tolerogenic Cytokines
Identify the theory on Induction of Oral Tolerance described/supported:
In mouse studies, those brought up in a germ-free environment (i.e. no intestinal flora) had no oral tolerance.
a. Clonal Anergy
b. Tolerogenic Cytokines
c. Priming Location
d. Commensal Gut Flora
d. Commensal Gut Flora
A normal gut flora contributes to oral tolerance.
In mouse studies, those brought up in a germ-free
environment (i.e. no intestinal flora) had no oral
tolerance. [2017]
Early exposure to cow’s milk as well as antibiotics may alter the intestinal flora and may lead to an immune response.
Probiotics may be used to prevent food allergy.
[2017]
True or False. Oral tolerance cannot be bypassed by presentation of allergens through alternate routes such as the respiratory tract or skin.
False.
Oral Tolerance might be bypassed by presentation of allergens through alternate routes such as the respiratory tract or skin.
The following are risk factors for food allergy, EXCEPT:
a. Immature immune mucosal system
b. Early introduction of solid food
c. Hereditary increase in mucosal permeability
d. IgA deficiency or delayed IgA production
e. AOTA
f. NOTA
e. NOTA
Risk Factors for Food Allergy
Immature immune mucosal system – easier absorption
(usually in children)
Early introduction of solid food – change in GI flora
Hereditary increase in mucosal permeability - more antigen entering mucosa
IgA deficiency or delayed IgA production
Inadequate challenge of intestinal immune system with commensal flora – patient not breastfed will not have the ideal commensal gut flora.
The top food allergen in children.
Cow’s milk
The top food allergen in adults.
Fruits
Class I or Class II Food Allergen:
Cow’s milk
Class I
- The allergic epitopes of cow’s milk are:
- caseins (alpha, beta, kappa)
- a-lactoalbumin
- B-lactoglobulin
- serum albumin
- Lahat ng Top food allergens ay Class I. Ang Class 2 Food allergens, on the other hand ay mga pollens, etc. - basta pag ang sensitization ay either sa skin (contact with plant-derived protein) or respiratory (inhaled pollens)
Class I or Class II Food Allergen:
sensitization occurs in the GI tract.
Class I
Ang Class II ay either sa respiratory or sa skin na sesensitize.
Class I or Class II Food Allergen:
Incomplete food allergen
Class II
Class I or Class II Food Allergen:
Cross-reactive
Class II
*Cross-reactivity occurs when the proteins in one substance are similar to the proteins in another and the immune system sees them as the same. In the case of food allergies, cross-reactivity can occur between one food and another but it is also seen between pollen and foods or latex and foods.
Class I or Class II Food Allergen:
stable to heat, acid, and proteases
Class I.
Class II, on the other hand is highly heat-labile and susceptible to enzymatic degradation.
Identify the disorder based on the following information:
- IgE-mediated
- Symptoms include HIVES, SWELLING, PRURITUS
a. Atopic Dermatitis
b. Urticaria
c. Dermatitis Herpetiformis
d. Asthma
b. Urticaria.
Sa IgE-mediated pa lang, pwede mo nang ma-narrow down to Urticaria.
Remember:
IgE-mediated: Urticaria
Mixed IgE and Non-IgE: Atopic Dermatitis
Non IgE: Dermatitis Herpetiformis.
Cell-mediated: Allergic Contact Dermatitis
- Method of diagnosis would be by clinical history, Skin Prick Test (SPT), elimination diet or oral challenge/
Identify the disorder based on the following information:
- Patient was the one who prepared the food
- eczematous rash
- marked pruritus
a. Atopic Dermatitis
b. Urticaria
c. Dermatitis Herpetiformis
d. Contact Dermatitis
d. Contact Dermatitis (most probable)
- Food allergies in people who prepare the food are usually Contact dermatitis
- Can be atopic dermatitis however: it is more common as an adverse food reaction in children and is very rare in adults - and most probably adult ang patient since siya ang nagprepare ng food.
Identify the disorder based on the following information:
- The sensitizing allergen was soybean
- Diagnosed using atopic patch test and history
a. Atopic Dermatitis
b. Urticaria
c. Dermatitis Herpetiformis
d. Contact Dermatitis
d. Contact dermatitis (best answer)
- Soybeans are known to contain NICKEL. Metals in food are usually associated with Systemic Contact Dermatitis.
