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Month: September 2017

Food Protein-Induced Enterocolitis Syndrome

The most common type of food allergy is an “immediate hypersensitivity” reaction (i.e., Type I reaction), where the symptoms usually begin within a few minutes of exposure to the offending food.  These reactions are mediated by an antibody called IgE which interacts with the protein (i.e., antigen, allergen) in the food.  This interaction causes a release of chemicals which are responsible for the undesirable allergic symptoms.  The most common foods that cause these types of reactions are nuts and shellfish, though any food can theoretically trigger IgE.

Food Protein-Induced Enterocolitis Syndrome (FPIES), though not as common, can also cause serious and potentially life-threatening adverse effects.  IgE is not involved in these reactions, because FPIES is likely to be caused by a “cell-mediated hypersensitivity” reaction (i.e., Type IV reaction), where a specific type of white blood cell called a T-lymphocyte (i.e., T-cell) is thought to play a role.

Clinically, the most distinguishing feature of FPIES is that the symptoms typically begin a few hours after the ingestion of the food.  Though it can affect people at any age, it most commonly involves infants and young children.

50 to 60% of patients with FPIES have a family history of allergic disorders such as asthmahay fever (i.e., allergic rhinitis) or eczema (i.e., atopic dermatitis) and approximately 20% have a family history of other food allergies.

Although any food can be a trigger for FPIES, the most common culprits are milk, soy, and grains.  Breast milk is not known to be a trigger and most infants develop symptoms when they are first introduced to formula or solid food.

Symptoms of FPIES (may include any or all of the following):

  1. Recurrent vomiting
  2. Diarrhea (occasionally mixed with blood)
  3. Dehydration
  4. Lethargy
  5. Failure to thrive
  6. Poor growth
  7. Shock-like symptoms – low blood pressure, pale and clammy skin; shallow fast breathing, weakness, dizziness, fainting, etc.

Note:  Unlike traditional IgE-mediated allergies, FPIES reactions do not manifest with itching, hives, swelling, coughing, and/or wheezing.

Diagnosis and Testing of FPIES

FPIES is occasionally mistaken for a bacterial or viral infection.  Although it is a type of allergy, prick skin tests and blood tests are not helpful in the detection of this condition.  The diagnosis primarily rests on a detailed history of ingestion of specific foods, nature and severity of the symptoms in conjunction with their temporal relationship with exposure, and a detailed physical examination.  Rarely oral food challenges under controlled conditions and clinical supervision are necessary to confirm the diagnosis.

Atopy patch testing is being studied for its effectiveness in diagnosing FPIES, as well as predicting if the problem food is no longer a trigger.  At this time, however, it is not considered a valid test to make the diagnosis.

Management of FPIES

The only option in the management of FPIES is strict avoidance of the triggering food(s).  A severe reaction might necessitate emergent intravenous fluids and rarely corticosteroid agents to control inflammation in the intestines. Occasionally, children may require hospitalization if the symptoms are very severe.

Epinephrine is usually not helpful in the treatment of FPIES and is not routinely prescribed, since this condition is a non-IgE-mediated reaction.

Most children with sensitivity to milk and soy can be well managed by switching to hypoallergenic formulas, such as a casein hydrolysate or amino acid based elemental formulas.  Many children sensitive to cereal grains can tolerate yellow fruits and vegetable based age-appropriate foods.  New foods are usually introduced very slowly, one food at a time, for an extended period of time per food.  In protracted cases, dietary advice from a certified nutritionist can be very helpful.

Prognosis of FPIES

In most instances, FPIES resolves spontaneously with time.  The affected children need to be closely monitored by a board certified allergist to determine if the condition has resolved.

With proper medical care and a personalized dietary plan to ensure proper nutrition, children with FPIES usually grow and develop normally.

We Can Help You

The board certified allergy doctors at Black & Kletz Allergy will promptly answer any questions you may have regarding FPIES or any related disorders.  Our allergists have been diagnosing and treating FPIES and other food allergies in the Washington, DC, Northern Virginia, and Maryland metropolitan area for more than 50 years.  We have 3 convenient locations in the DC metro area with offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  There is on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  To schedule an appointment, please call us at any one of our 3 locations.  Alternatively, you can click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy is dedicated in providing the most up-to-date diagnostic and treatment modalities in the field of allergy, asthma, and immunology.

Recurrent Infections – Are They Due to Allergies?

