Common respiratory manifestations of food allergy: A critical focus on otitis media

Previous investigations have established the pathogenic role of food allergy in respiratory tract symptoms, which rarely occur in isolation. Specific foods have been implicated in these reactions. The role of food allergy in otitis media is controversial, probably uncommon, and further studies are needed. Food-induced asthma is more common in young pediatric patients, especially those with atopic dermatitis. Asthma induced by food allergy is considered a risk factor for fatal and near-fatal anaphylactic reactions. Moreover, food allergy can elicit airway hyperreactivity and asthmatic responses. Therefore, evaluation for food allergy should be considered among patients with recalcitrant or otherwise unexplained acute severe asthma exacerbations; asthma triggered by ingestion of particular foods; and asthma and other manifestations of food allergy (eg, anaphylaxis, moderate to severe atopic dermatitis).     

Asthma and allergic rhinitis in a patient with BTK deficiency

BTK deficiency is a primary immunodeficiency disease characterized by the absence of circulating B cells and agammaglobulinemia. While recurrent bacterial infections are the most common manifestations, symptoms of allergy and asthma are rare. We present the case of a 7-year-old boy who presented with asthma symptoms, allergic rhinitis, and severe papular urticaria. He had a positive skin prick test to aeroallergens and food allergens. However, further laboratory tests revealed a low number of B cells and decreased serum levels of all immunoglobulin isotypes. Molecular analysis revealed a mutation in the BTK gene. Although patients with BTK deficiency seem to be protected from atopy, our patient had allergic symptoms suggesting a bias toward a type 2 helper T cell pattern in this case. Primary antibody deficiency should be considered in the differential diagnosis of pediatric allergy and asthma when respiratory infection persists despite appropriate treatment.     

Gastrointestinal food hypersensitivity: Symptoms, diagnosis and provocation tests.

As many as 25% of the general population in Western countries believe that they suffer from adverse reactions to food. However, the actual prevalence of food allergy is much lower. Food-induced allergic reactions cause a variety of symptoms including cutaneous, gastrointestinal and respiratory tract. Food allergy might be caused by IgE-mediated, mixed (IgE and/or non-IgE) or non-IgE-mediated (cellular) mechanisms. The clinical diagnosis is based on a careful history, laboratory findings (total and specific IgE), skin prick test, elimination diet and food challenges. New intestinal provocation tests have also been applied to pick up the allergic response of the duodenal mucosa by endosonography and external ultrasound. The management of food allergy continues to be a strict avoidance of the offending food item.     

Gastrointestinal allergy in adults

The prevalence of food allergy reaches 3% in the adult population. Chronic gastrointestinal allergy is a rare entity: 4.2% of food allergies in adults, and represents 3.2% of all intestinal disorders. Non-specific symptoms are the rule but eosinophilic gastrointestinal disorders are the subject of much interest. Endoscopy and biopsies of the gastrointestinal tract help the differential diagnoses. Food allergy is suspected from the patient's history leading to skin tests and laboratory tests identifying a sensitization but allergy is only confirmed by standardized challenges or eviction diets over a sufficiently long period. New types of investigations coupling oral challenges to foods to gastroenterological techniques should be studied further.     

Nasal polyps in patients with rhinitis and asthma.

The objective of this study was to investigate the prevalence of nasal polyposis in Greek patients with chronic rhinitis and asthma. We studied 3817 patients (2342 men and 1385 women) who were referred for allergy evaluation during 1990-1998 and diagnosed as having chronic rhinitis and asthma. Skin-prick tests with allergens common in Greece and controls were used in all subjects. A wheal with a mean diameter > or = 3 mm was considered as positive. According to the history of symptoms and the results of skin tests, patients were divided into the following groups: patients who have allergic rhinitis (seasonal, perennial), patients who have allergic asthma (seasonal, perennial), patients who have nonallergic rhinitis, and patients who have nonallergic asthma. All patients were examined for nasal polyps by anterior rhinoscopy and endoscopic investigation with a rigid or/and flexible endoscope. We found that 4.2% of the patients with chronic rhinitis and asthma (4.4% of the men and 3.8% of the women; p > 0.05) had nasal polyps. The prevalence of nasal polyps increased with age (p < 0.001) in both sexes. The prevalence of nasal polyps was 13% in patients with nonallergic asthma, 2.4% in patients with allergic asthma, 8.9% in patients with nonallergic rhinitis, and 1.7% in patients with allergic rhinitis. Nasal polyps were found in 3.6% of the patients with rhinitis and in 4.8% of the patients with asthma (p > 0.05). Nasal polyps were present more frequently (1) in patients with nonallergic respiratory disease (rhinitis, asthma) than in patients with allergic respiratory disease (10.8% versus 2.1%; p < 0.001) and (2) in patients with perennial respiratory allergy (rhinitis, asthma) than in patients with seasonal respiratory allergy (4.8% versus 0.4%; p < 0.001). We found that 4.2% of patients with chronic rhinitis and asthma had nasal polyps. Nasal polyps were present more frequently in nonallergic patients than in allergic patients and in patients with perennial allergy than in patients with seasonal allergy.     

