Clinical Spectrum
Clinical Spectrum
Clinical Spectrum
DOI 10.1007/s12016-012-8339-6
Introduction
Food allergy is a common complaint from the general
public which often leads to self-imposed food avoidance. Whether it leads to subsequent medical consultation is dependent on several factors such as the severity
and persistence of the symptoms, the perceived usefulness of medical opinions, the accessibility and availability of the relevant health care, and the prevailing healthseeking behaviors of the local community and culture.
Though patients, parents, caretakers, and families alike
generally believe themselves or their children have food
allergy; these usually represent cases of non-immunological
adverse food reactions or food intolerances instead. Of the
20 to 30 % of people who report food allergy in themselves or their children, food allergy can be ascertained in
only 68 % of children under five, and in 34 % of
adults [1, 2].
Adverse food reaction should be used as a general term
for any untoward response to the ingestion of a food. It can
be cases of food allergy or other non-immunological reactions. There are many types of non-immunological adverse
reactions to ingestion of food, such as gastroesophageal
reflux, gastrointestinal anatomical or functional abnormalities, food poisoning, infection, etc.
Prevalence
It appears to be the general consensus that the prevalence of
food allergies and related atopic disorders is increasing in
industrialized countries [3, 4]. However, it has remained
unresolved to what extent this represents a true prevalence
increase or is attributable to an increasing awareness of the
clinical manifestations of food allergy [3]. The available
prevalence studies cannot easily be compared due to differences in epidemiological methodology. Some studies define
food allergy according to laboratory findings or objective
proof of sensitization, whereas other studies define food
allergy by clinical reactivity. Food-specific IgE antibodies
can be found in healthy individuals clearly tolerant to that
food and even without any history of clinical reaction.
Another difficulty in defining the prevalence of food allergies is the variation of the prevalence with age, as a significant proportion of food allergic infants will develop
tolerance during early childhood. Finally, the prevalence of
food allergy and the spectrum of food allergens may vary
between countries due to differences in environmental and
genetic factors [4, 5].
A telephone survey in Americans revealed a self-reported
prevalence of peanut allergy of 1.1 % [6]. The prevalence
doubled from 1997 to 2002 [6, 7]. However, reliance on
self-reporting may be prone to overestimation of the true
prevalence of food allergy [13]. Based on Isle of Wight
birth cohort studies, Grundy et al. [8] compared the prevalence of peanut allergy in two birth cohorts less than a
decade apart. They reported a significant increase in sensitization to peanut, from 1.1 % in 1989 to 3.3 % in 1994
1996. Only a small proportion reacted upon challenge and
there was a high clinical tolerance rate despite the sensitization. Furthermore, the overall recruitment rate was less than
50 %. This highlights the importance of differentiating
Anaphylaxis
Oral allergy syndrome
Atopic dermatitis
Urticaria
Asthma
Chronic rhinitis
3555 %
2575 % in pollen allergic patients
35 % in children (rare in adults)
20 % in acute (rare in chronic)
56 % in asthmatic or food allergic children
Rare
with isolated gastrointestinal symptoms. Food proteininduced enterocolitis, proctitis, proctocolitis, celiac disease,
dermatitis herpetiformis, and food-induced pulmonary hemosiderosis are forms of food allergy with a non-IgE-mediated
immunological basis.
Food allergy with abnormal eosinophilic infiltration of
the intestinal tract is another form of food allergy. Examples
include eosinophilic esophagitis and eosinophilic gastroenteritis. The only region of the gastrointestinal system where
eosinophils are not normally found is the esophagus. The
underlying pathophysiology of eosinophilic gastrointestinal
diseases and its relationship to food allergy have yet to be
clearly defined. Studies have demonstrated food sensitivity
in some of the patients and food elimination can be
helpful in both the diagnosis and therapy of eosinophilic
esophagitis [15, 16]. Endoscopy and biopsy are often needed
for definitive diagnosis.
International agreement has been reached on a classification of gastrointestinal disorders due to adverse immune
reaction to foods [17, 18] based on clinical observations.
Figure 1 summarizes the spectrum of food allergy with
regard to the different immunopathophysiology.
Many patients and even some healthcare professionals
believe that certain foods might be a trigger or aggravating
factors to certain chronic conditions such as migraines;
behavioral/developmental disorder such as autism, arthritis,
seizures, and inflammatory bowel disease. It should be
emphasized that there has never been any solid scientific
evidence for any of these associations [1921].