Recurrent infections occur in many individuals in the U.S., as well as around the world.  In the U.S., malnutrition is not a common cause as it is in many undeveloped third-world countries.  Parasitic infections are also not very common in the U.S. unless an individual travels to a developing country, consumes uncooked meat/fish, drinks tainted water, or has an immune deficiency.  The most common types of infections found in the U.S. are numerous and include sinus infections, pneumonias, bronchial infections (i.e., bronchitis), skin infections (e.g., cellulitis, boils, abscesses), ear infections, throat infections, eye infections, gastrointestinal infections, urinary tract infections, and surgical site infections.  Nosocomial infections are a subset of infections specific to those infections that are acquired in a hospital setting.

The causative agents of most infections include bacteria, viruses, parasites, fungi, and prions.  These microbes or infectious agents can be transmitted in many ways such as person to person, mother to child, animal to person, and by food contamination.  Infections can be spread by direct contact, indirect contact, bug bites, and food contamination.

What about allergies?  Can they cause infections?  The answer is that having allergies predisposes an individual to the development of some types of infections.  The typical types of infections found more in allergic individuals may include sinus infections, ear infections, bronchitis, and pneumonia.  As a caveat to this, people with immune problems (i.e., immunodeficiencies) are more likely to develop infections.  In fact, most immunodeficiencies are found because the individual complains of recurrent infections.  People with immunodeficiencies can be stricken with infections from bacteria, viruses, fungi, and/or parasites.  These immune defects may involve B cells, T cells, NK cells (i.e., natural killer cells), phagocytic cells, and/or complement deficiencies.  The cells mentioned above are types of white blood cells in one’s body. Immunodeficiencies can be hereditary (i.e., genetic) or acquired (i.e., developed as a result of diseases, cancers, infections, malnutrition, or side effects of medications)

Some examples of hereditary immunodeficiencies include:

  1. B cell deficiencies – selective IgA deficiency, common variable immunodeficiency (CVID), X-linked agammaglobulinemia (i.e., Bruton’s agammaglobulinemia
  2. T cell deficiencies – DiGeorge syndrome, ataxia telangiectasia, Bloom’s syndrome, hyper IgE syndrome (Job’s syndrome), cartilage-hair hypoplasia, Wiskott Aldrich syndrome, X-linked lymphoproliferative syndromes, immunodeficiency-centromeric instability-facial anomalies syndrome (ICF syndrome), chromosome 22q11.2 deletion syndrome, candidiasis familial chronic mucocutaneous, dyskeratosis congenita, immunodysregulation, polyendocrinopathy and enteropathy X-linked (IPEX syndrome), hepatic venoocclusive disease with immunodeficiency, Schimke immunoosseous dysplasia
  3. NK cell deficiencies – classical NK cell deficiency (CNKD), functional NK cell deficiency (FNKD)
  4. Combined immunodeficiencies – severe combined immunodeficiency (SCID), X-linked hyper-IgM syndrome
  5. Phagocytic disorders – Chediak-Higashi syndrome, leukocyte adhesion deficiency, chronic granulomatous disease
  6. Complement system deficiencies – C1, C2, C3, C4, C5, C6, C7, C8, or C9 deficiency, properdin deficiency, mannose-binding lectin deficiency, factor B deficiency, factor D deficiency

Some examples of acquired immunodeficiencies include acquired immunodeficiency syndrome (AIDS), severe acute respiratory syndrome (SARS), cancers of the immune system (e.g., leukemia, multiple myeloma), and immune complex diseases (e.g., viral hepatitis).

In summary, many individuals suffer from recurrent infections and many can be attributed to allergy and/or immunology problems.  Allergic rhinitisasthma, and immune disorders predispose individuals to the increase risk of various types of infections.  The allergists at Black & Kletz Allergy have been diagnosing and treating both adults and children with all types of infections for many decades in the Washington, DC, Northern Virginia, and Maryland metropolitan area.  We are board certified in both adult and pediatric allergy and immunology.  If you or someone you know suffers from recurrent infections (e.g., sinus, ears, lungs, skin), please call us to make an appointment at one of our 3 convenient offices.  We have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  All of the offices have on-site parking.  The Washington, DC and McLean, VA offices are Metro accessible and the McLean, VA office has a free shuttle that runs between our office and the Spring Hill metro station on the silver line.  You may also click Request an Appointment and we will respond within 24 hours by the next business day.  Black & Kletz Allergy has been a fixture in the greater Washington, DC and Northern Virginia community for over 50 years for our exceptional services for the diagnosis and treatment of allergic, asthmatic, and immunological conditions.