Phenotypes of IgE-mediated food allergy in Turkish children

Data on food allergy-related comorbid diseases and the knowledge on factors associating specific food types with specific allergic outcomes are limited. The aim of this study was to determine the clinical spectrum of IgE-dependent food allergy and the specific food-related phenotypes in a group of children with IgE-mediated food allergy. Children diagnosed with IgE-mediated food allergy were included in a cross-sectional study. IgE-mediated food allergy was diagnosed in the presence of specific IgE or skin-prick test and a consistent and clear-cut history of food-related symptoms or positive open provocation test. Egg (57.8%), cow's milk (55.9%), hazelnut (21.9%), peanut (11.7%), walnut (7.6%), lentil (7.0%), wheat (5.7%), and beef (5.7%) were the most common food allergies in children with food allergy. The respiratory symptoms and pollen sensitization were more frequent in children with isolated tree nuts-peanut allergy compared with those with egg or milk allergy (p < 0.001); whereas atopic dermatitis was more frequent in children with isolated egg allergy compared with those with isolated cow's milk and tree nuts-peanut allergy (p < 0.001). Children with food allergy were 3.1 (p = 0.003) and 2.3 (p = 0.003) times more likely to have asthma in the presence of allergic rhinitis and tree nuts-peanut allergy, respectively. Interestingly, children with atopic dermatitis were 0.5 (p = 0.005) times less likely to have asthma. Asthma (odds ratio [OR], 2.3; p = 0.002) and having multiple food allergies (OR, 5.4; p < 0.001) were significant risk factors for anaphylaxis. The phenotypes of IgE-mediated food allergy are highly heterogeneous and some clinical phenotypes may be associated with the specific type of food and the number of food allergies.     

Prevention of allergic diseases

The prevalence of asthma and allergic diseases has increased in recent years, particularly in the industrialized world. Allergic disease begins to manifest in the first years of life. The disorder usually manifests initially in the form of food allergy and atopic dermatitis, followed in later stages by respiratory allergy with rhinitis and/or asthma. This has led to the adoption of preventive measures in those children with a high risk of atopy, based on the following considerations: 1) A family history of allergic diseases (asthma, eczema, and/or allergic rhinitis); 2) A personal history of atopy such as atopic dermatitis, particularly when associated to food allergy; and 3) The existence of allergic sensitization, particularly to pneumoallergens, of early or late onset, but persistent during childhood. Prevention is established at three different levels: primary prevention, avoiding sensitization; secondary prevention, avoiding appearance of the disease; and tertiary prevention, avoiding the symptoms. The present study discusses current knowledge of prevention and its efficacy, with mention of the importance of breastfeeding and the use of pre- and probiotics for securing adequate prevention.     

Diagnosing Pollen-food Allergy Syndrome Allergologically in a Patient with Suspected Eosinophilic Gastroenteritis

Pollen-food allergy syndrome (PFAS) consists of type I allergy to pollen and multiple food items that are cross-reactive to the pollen. PFAS typically occurs in the oral cavity and can co-occur with eosinophilic esophagitis. However, it is infrequently reported to present with symptoms of eosinophilic gastroenteritis (EGE), such as abdominal pain and eosinophilic infiltration of the gastrointestinal tract. We herein report a patient with a condition initially suspected of being EGE based on symptoms and pathological findings that was later diagnosed as PFAS associated with birch pollen. PFAS should be considered as a differential diagnosis in patients with EGE-like symptoms.     

