Food Allergies and Hypersensitivities: Diagnosis and Management

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Food Allergies andHypersensitivitiesDiagnosis
and Management

• Adam Ray, MD
• SIU Division of Otolaryngology-
• Head Neck Surgery

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Objectives

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

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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

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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

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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

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History Rinkel

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

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Types of Adverse Reactions

• Non-Immunologic
• Anaphylactoid
• Idiosyncratic
• Enzyme deficiencies
• Toxic reactions
• Pharmacologic

• Immunologic

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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

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Types of Adverse Reactions

• Non-Immunologic
• Anaphylactoid
• Idiosyncratic
• Enzyme deficiencies
• Toxic reactions
• Pharmacologic

• Immunologic
• Fixed
• Cyclic

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Immunologic

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

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Immunologic

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

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Diagnosis

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

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Diagnosis

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

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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

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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

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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

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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

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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

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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

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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

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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