Professional Documents
Culture Documents
Clinical assessment
Diagnostic tests
Management
Disclosures
Novartis/Genentec - Xolair No other potential conflict of interest with any organization or company that is involved in food allergy diagnosis, treatment, or tolerance induction
Allergy
An immunologically specific Reaction to an exogenous antigen That results in a pathologic effect
Immune Exclusion
Identify and respond to digestion resistant proteins that reach the intestinal wall in significant amounts
IgA and IgG responses are common
IL-4
B cell
germline transcription
T cells
IgE synthesis
Immediate Release
Granule contents: Histamine, TNF-, Proteases, Heparin
IgE antibody-mediated
Atopic dermatitis
Eosinophilic esophagitis and enteritis
Cell-Mediated
Contact dermatitis Dermatitis herpetiformis Food protein-induced enteropathy syndromes Celiac disease Food-induced pulmonary hemosiderosis (Heiners syndrome)
Based on questionnaire studies, 20% to 25% of Americans think they have a food allergy
Based on studies of patients, ~6% of children and 2% to 4% of adults in the US have, or have had, food allergy Peanut allergy has increased in prevalence 2fold in the US and UK over the past decade
The Big 8
Milk
Egg
Tree nuts
Peanuts
Soy
Wheat
Shellfish
Fish
Analysis of Cause
Positive with shrimp wheal 15 mm/flare 38 mm Negative with egg, wheat, peanut, soybean, several fish antigens
Positive with shrimp 25 kU/L Negative with egg, wheat, peanut, soybean, several fish antigens < 0.35 kU/L
Maulitz RM, Pratt DS, Schocket AL. Exerciseinduced anaphylaxic reaction to shellfish. J Allergy & Clinical Immunology. 63(6):433-4, 1979.
Within a short time dozens of case reports published Two variations recognized
Subclinical specific food allergy + Exercise Eating any meal within 2 hours + Exercise
Williams PB, Barnes JH, Szeinbach SL, Sullivan TJ. Analytical precision and accuracy of commercial immunoassays for specific IgE: Establishing a standard. J Allergy Clin Immunol 2000;105:1221-1230.
Szeinbach SL, Barnes JH, Sullivan TJ, Williams PB. Precision and accuracy of commercial laboratories ability to classify positive and/or negative allergen-specific IgE results. Ann Allergy Asthma Immunol 2001;86:373-381.
17 serum samples with varying levels of specific IgE to aeroallergens sent to 6 labs using 5 different assays 3 times, a month apart.
Some strongly positive samples were serially diluted with negative sera and sent to these labs to see if their assays were linear with antibody concentration.
Sensitive
May detect IgE that does not lead to allergic reactions when food is ingested
Antigens for some foods may be degraded by the time tests are done
Can use fresh food, especially fruit, to detect IgE to labile antigens
Patient Education
Food Allergy Research & Education (FARE)
http://www.foodallergy.org/ Food Allergy Action Plan http://www.foodallergy.org/document.doc?id= 125
Epinephrine Administration
Small Children: Place the child on the ground face up. Administer the medication to the upper outer thigh.
Older Children: Stand behind the child. Hold the child with one hand across the chest. Administer the medication to the upper outer thigh. Independent Patients
Swing and firmly push orange tip against outer thigh. Hold on thigh for approximately 10 seconds.
Remove Auto-Injector and massage the area for 10 more seconds.
Immediate Release
Granule contents: Histamine, TNF-, Proteases, Heparin
Eosinophilic Esophagitis
Endoscopy and multiple esophageal biopsies essential to diagnose EoE
Symptoms of EoE
Dysphagia, chest pain, food impaction, upper abdominal pain 33% to 54% develop food impaction
Elemental diet:
Up to 97% have clinical and biopsy improvement. Up to 84% can then identify foods to avoid
Avoid foods to which the patient expresses IgE Remission in up to 80% of EoE patients
Aeroallergen immunotherapy
Treatment of EoE
Birch
Mugwort
Ragweed
Ragweed Pollen
Watermelon
Chamomile tea
Type I food antigens elicit immune responses via the gastrointestinal route
Heat stable, acid stable, resistant to digestive enzymes More common in children
Type II food antigens cross-react with antigens in aeroallergens that have provoked an immune response by inhalation
How can fruit and vegetable antigens cross-react with pollen antigens?
Oral immunotherapy
Sublingual immunotherapy for peanut allergy: a randomized, doubleblind, placebo-controlled multicenter trial. DM Fleischer et al. JACI
Safety and predictors of adverse events during oral immunotherapy for milk allergy: severity of reaction at oral challenge, specific IgE and prick test. M Vasquez-Ortiz et al. Clin Exp Allergy 2012. 43:92102.
Tolerance of 200 mL of cows milk in 86% of 81 children. 25% had frequent, fairly severe, and unpredictable reactions during and after reaching maintenance doses. High serum specific IgE and strong positive skin tests predicted strong reactions
Anti-IgE