Test de provocation par voie orale aux aliments chez l'enfant. Quand,pour qui et comment ? Interprétation

Oral food challenges (OFC) have to be carefully interpreted. OFC prove the food allergy or persistent food allergy. OFC prove also the absence or the cure of food allergy. Objective and subjective signs are distinguished. Cutaneous and gastrointestinal symptoms are more frequent than respiratory or systemic symptoms. Delayed reactions, isolated or associated, have to be taken into account. In some cases, the OFC cannot be interpreted. Negative double-blind placebo-controlled food challenge must be confirmed by an open manner.     

Exhaled nitric oxide: independent effects of atopy, smoking, respiratory tract infection, gender and height

Measurement of exhaled nitric oxide is widely used in respiratory research and clinical practice, especially in patients with asthma. However, interpretation is often difficult, due to common interfering factors, and little is known about interactions between factors. We assessed the influences and interactions of factors such as smoking, respiratory tract infections and respiratory allergy concerning exhaled nitric oxide values, with the aim to derive a scheme for adjustment. We studied 897 subjects (514 females, 383 males; mean age+/-standard deviation 34.5+/-13.0 years) with and without respiratory allergy (allergic rhinitis and/or asthma), smoking and respiratory tract infection. Logarithmic nitric oxide levels were described by an additive model comprising respiratory allergy, smoking, respiratory tract infection, gender and height (p0.001 each), without significant interaction terms. Geometric mean was 17.5ppb in a healthy female non smoker of height 170cm, whereby respiratory allergy corresponded to a change by factor 1.50, smoking 0.63, infection 1.24, male gender 1.17, and each 10cm increase (decrease) in height to 1.11 (0.90). Factors were virtually identical when excluding asthma and using the category allergic rhinitis instead of respiratory allergy (n=863). Within each category formed by combinations of these different predictors, the range of residual variation was approximately constant. We conclude that the factors influencing exhaled nitric oxide, which we analyzed, act independently of each other. Thus, circumstances such as smoking and respiratory tract infection do not appear to affect the usefulness of exhaled nitric oxide, provided that appropriate factors for adjustment are applied.     

Oral Food Challenges in Children: Review and Future Perspectives

Food allergy is a lifelong condition with no known treatment or cure. Allergy tests such as skin tests and blood tests are not always accurate when positive and are not necessarily diagnostic of a food allergy. A food allergy takes into consideration both the history of exposure and the testing. The food challenge is considered the diagnostic gold standard for food allergy. However, recent evidence suggests that not enough challenges are being performed. Several techniques exist with which clinicians can challenge patients. Providers who perform challenges should be familiar with assessing signs and symptoms of a potential reaction and must be prepared to treat anaphylaxis. The magnitude of the serum and skin tests may be of assistance in stratifying a patient’s risk of passing a challenge, and newer diagnostic tests may help better stratify such risk of based on particular epitope recognition.     

Gastrointestinal food allergies: do they exist?

Gastrointestinal (GI) symptoms are often attributed to adverse reactions to foods (ARF), but it is not always clear whether such reactions are caused by food allergy. A reaction to food proteins that is mediated by immunologic events is referred to as food allergy or food hypersensitivity. One of the most common types of food allergy is the IgE-mediated immediate hypersensitivity reaction to foods, which can give rise to dermatologic and respiratory tract symptoms in addition to GI complaints. Other GI forms of food allergy include food protein-induced enterocolitis or gastroenteropathy, celiac disease, and some cases of eosinophilic gastroenteritis. Because most patients complaining of adverse reactions to food have non-immune mechanisms for their complaints, it is important to distinguish the various types of ARF, as their management may differ substantially. Recent advances in the field of food allergy provide opportunities to improve diagnostic methods and develop new modalities for management that will complement the current practice of allergen avoidance.     

