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Luqman Seidu, MD Allergy and Asthma of Atlanta Food Allergy and Intolerances 5445 Meridian Mark404-257-3338 Suite 390 Atlanta, GA.

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Presentation on theme: "Luqman Seidu, MD Allergy and Asthma of Atlanta Food Allergy and Intolerances 5445 Meridian Mark404-257-3338 Suite 390 Atlanta, GA."— Presentation transcript:

1 Luqman Seidu, MD Allergy and Asthma of Atlanta Food Allergy and Intolerances 5445 Meridian Mark Suite 390 Atlanta, GA

2 Adverse Food Reactions/Intolerances Food Allergy Spectrum Toxic /Pharmacological Non- Immunological IgE MediatedNon-IgE Mediated Oral Allergy Syndrome Atopic Dermatitis Herpetiformis Heavy Metal Poisoning Lactase deficiency Anaphylaxis Hives/urticaria Rhinitis Vomiting Diarrhea Wheezing Hypotension Eosinophilic Disorders Heiner’s Syndrome ScromboidGalactosemia FPIES CaffeineGallbladder/liver disease Chinese Restaurant Syndrome/MSG Hiatal Hernia Celiac diseaseBacterial Food Poisoning Enterocolitis Enteropathy Protocolitis Pancreatic Disease

3 Allergy-Mediated Food Intolerances IgE MediatedCell Mediated Anaphylaxis Oral Allergy Syndrome Celiac Disease FPIES Milk Enterocolitis Eosinophilic Esophagitis Eczema

4 IgE Food Allergy Prevalence FoodYoung ChildrenAdults Milk2.5%0.3% Egg1.3%0.2% Peanut0.8%0.6% Tree Nuts0.2%0.5% Fish0.1%0.4% Shellfish0.1%2.0% Overall6%3.7% *In the general public, 20-25% believe they have food allergy. *Food allergy is most common cause of anaphylaxis outside hospital setting. *Certain US and UK studies indicate a doubling of food allergy in children.

5 Case 1 A local MD presents with new onset increased discomfort after ingesting shrimp.  Hives  Itching, difficulty swallowing.

6 Case 1 cont’d In the office  Skin prick Skin prick positive to shrimp only Negative to all other shellfish, and fish  RAST RAST negative to all fish/shellfish

7 What to you do? Ignore skin prick, follow RAST, he can eat seafood. He should avoid all shellfish and probably fish as well. He should avoid shrimp only, all other seafood is okay. Check IgG to fish and shrimp

8 Case 2 9 year old female (HM), initial visit food allergy evaluation PHMx:  Anaphylaxis at one 1year with milk Skin prick positive to dairy and eggs. Stomaches with beef, told to avoid with no formal testing.

9 Case 2 cont’d Facial swelling and throat discomfort recently at Olive Garden She doesn’t read labels Still with “funny feeling” eating plain hotdogs No anaphylaxis

10 Case 2 cont’d AllergenkU/LClass Egg white (IgE)0.421 Beef α-lactalbumin β-lactoglobulin Casein Egg yolk<0.350 Skin prick testing  Positive histamine, negative saline control  Positive egg (egg white, egg yolk), dairy (casein, milk)  Negative beef RAST/Immunocap

11 Case 2 Tell the family to avoid egg, beef, dairy forever and she will be allergic to these for the rest of her life. Tell the family and to avoid egg, beef, dairy. Draw lab work to check for other common foods such as peanut, tree nuts, wheat, fish and soy since she is likely to be allergic to those as well. Tell them to avoid milk. Schedule a challenge for beef and one for egg. Tell the family to avoid beef and dairy only and they can reintroduce egg at home. What do you do? SkinLabs Egg ++/- Milk +++ Beef -++

12 Diagnosis of IgE Food Allergy History  Timing, reproducibility, symptoms Immediate, less than 20 minutes, the next day.  Identifiable exposure Specific Hidden ingredients, alternative nomenclature  Atopic history  Family History

13 Prognosis & Evaluation Prognosis  With common foods (milk, eggs, wheat, soy) 85% resolution between ages 3-5  Peanut 20% resolution 7% of these have recrudescene of symptoms  Tree nut and shellfish ~50% lifetime resolution

14 Evaluation of IgE Food Allergy Evaluate (6 months – annually)  Skin prick testing  In vitro testing IgE RAST IgE Immunocap  Food Challenge

15 Skin prick/Scratch testing (percutaneous testing)  High negative predictive value >95%.  Demonstrates presence of specific IgE not clinical reactivity.  Significant false positive rate.  Never perform intradermal testing to foods/  Contraindicated in food allergy evaluation.