Food Allergens
There are two types of food allergens [22]. Class 1 food
allergens are the primary sensitizers. Sensitization may occur
through the gastrointestinal tract. These are water-soluble
glycoproteins of molecular weights ranging from 10 to
70 kD. They are stable to heat, acid, and proteases. Table 2
illustrates some examples of the class 1 food allergens.
Chicken egg
Peanut
Soybean
Shrimp
Fish
Fruits, vegetables
products prepared on the same equipment. Dishwashing liquid has been shown to be inadequate in the removal of food
allergens from contaminated dishware [24].
Clinical implications of cross-reactions of different foods
include an assessment of cross-reacting foods when evaluating a patient for food allergies (Fig. 3).
negative IgE testing should alert the clinician to the possibility of fish parasite Anisakis simplex allergy. The Anisakis
allergy is an interesting entity and researchers believed that
the parasite must be alive and be able to penetrate through
gastric mucosa in order to elicit the cascade of events.
Neither the skin prick test with parasite extract nor oral
challenge reproduces the symptoms [62]. It should also be
noted that other diseases can mimic a food allergy to seafood. Ciguatera, caused by Gambierdiscus toxicus toxins
including ciguatoxin, maitotoxin, scaritoxin, and palytoxin,
can cause gastrointestinal symptoms such as vomiting, nausea, and diarrhea, as well as neurological symptoms including dyspareunia and allodynia. Scombroid fish poisoning
can also mimic type 1 hypersensitivity reactions because of
the production of histamine from histidine occurring naturally in spoiled fish.
Seafood Allergy
Oral Allergy Syndrome
Seafood allergy includes both fish and shellfish allergy.
Seafood allergy often develops in young children but is
increasingly prevalent in teens and adults, as less than 5 %
of initially allergic subjects develop tolerance over time.
IgE-mediated reactions accounts for the majority of allergic
reactions to seafood. Clinical presentation may include generalized reactions or isolated gastrointestinal or extragastrointestinal reactions. The severity varies, ranging from
mild to severe or even fatal. Seafood allergy tends to recur
for some of the subjects showing initial resolution [59].
The specific type of fish or shellfish perhaps depends on
the availability of the type of seafood in a particular geographic region, which affects the pattern of consumption
and exposure. Parvalbumin in fish and tropomyosin in
shellfish are the key seafood allergens. They are different
proteins so there is not a great deal of clinical crossreactivity between fish and seafood, although food contamination may play a role. Within the group, however, there is
homology of protein structure across various types of fish or
shellfish and hence cross-reactivity is highly possible. The
negative predictive value of skin prick test by commercial
food extracts is relatively high and a negative test diminishes the possibility of a food allergy. If the history is
suggestive while the skin prick test or specific IgE level
are negative, a controlled food challenge with the implicated
seafood prepared in a manner similar to the exposure that
caused the reaction should be performed.
Non-IgE-mediated mechanisms are much less recognized
with regard to seafood allergy. If this type of reaction is the
predominant mechanism, clinically, the patient may experience food protein-induced enterocolitis resulting in nausea,
diarrhea, and abdominal pain after a few minutes to several
hours post-ingestion [60]. Contact dermatitis to seafood in
occupational and household exposure to seafood has been
reported [61]. Clinically apparent, seafood allergy with
challenges generally provoke a markedly pruritic, erythematous, morbilliform rash [75, 76].
In the Melbourne Atopy Cohort Study (MACS) birth
cohort of 620 Australian children with a positive family
history of atopy, the association between IgE food allergy
(IgEFA) to common food allergen (cows milk, egg, and
peanut) and AE was investigated [77]. IgF FA was compared between MACS children with AE (MACS AE+) and
without AE (MACS AE) in a group of consecutively
referred infants of similar age with severe AE. The calculated attributable risk percent for IgEFA as a cause of AE
was 65 and 62 %, at 6 and 12 months of age, respectively. In
the separate group of infants with severe AE, the equivalent
degree of IgE food allergy was 83 % at 6 months and 65 %
at 12 months. A critique of the study was that the patients
were selected from an allergy clinic and this introduced a
selection bias. The authors thus extended the study to in
infants with eczema attending a Dermatology Department in
the same Children Hospital. Their clinical history and eczema severity were documented. The results showed 90% of
the infants had IgEFA to milk, egg and/or peanut. The
findings highlighted the strong association between IgEFA
and eczema in infants attending a dermatology clinic. Management of infantile atopic eczema at both the individual
and community level should incorporate appropriate diagnostic and dietary strategies [78].