Clinical profile of a Mediterranean population sensitised to date palm pollen (Phoenix dactylifera). A retrospective study

BackgroundDate palm pollen allergy is frequently associated with polysensitisation. Observational studies have suggested that date-palm-sensitised individuals could be included in a distinct group of polysensitised patients. The objectives of the study were to analyse the clinical characteristics of a group of patients diagnosed of date-palm pollen allergy and to compare them with pollen allergic patients without date-palm sensitisation.MethodsForty-eight palm-pollen sensitised individuals were classified as Group A. A control group of 48 patients sensitised to pollens but without palm-pollen allergy were included as Group B. All individuals were skin prick tested with a common battery of aeroallergens. Information about age, sex, family history of atopy, respiratory symptoms, food allergy and sensitisation to other pollens were considered variables of the study. Specific IgE and the allergogram to date-palm pollen were determined in a subgroup of Group A.ResultsSignificant differences in the family history of atopy and number of sensitisations were observed. Both parameters were significantly higher in Group A. Group A showed high prevalence of asthma and higher level of sensitisation to foods (p < 0.05). Significant differences were obtained for sensitisation to epithelia and pollens. Pho d 2 was the most commonly recognised allergen (83.3%) in the palm-pollen allergic group.ConclusionsDate-palm pollen allergic patients constitute a homogeneous group characterised for showing bronchial asthma, sensitisation to food allergens and polysensitisation. These results suggest that the reasons for sensitisation to date-palm pollen remain to be elucidated, but could relate to the existence of as yet non-identified pan-allergens.     

Short-term respiratory effects of cleaning exposures in female domestic cleaners.

Symptoms of obstructive lung disease in domestic cleaners have been related to the use of bleach and other irritant cleaning products. The short-term effects of cleaning exposures on respiratory symptoms and peak expiratory flow (PEF) were investigated in domestic cleaners with respiratory disorders. In a panel study, 43 female domestic cleaners with a recent history of asthma and/or chronic bronchitis completed a 2-week diary, collecting information on respiratory symptoms, PEF and cleaning exposures. Mixed regression models were used to assess daily changes in symptoms and PEF associated with specific cleaning exposures. The probability of having work-related asthma was individually assessed by a computerised diagnostic system and an occupational asthma expert. Lower respiratory tract symptoms were more common on working days and were predominantly associated with exposure to diluted bleach, degreasing sprays/atomisers and air fresheners. Associations with upper respiratory tract symptoms and PEF were less apparent. Eleven (30%) subjects scored positively for work-related asthma. It is concluded that exposure to certain irritant cleaning products aggravates lower respiratory tract symptoms in female domestic cleaners with asthma or chronic bronchitis.     

Trends in allergy prevalence among children aged 0–17 years by asthma status,United States, 2001–2013

Objectives: Children with asthma and allergies—particularly food and/or multiple allergies–are at risk for adverse asthma outcomes. This analysis describes allergy prevalence trends among US children by asthma status. Methods: We analyzed 2001–2013 National Health Interview Survey data for children aged 0–17?years. We estimated trends for reported respiratory, food, and skin allergy and the percentage of children with one, two, or all three allergy types by asthma status. We estimated unadjusted trends, and among children with asthma, adjusted associations between demographic characteristics and allergy. Results: Prevalence of any allergy increased by 0.3 percentage points annually among children without asthma but not among children with asthma. However, underlying patterns changed among children with asthma: food and skin allergy prevalence increased as did the percentage with all three allergy types. Among children with asthma, risk was higher among younger and non-Hispanic black children for reported skin allergy, among non-Hispanic white children for reported respiratory allergy, and among non-poor children for food and respiratory allergies. Prevalence of having one allergy type decreased by 0.50 percentage points annually, while the percent with all three types increased 0.2 percentage points annually. Non-poor and non-Hispanic white children with asthma were more likely to have multiple allergy types. Conclusions: While overall allergy prevalence among children with asthma remained stable, patterns in reported allergy type and number suggested a greater proportion may be at risk of adverse asthma outcomes associated with allergy: food allergy increased as did the percentage with all three allergy types.     