16 In vitro Testing RAST vs Immunocap RAST (radioallergosorbent test)  Detects specific IgE  Less sensitive Immunocap  Detects specific IgE  FEIA (fluoroenzyme- immunoassay)  Preferred test  Basis for likelihoods in literature Neither has exact thresholds  Use conjunction with clinical history, skin prick and age specific thresholds. YY Y Y YYY Y Y Y YY Y Y YYYYY YYYYYY Y YY Y Y YY Y Y Detector

17 In vitro Evaluation

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19 IgE testing in Food Allergy Spectrum of Reactions with positive skin test or labs. + Anaphylaxis + Eczema - Anaphylaxis + Contact reactions - Eczema - Anaphylaxis No reaction at all

20 IgE and IgG Mast Cell IgE  Bound to mast cell Helps induce the release of histamine, leukotrienes, prostaglandins Y Y Y Y Y Y Y IgG  Bound to B-cells or free floating Binds to pathogens Complement activation Opsinization for phagocytosis Y Y Y Y Y Y Y Y

21 The Right Tool for the Right Job Skin Prick Serum IgEPatch Testing Serum IgG IgE Mediated Food Allergy +++- Oral Allergy +??- Eosinophilic Esophagitis +±+- Eczema ++?- FPIES --?- $$$$ ---+

22 Graded Food Challenge Double-blinded  Both medical professional and patient are blinded  Gold standard  Time consuming  Used with “complicated” cases Open  Specialty norm  No one is blinded.

23 Management Education  Avoidance  Nutrition 1.(nutritionist, dietician)  Epipen (≥30 kg), Epipen Jr (≤ 30 kg) 1. Babies/infants <15kg?  Label reading  Reassessment 1.Skin testing, 2.RAST/Immuncap 3.Food challenge

24 Case 3 Previously healthy 5 month old at home in usual state of health with dad.  Presents to hospital ED hypotensive.  Mom was breastfeeding, she just returned to work so dad is taking care of him.  Dad had given formula feeding 1-2 hours earlier:  Vomiting, diarrhea, pale and obtunded  No rash nor wheezing.  In-house w/u negative.  In house skin prick testing is negative.  Responds to fluids an discharged home  Return 2 days later with same presentation.

25 Case 3 Admit the patient for observation for possible Munchausen, arrest the parents and arrange for foster care. Tell the family the child is allergic to milk, provide them with an EpiPen and confirm your diagnosis with RAST/Immunocap. Reassure the family, tell them to avoid dairy and the kid with “outgrow” this illness. Force your junior colleague to switch call weeks. What do you do?

26 FPIES Food Protein Induced Enterocolitis Syndrome (FPIES)  Usually occurs in infants  First exposure to early food 1.Dairy, soy. 2.Rice, oats, barley and other grains. 3.Green beans, peas, sweet potatoes, squash, chicken and turkey.  Presentation Shock/sepsis picture Negative w/u Blood cultures, etc.  Non-IgE mediated Enterocolitis Cell-mediated (CMI)

27 FPIES Treatment  Strict avoidance  Symptoms usually resolve spontaneously between 3-5 years of age Confirm with food challenge In office if symptoms were only vomiting/diarrhea In hospital/ICU if symptoms proceeded to shock

28 Case 4 Mom presents with 8 y/o  F/u from ED for disimpaction  Weight loss 5 kg over last month  Nausea & difficulty swallowing Worse with sandwiches  No hives, anaphylaxis, etc.  No anaphylaxis  Always been a slow eater

29 Case 4 Refer the patient to G/I for endoscopy Reassure the family, but restrict her diet (no meats or grains) and place the patient on ranitidine and f/u in 6 months. Order an upper G/I series to evaluate the patient and schedule for an open challenge in your office. Referral to allergy for skin prick testing and RAST testing. What do you do?

30 Eosinophilic Esophagitis Overview Esophagus normal devoid of eosinophils Eosinophilic esophagitis (EE) first described in late 1970’s in literature Prevalence is unknown  Estimates of 4.3/10 5 in children and 2.5/10 5 in adults in the United States  Others have suggested 6-10% of patients with GERD truly suffer from EE.

31 EE Clinical Presentation Difficulty feeding, failure to thrive, vomiting, epigastric or chest pain, dysphagia, and food impaction. Vomiting, food impaction, dysphagia, achalasia, “slow eater,” and weight loss. Abdominal pain and anemia. Benefit little from anti-reflux medicines and have normal to mildly positive pH probe studies. Usually young males.  About 3:1, males:females  Link to maternal inheritance

32 EE Diagnostic Criteria Evolving clinical and histological criteria  eos/hpf GERD, 0-6 eos/hpf This disease is patchy, recommend at least 5 biopsies.  Refractory to 2 month trial of anti-reflux medication (PPI).  Presence of basal cell hyperplasia, papillary thickening and crypt abcesses.  75% of patients with EE have pollen or food allergies. 50% food allergic, 50% non-food allergic. Skin prick testing (SPT), Atopy patch testing (APT), and RAST. Few patients report anaphylaxis. Reports of patient with seasonal variations in symptoms and histology, authors suggesting pollens playing a role.