Identify the disorder based on the following information:
- best diagnosed using skin biopsy (to check for IgA deposition)
- papulovesicular lesions
a. Atopic Dermatitis
b. Urticaria
c. Dermatitis Herpetiformis
d. Contact Dermatitis
c. Dermatitis Herpetiformis
* Big clue ang skin biopsy to “check for IgA deposition”. Meaning, most probably non-IgE-mediated siya + papulovesicular lesions = Dermatitis Herpetiformis
Identify the disorder based on the following information:
- IgE-mediated
- with Conjunctival erythema
- with Periocular pruritus
- Rhinorrhea
- Sneezing
a. Allergenic rhinoconjunctivitis
b. Asthma
c. Sore eyes
d. Heiner’s syndrome
a. Allergenic rhinoconjunctivitis
Identify the disorder/clinical condition based on the following information:
- Acute bronchospasm usually seen in food-induced symptoms
- Cough
- Dyspnea
- Wheezing associated with other reactions such as urticaria.
a. Allergenic rhinoconjunctivitis
b. Asthma
c. Chronic Urticaria
d. Heiner’s syndrome
b. Asthma
Identify the disorder/clinical condition based on the following information:
- Recurrent pneumonia
- Hemosiderinosis
- Diagnosed using Lung biopsy, elimination diet, history.
a. Allergenic rhinoconjunctivitis
b. Asthma
c. Chronic Urticaria
d. Heiner’s syndrome
d. Heiner’s Syndrome (Non-IgE-mediated)
Identify the disorder/clinical condition based on the following information:
- Mild pruritus, tingling and angioedema after contact with pollen
- Localized to oral mucosa
a. Gastrointestinal Anaphylaxis
b. Plant Food Allergy Syndrome
c. Oral Allergy Syndrome
d. Eosinophilic Esophagitis
b. Plant Food Allergy Syndrome (aka Oral Allergy Syndrome)
Identify the disorder/clinical condition based on the following information:
- Rapid onset nausea and vomiting
- Diarrhea as initial manifestation
a. Gastrointestinal Anaphylaxis
b. Plant Food Allergy Syndrome
c. Oral Allergy Syndrome
d. Eosinophilic Esophagitis
a. Gastrointestinal Anaphylaxis
Identify the disorder/clinical condition based on the following information:
- Presents with GERD and dysphagia
- INTERMITTENT abdominal pain
- Sleep disturbance and irritability
- unresponsive to reflux medications
a. Gastrointestinal Anaphylaxis
b. Plant Food Allergy Syndrome
c. Oral Allergy Syndrome
d. Eosinophilic Esophagitis
d. Eosinophilic Esophagitis
Identify the disorder/clinical condition based on the following information:
- RECURRENT abdominal pain
- Weight loss
- Early satiety
a. Gastrointestinal Anaphylaxis
b. Plant Food Allergy Syndrome
c. Oral Allergy Syndrome
d. Eosinophilic Esophagitis
e. NOTA
e. NOTA
The condition described is Eosinophilic Gastroenteritis.
- INTERMITTENT ABDOMINAL PAIN - Eosinophilic Esophagitis
- RECURRENT ABDOMINAL PAIN - Eosinophilic Gastroenteritis
In EOSINOPHILIC ESOPHAGITIS, responsible food allergens may need to be eliminated from the diet for up to ____ weeks to bring about resolution of symptoms and up to _____ weeks to bring about normalization of intestinal histology.
8 weeks to bring about resolution and up to 12 weeks to bring about normalization of intestinal histology.
Identify the disorder/clinical condition based on the following information:
- Gross or occult blood in stool of healthy infants
- Hematopesia
- Melena
- Presents in the first few months of life.