Allergic Eosinophilic Disorders
These conditions are gaining medical attention and are
perhaps on a rising trend in industrialized countries. They
are considered mixed IgE/non-IgE-mediated gastrointestinal
manifestations of food allergy. Allergic eosinophilic esophagitis (AEE) can occur in children [7981] and adults. A
yearly incidence was estimated to be 23/100,000 population
in Switzerland. In children, symptoms similar to gastroesophageal reflux [80], and in adults, dysphagia and impaction, are common. Patients with AEE often have a poor
response to anti-reflux drugs [79, 80]. Almost 50 % of
patients have other atopic diseases [82, 83].
Diagnosis is based on endoscopic findings and biopsy [79].
In AEE, endoscopic findings show characteristic rings and
white plagues which correspond to underlying mucosal infiltration of eosinophils. Furrowing can also be seen in advanced
cases. Histological findings of allergic eosinophilic disorders
are characterized by infiltration of the esophagus, stomach
and/or intestinal walls with eosinophils, basal zone hyperplasia, papillary elongation, absence of vasculitis, and peripheral
eosinophilia in about 50 % of patients. Normally, a cut off of
>15 eosinophils per high-power field is required for diagnosis
of AEE [84]. Eotaxin-3 tissue expression has been found to
correlate with eosinophilia and likely plays a crucial role in the
pathogenesis of this disorder [85].
Age of onset
Times from onset to remission
Clinical features
Enterocolitis
Enteropathy
Proctocolitis
Infant
1224 months
Failure to thrive
Shock
Lethargy
Infant/toddler
? 1224 months
Malabsorption syndrome
Villous atrophy on biopsy
Chronic diarrhea
Newborn
<12 months
Bloody stools
Usually well baby
Eosinophil in
peripheral blood
Chronic diarrhea
Infantile Colic
gliadin peptides (wheat, rye, and barley) resulting in extensive enteropathy leading to malabsorption syndrome
[92]. Host factor plays an important role. Celiac disease
is highly associated with HLA-DQ2 (1*0501, 1*0201)
[91, 93, 94]. Positive serology tests of anti-transglutaminase
IgA and anti-gliadin IgA are often supportive criteria for
diagnosis, and quite useful in screening high-risk families [60, 95]. Even among asymptomatic individuals, it
is not an uncommonly seen positive serology. Hence,
clinicians have to interpret antibody testing results in the
context of clinical symptomatology, physical findings,
and response to elimination diets. Treatment for confirmed
celiac disease is essentially a complete elimination of glutencontaining foods.
Non-IgE-Mediated Syndromes Affecting the Skin and Lung
Dermatitis herpetiformis is a form of dermatitis characterized by a vesicular, pruritic eruption which occurs in glutensensitive subjects and tends to be associated with celiac
disease. Heiners syndrome is a rare form of infantile pulmonary hemosideroisis resulted in anemia and failure to
thrive. It is widely believed to be cows milk associated
and infants may develop precipitating antibodies to cows
milk protein.
Conclusion
Allergic reactions to foods are classified by clinical presentations and allergen testing profiles. Food allergies can be
simplistically categorized into three main types: IgE- mediated, mixed (IgE/non-IgE), and non-IgE-mediated (cellular,
delayed type). Patients can be allergic to only a single food,
but may also be allergic to multiple foods. The delayed type
food allergy may be mediated by antigen-specific activated
T-helper cells. There is evidence that T cells play a role in
IgE-mediated food allergy as well. Researchers have yet to
define the exact pathophysiologic mechanisms behind many
types of food allergies, especially mixed and non-IgEmediated allergy [109112].
History and clinical examination are of paramount importance in clinical practice to differentiate the different
forms of food allergy. Despite the improvement in diagnostic methodology using wheal size diameters in allergen skin
testing or levels of food-specific IgE by ELISA testing
(CAP-FEIA), a conclusive diagnosis is still dependent on
elimination and challenge testing. To demonstrate the tolerance, natural resolution or the persistence of food allergy,
periodic re-challenge remains the cornerstone of practice.
Monitoring for the development of tolerance by clinical
history upon inadvertent exposure, in vivo skin testing,
and the level of food-specific IgE may also provide useful
information regarding a time to conduct a food challenge.
Recent advances in food allergy in early childhood have
highlighted increasing recognition of a spectrum of delayedonset, non-IgE-mediated manifestations of food allergy.
Common presentations in infancy including atopic eczema,
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