33 Eosinophilic EsophagitisTherapies Dietary management  Elimination Diet Difficult to institute with patient with multiple foods. Accidental exposures with “ubiquitous” items. Risk for nutritional deprivation.  Elemental Diet Difficult in older patients. Expensive. Often requires G-tube/NG-tube to ensure calories. Neocate, EO 28

34 Eosinophilic Esophagitis Therapies Pharmacological management  Steroids Systemic: Well known adverse effects Swallowed: Thrush Delivery in infants  Biologicals Anti-IL-5 (mepolizumab) trial ongoing (peds/adults) Newer agent reslizumab Being studied in patients with eosinophilic asthma.

35 Case 5 During his son’s 6 year check up, 405 y/o dad of your patient  Complains of itching in his mouth and throat tightness when he eats bananas and apples and other fruits.  He denies wheezing, vomiting diarrhea, symptoms of hypotension.  Does have allergic rhinitis, but no other medical issues.  Tolerates McDonalds apple pies.

36 Case 5 Tell the dad that he needs to avoid all citrus fruits for risk of anaphylaxis and provide him with an Epipen. Advise him to get skin testing to environmental antigens and foods. Reassure him and tell that his symptoms will be improved if he better washes his fruit and eats only organic foods. Write a script for Singulair. What do you do Willis?

37 Oral Allergy Syndrome (OAS) Patients almost all have environmental allergies Symptoms  Itching  Burning  Swelling Lip and upper airway

38 Oral Allergy Syndrome (OAS) Sensitivity to food reported by 65-72% of patients with birch sensitivity 80% of patients with allergy to vegetables and fruits had pollen allergy. The prevalence of birch allergy in the patients with vegetable and fruit allergy was 4 times that of the control group. OAS associated with more severe respiratory symptoms. OAS associated with higher birch-specific and total IgE High negative predictive value of negative PST with fresh fruits or RASTs to the food

39 OAS Diagnosis Diagnosis  History  Symptoms with raw implicated foods Tolerate cooked, canned, jarred, etc. foods.  Skin prick testing to environmentals  Skin prick testing to fruits Commercial extracts Prick-prick testing

40 OAS PollenFoods Birch(Bet v 1) Apple, apricot, carrot, hazel, pear, parsley (Bet v 2) Latex, celery, mugwort, potato, pear, soy, peanut, cherry RagweedBanana, cucumber, melon, watermelon Poison ivy/sumacPistachio, cashew nut, mango, plum LatexBanana, kiwi; avocado; apple, cherry

41 OAS Treatment  Avoidance  Eat processed foods  No studies performed on IT and OAS

42 Diagnostic approach to food allergy

43 Case 2 Tell the family to avoid egg, beef, dairy forever and she will be allergic to these for the rest of her life. Tell the family and to avoid egg, beef, dairy. Draw lab work to check for other common foods such as peanut, tree nuts, wheat, fish and soy since she is likely to be allergic to those as well. Tell them to avoid milk. Schedule a challenge for beef and one for egg. Tell the family to avoid beef and dairy only and they can reintroduce egg at home. What do you do? SkinLabs Egg ++/- Milk +++ Beef -++

44 Case 3 Admit the patient for observation for possible Munchausen, arrest the parents and arrange for foster care. Tell the family the child is allergic to milk, provide them with an EpiPen and confirm your diagnosis with RAST/Immunocap. Reassure the family, tell them to avoid dairy and the kid with “outgrow” this illness. Force your junior colleague to switch call weeks. What do you do?

45 Case 4 Refer the patient to G/I for endoscopy. Reassure the family, but restrict her diet (no meats or grains) and place the patient on PPI and f/u in 6 months. Order an upper G/I series to evaluate the patient and schedule for an open challenge in your office. Referral to allergy for skin prick testing and RAST testing. What do you do?

46 Case 5 Tell the dad that he needs to avoid all citrus fruits for risk of anaphylaxis and provide him with an Epipen. Advise him to get skin testing to environmental antigens and foods. Reassure him and tell that his symptoms will be improved if he better washes his fruit and eats only organic foods. Write a script for Singulair. What do you do Willis?

47 Pearls Skin testing and labs complimentary Collect total IgE with RAST/Immunocap IgG not relevant Retest/re-evaluate


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