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Food Allergies and Hypersensitivities: Diagnosis and Management

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Toxic reactions. Pharmacologic ... Toxic rxn= food poisoning ... Day 5: eat breakfast, drink nothing but water for 5 hours prior to test. Challenge ... – PowerPoint PPT presentation

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Title: Food Allergies and Hypersensitivities: Diagnosis and Management


1
Food Allergies andHypersensitivitiesDiagnosis
and Management
  • Adam Ray, MD
  • SIU Division of Otolaryngology-
  • Head Neck Surgery

2
Objectives
  • Understand the immunologic basis for food
    allergies
  • Discuss symptomatology
  • Distinguish between the different types of food
    allergies
  • Understand effective treatment modalities

3
Case Presentation
  • 17 mos old female
  • No PMHx
  • Acute uticaria after bottles that resolves
  • RAST test shows milk allergy
  • 2 y/o female
  • BMT x 2
  • Adenoidectomy
  • Maximal medical management
  • Major ENT symptoms
  • Trial of milk avoidance for 6 weeks

4
For those to whom less than the best possible
result is unacceptable, the field of food
sensitivity is a fascinating, frustrating, and
rewarding one.
  • King, Mabry, and Mabry. Allergy in ENT
    Practice New York, Stuttgart Thieme 1997

5
Definition and History
  • Immune-mediated production of symptoms brought on
    by the ingestion of a food antigen
  • Old Testament
  • Hippocrates observed milk allergies
  • China 3000 BC noted cutaneous rxns
  • Van Pirquet 1906, Schloss 1912,
  • Rinkel 1930s

6
History Rinkel
  • Noted food allergies distinctively different from
    type 1 hypersensitivities
  • Sensitization and masking phenomenon
  • Rotation diets
  • IgG immune complex disease

7
Types of Adverse Reactions
  • Non-Immunologic
  • Anaphylactoid
  • Idiosyncratic
  • Enzyme deficiencies
  • Toxic reactions
  • Pharmacologic
  • Immunologic

8
Non-immunologic
  • Anaphylactoid rxn histamine release from
    tomatoes and strawberries
  • Idiosyncratic rxn genetically predisposed pt
    (asthmatic and ASA)
  • Enzyme deficiencies lactose intolerance
  • Toxic rxn food poisoning
  • Pharmacologic food rxn tyramine in red wine,
    MSG, phentolamine from chocolate

9
Types of Adverse Reactions
  • Non-Immunologic
  • Anaphylactoid
  • Idiosyncratic
  • Enzyme deficiencies
  • Toxic reactions
  • Pharmacologic
  • Immunologic
  • Fixed
  • Cyclic

10
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11
Immunologic
  • Fixed
  • IgE mediated
  • Seconds to hours of onset
  • Not exposure dependent
  • Angioedema, respiratory compromise, vascular
    collapse, GI symptoms

12
Immunologic
  • Cyclic
  • All other types of allergies other than fixed
  • 80 of food allergies seen in clinic
  • IgG Type III
  • Dose and frequency dependent

13
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14
Diagnosis
  • Pts history
  • Multiplicity of target organs
  • Neurologic
  • Ophthalmologic
  • Otologic, Nasal, Oral cavity, Pharynx/larynx
  • Pulmonary, Cardiac
  • GI
  • Skin
  • Musculoskeletal

15
Diagnosis
  • Diet Diary
  • Normal dietary habits
  • Enter throughout the day
  • Symptoms or improvement (masking)
  • Evaluation

16
Diagnostic Techniques
  • Oral challenge test
  • Skin testing
  • In vitro testing
  • IgG RAST, IgE RAST
  • Enzyme-linked immunosorbant assay/activated cell
    test
  • Difficult to reproduce
  • Immunoglobulin levels do not imply clinical dz

17
Oral Challenge Test
  • Dietary analysis
  • Elimination
  • Test food should be eaten every day x 2wks
  • Eliminate the test food completely x 4 days
  • Day 5 eat breakfast, drink nothing but water
    for 5 hours prior to test
  • Challenge

18
Oral Challenge Test
  • Challenge
  • Record baseline symptoms
  • Eat and average portion of the pure food within 5
    minutes
  • Record symptoms over the 1st hour
  • May repeat a feeding in no symptoms in the 1st
    hour
  • Observe pt a minimum of 2 hours
  • Record subjective and objective symptoms

19
Oral Challenge Test
  • Symptoms that develop within an hour or ½ hour
    after the second feeding are positive
  • Symptoms that develop 10 to 20 hours later
    indicate the food is a delayed offender
  • Test considered more accurate than skin testing
    or in vitro testing

20
Oral Challenge Test
  • Alternative
  • Elemental Diet
  • Tolorex for 5 days
  • Not well tolerated
  • Test more foods at one time
  • Modified Fast or Hypoallergenic Diet
  • Diet containing no foods or food families in the
    patients normal diet
  • Tends to be better accepted over the Elemental
    diet

21
Treatment of Food Allergies
  • Elimination
  • Reintroduction and Rotation
  • Eliminate 5-6 mos
  • Reintroduce and a rotating basis not more than
    1-2xs/week
  • Neutralization
  • .05ml of the 1st reactive wheal SubQ qday x2wks,
    2x/wk x 2mos, 1x/wk x 6-7 mos
  • .05ml sublingually with meals (prostaglandins)
  • Not escalated as in inhalant treatment

22
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23
Conclusion
  • IgE and IgG play a role
  • Patients symptomatology can be quite varied and
    vast
  • There are immunologic as well as non-immunologic
    food allergies
  • Elimination is not the only treatment for a
    patient

24
References
  • King Hueston, Mabry Richard, Mabry Cynthia.
    Allergy in ENT practice a basic guide. New York
    Stuttgart Thieme 1998
  • King HC, King WP. Alternatives in diagnosis and
    treatment of food allergies. Otolaryngol Clin N
    Amer. 1997
  • Breneman JC. Basics of Food Allergy. 2nd ed.
    Springfield, IL Charles C Thomas Publishers
    1984
  • Strobel S Mechanisms of tolerance and
    sensitization in the intestine and other organs
    of the body. Allergy 19955018-25
  • Trevina RJ Food allergies and
    hypersensitivities, in Donald PJ, Gluckman JL,
    Rice DH (eds) The Sinuses. New York, Raven
    Press, 1995, p126
  • Veiling MC, Trevino RJ. Food allergies and
    Hypersensitivities. Rochester, MN Custom
    Printing Inc 2002
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