A consistent pattern of minor immunodeficiency and subtle enteropathy in children with multiple food allergy
ABSTRACT Although immunoglobulin (Ig)E-mediated allergies are readily identifiable, non-IgE-mediated allergies present more diagnostic difficulty. We performed a formal retrospective analysis to determine whether there is a recognizable clinical pattern in children.
We studied 121 children (mean age, 17.3 months) with multiple food allergies who were recruited on the basis of adequate immunological assessment by using case notes and parental questionnaire.
Group 1 (n=44) had rapid reactions to dietary antigens, of whom 41 also showed delayed reactions. Group 2 (n=77) had delayed reactions only. Mean IgE was increased in group 1 but both groups otherwise shared a pattern of increased IgG1, decreased IgG2/4, and low-normal IgA. Lymphocyte subsets were skewed, with an increased percentage of CD4 and CD19 and decreased CD8 and natural killer cells. Gastroesophageal reflux, esophagitis, subtle enteropathy, and constipation were frequent in both groups. Of 55 exclusively breast-fed infants, 44 sensitized before weaning. Twenty-one of the mothers suffered from autoimmunity.
There appears to be a recognizable pattern of immune deviation and minor enteropathy in children with multiple food allergy, irrespective of the speed of reactions. Disturbed gut motility is particularly common, as is a maternal history of autoimmunity.
Full-textDOI: · Available from: Simon H Murch, Sep 04, 2014
- SourceAvailable from: Fagundes Neto Ulysses[Show abstract] [Hide abstract]
ABSTRACT: Objetivo: Descrever um caso da síndrome de Munchau- sen simulada na forma de alergia alimentar múltipla, cujo diagnóstico pode ter sido retardado, em parte, por alguns resultados de exames subsidiários. Descrição do caso: Paciente do sexo masculino atendido aos 3,5 anos com diarréia e vômitos desde o nascimento. Anterior- mente havia recebido diagnóstico de hiperplasia nodular linfóide no íleo terminal. Vinha sendo alimentado apenas com fórmula de proteínas parcialmente hidrolisadas. A biópsia retal foi sugestiva de colite alérgica. Foi mantida terapia alimentar exclusiva com fórmula contendo proteína extensamente hidrolisada. Sempre que se recomendava introduzir outros alimentos, o paciente, de acordo com a mãe, apresentava diarréia, às vezes com sangue, e vômitos. A introdução de outros alimentos sob supervisão, no ambulatório, não se acompanhou de reação adversa no período de observação de seis horas. No entanto, segundo a mãe, uma semana depois a criança apresentou manifestações respiratórias graves necessitando de internação por 3 dias em unidade de terapia intensiva em hospital de sua cidade. Foi internado em nosso hospital, onde se descartou a hipótese de alergia alimentar múltipla e se estabeleceu o diagnóstico de síndrome de Munchausen por terceiro. Comentários: Características clínicas e/ou evolução in- compatível com a hipótese diagnóstica de alergia alimentar ou de outra entidade clínica pediátrica indicam a necessidade de considerar a possibilidade da síndrome de Munchausen por terceiro no diagnóstico diferencial. ABSTRACT Objective: To describe a case of Munchausen syn- drome by proxy mistakenly identified as multiple food allergy. The diagnosis was delayed, in part, by some subsidiary exams. Description: The patient was a 3.5 year old boy who suffe- red from vomiting and diarrhea since birth. He was diagnosed as having a nodular lymphoid hyperplasia in the terminal ileum before our evaluation. A partially hydrolyzed protein formula had been used in his feeding. A rectal biopsy showed evidence of allergic colitis and a highly hydrolyzed protein formula was recommended for his treatment. According to his mother, the introduction of any other kind of food in his feeding regimen was always followed by diarrhea, sometimes bloody, and vomiting. In our outpatient clinic, a supervised challenge test did not cause any reaction during a six-hour observation period. However, one week later his mother said that he had shown serious respiratory problems that required admission in a pediatric intensive care unit for 3 days in his hometown. Patient was admitted in our hospital where the diagnosis of multiple food allergy was ruled out and the diag- nosis of Munchausen syndrome by proxy was established. Comments: Symptoms, signals and clinical evolu- tion not compatible with the diagnosis of food allergy or another pediatric disease should lead pediatricians to consider Munchausen syndrome by proxy in the diffe- rential diagnosis.
- [Show abstract] [Hide abstract]
ABSTRACT: Central to the management of cow's milk allergy in infancy is the complete elimination of cow's milk protein from the infant's diet for a variable period of time. The principal part of this approach is to provide nutrition for the child by means of hypoallergenic feeding formulas. Although a number of formulas are indeed marketed as hypoallergenic, it is not known with certainty how hypoallergenic they really are. A variety of ways of testing for hypoallergenicity have been developed, including the use of in vivo and in vitro animal model systems, chemical analyses, and patient studies, which are the ultimate test. The purpose of the present report was to review the various ways of testing sensitizing capacity of infant feeding formulas for the treatment of children with cow's milk allergy. English language articles were selected from PubMed, as were selected abstracts that would have immediate, practical clinical implications. The review focuses on themes related to animal models, chemical analysis, and clinical testing and clinical studies of intolerance to hydrolysates. Sensitizing capacity can be tested first in animal models either by in vivo or in vitro techniques. Although the information gained is valuable for preliminary evaluation, such techniques are intrinsically artificial. Second chemical analyses indicate that absence of larger peptides greater than 1,500 Da provides a critical industrial cutoff point. Third clinical effectiveness in child patients is of paramount importance. The results of the present review demonstrate that extensively hydrolyzed formulas are usually effective, but recently intolerance to hydrolysates has been observed. However, use of amino acid-based formulas free of antigens is highly effective in such infants.Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 07/2003; 90(6 Suppl 3):112-4. DOI:10.1016/S1081-1206(10)61671-7 · 2.75 Impact Factor