a. Food protein-induced Enterocolitis Syndrome (FPIES)
b. Food protein-induced Proctocolitis
c. Food protein-induced Enteropathy
d. Eosinophilic Gastroenteritis
a. FPIES
Diagnosed by:
(-) SPT, endoscopy, biopsy
Elimination of food protein and subsequent clearing of symptoms in 72 hours
Identify the disorder/clinical condition based on the following information:
- Recurrent abdominal pain
- Diarrhea
- Abdominal distension
a. Food protein-induced Enterocolitis Syndrome (FPIES)
b. Food protein-induced Proctocolitis
c. Food protein-induced Enteropathy
d. Eosinophilic Gastroenteritis
b. Food protein-induced Proctocolitis
Diagnosis:
Clinical history
(-) SPT, endoscopy, biopsy
Elimination and food protein with with clearing of symptoms in 24-72 hours
Recurrent vomiting within 1-2 hours (15% of cases)
- Differentiate from Eosinophilic Gastroenteritis (Mixed IgE and Non-IgE-mediated):
Food protein-induced Proctocolitis is Non-IgE-mediated and with Diarrhea and development of dehydration and hypotension
In anaphylaxis, Mast cells release this serum which is also used for testing for allergy:
serum beta-tryptase
- if not elevated: food-induced anaphylaxis (most of the time)
- if elevated: drug-induced anaphylaxis
True or False: Exercise-induced anaphylaxis is more common in adolescent males.
False.
Usually in adolescent females
If you ingest the food but did not exercise, you will not develop anaphylaxis; if you ingest the food allergen and exercised, there’ll be an ↑ in your body temperature and gastrin, and anaphylaxis develops
Mediators: Histamines, Others (LTD4, PAF, etc.)
In the Skin Prick Test, to be considered positive, an allergen must elicit a wheal of at least ____mm greater than the negative control.
3mm
What is used as the negative control for the Skin Prick Test?
Phosphate buffer with saline solution
The test for Class II allergens done by pricking the food, then pricking the skin with the prick.
Prick-Prick Test
QUALITATIVE Measurement of specific IgE
Radioallergosorbent Test (RAST)
QUANTITATIVE measurement of specific IgE.
Fluorescence-labeled antibody assays.
Detects presence of serum IgE antibodies and indicated if SPTs are contraindicated.
Allergen-specific Serum IgE
Used to assess delayed or non-IgE-mediated reactions.
Atopy Patch Test
- Patch tests use antigens that typically provoke T cell-mediated reactions
- You put a patch at the back of the patient and check reaction after 24-48 hours.
The Gold Standard for Oral Food Challenge (OFC)
a. Open
b. Single-blind
c. Double-blind placebo-controlled food challenge
c. Double-blind placebo-controlled food challenge (DBPCFC) - Both physician and patient are unaware of the food given by third party for the challenge. The food is also lyophilized and even put into capsules or liquid to remove bias.
Open - both patient and physician knows the food (given in natural form); used if symptoms are objective such as urticaria and wheezing.
Single-blind - Only the physician knows the food being given
The mainstay of treatment for Adverse Food reactions
a. Avoidance of Causal Food
b. Medication
c. Patient Education
d. Other therapeutic models
a. Avoidance of Causal Food.
Drug of Choice for anaphylaxis
Epinephrine
Used to prevent late reactions for IgE-mediated reactions
Corticosteroids
True or False: Immunotherapy is recommended for food allergies.
False.
It is NOT recommended. Its ability to induce tolerance remains uncertain.
True or False: Maternal diet during pregnancy must be restricted in cases for Food allergies.
False.
The NIAID EP does not recommend restricting maternal diet during pregnancy or lactation as a
strategy for preventing the development or clinical
course of FA.
True or False: Hydrolyzed infant formulas can be used for prevention of FA in at-risk infants.
TRUE.
The NIAID EP suggests that the use of hydrolyzed infant formulas, as opposed to cow’s milk formula, may be considered as a strategy for preventing the development of FA in at-risk infants who are not exclusively breastfed.
- Which of the following is a TRUE IgE-mediated reaction?
a. An entire household developing flushed skin and vomiting after eating tuna.
b. A 7-year old male developing abdominal pain and diarrhea after drinking glass of milk.
c. School children developing vomiting, diarrhea and fever after eating chicken sandwich.
d. A 2-year old child developing flushed skin and difficult of breathing after eating peanuts.
d.
a. is a case of poisoning with scombroid fish
b. is a case of lactose intolerance. Obviously not IgE-mediated
c. is a case of food poisoning.
- What is your diagnosis for this 4 1⁄2 month old baby (previously breastfed until 4-months old) who developed itchy elevated patches after taking cow milk formula?
a. Anaphylaxis
b. Acute Urticaria
c. Asthma
d. Atopic Dermatitis
b. Acute urticaria.
- What will you do now to establish the diagnosis?
a. Do an elimination diet
b. An allergy skin test
c. Do a serum food-specific IgE determination
d. Do double blind placebo controlled food challenge.
d. is best answer. Can also be b.