The Pattern of Gastroesophageal Reflux in Asthmatic Children

The association between gastroesophageal reflux (GER) and asthma is not fortuitous. The objective of our study was to test a group of children with asthma by 24 hr gastroesophageal pH monitoring and to relate the results to the patients' medical history and clinical data. We studied 77 children aged from 39 to 170 months suffering from particularly recurrent and/or therapy-resistant asthma. Medical history data were collected for each patient and included: severity and characteristics of respiratory symptoms; presence, if any, of allergy; presence, if any, of GER-related symptoms; and presence, if any, of esophagitis-related symptoms. Esophageal pH was measured by 24 hr computerized monitoring of the main measures in all patients. Forty-seven children were also examined by gastroesophageal endoscopy. The prevalence of GER was 61% on the basis of the reflux index (cutoff: 4.2%). Gastroesophageal reflux in these asthmatic children was characterized mainly by short-lasting daytime episodes. The patients tended to present GER mainly associated with vomiting but not with signs and symptoms of esophagitis. The short-lasting nature of the reflux episodes demonstrates good esophageal clearance. The time of onset of respiratory symptoms (day/night) was not associated with any particular type of GER, the severity of which tends to be proportional to the seriousness of the asthma. No correlation was found between GER and allergy. No statistically significant differences were found in clinical or medical history findings between patients with pathologic and nonpathologic GER.     

Allergie à lˈarachide

Peanut allergy, which is frequent in the United States and was much less so in Europe up to the mid-eighties, has become a major problem in many industrialized countries. Peanut consumption is high in Eastern Europe, the United Kingdom, The Netherlands, Germany and France. The frequency of peanut allergy is between 0.5 and 0.7% in the general population. Two million Americans are now thought to be affected. In France peanuts are one of the most frequent allergens, lying second (27.4%) to egg in food allergies in children, and holding first place in food allergies in children aged over 3 years. Sensitization occurs through ingestion, contact even if indirect, and inhalation. The symptoms, which affect the skin and the respiratory or gastrointestinal tract, appear a few minutes to a few hours after exposure. Serious reactions (anaphylactic shock, life-threatening reactions, sudden death) have been described. Asthma has a significantly higher association with peanut allergy than with other allergies, taken overall. As with other food allergies, diagnosis is based on history, prick-tests, screening for specific serum IgE and food challenge whose modalities (labial and oral challenge) are debated. For the time being, elimination is the only form of treatment. The development of a modified allergen as immunogenic as possible but practically without allergenic effects should give immunotherapy new impetus. Patients with severe peanut allergy should carry a card or wear a distinctive bracelet indicating their condition as well as an emergency kit including in particular epinephrine.     

Japanese Guideline for Food Allergy

Food allergy is defined as “a phenomenon in which adverse reactions (symptoms in skin, mucosal, digestive, respiratory systems, and anaphylactic reactions) are caused in living body through immunological mechanisms after intake of causative food.”Various symptoms of food allergy occur in many organs. Food allergy falls into four general clinical types; 1) neonatal and infantile gastrointestinal allergy, 2) infantile atopic dermatitis associated with food allergy, 3) immediate symptoms (urticaria, anaphylaxis, etc.), and 4) food-dependent exercise-induced anaphylaxis and oral allergy syndrome (i.e., specific forms of immediate-type food allergy).Therapy for food allergy includes treatments of and prophylactic measures against hypersensitivity like anaphylaxis. A fundamental prophylactic measure is the elimination diet. However, elimination diets should be conducted only if they are inevitable because they places a burden on patients. For this purpose, it is highly important that causative foods are accurately identified. Many means to determine the causative foods are available, including history taking, skin prick test, antigen specific IgE antibodies in blood, basophil histamine release test, elimination diet test, oral food challenge test, etc. Of these, the oral food challenge test is the most reliable. However, it should be conducted under the supervision of experienced physicians because it may cause adverse reactions such as anaphylaxis.     

Management of allergic problems in primary care: time for a rethink?

Allergic diseases affect 20-30% of the UK population and when severe are associated with considerable morbidity and occasional mortality. Initiatives to improve allergy services in the UK have been led by consultant allergists and have focussed on increasing the number of hospital training posts to improve access to specialist services. A high profile campaign to raise awareness of the lack of allergy services has so far failed to generate further training numbers for allergy as a single specialty. Although the campaign to improve tertiary allergy services continues, most mild or moderate allergy symptoms (e.g. hayfever, allergic asthma, urticaria and some food allergy problems), can be managed successfully in primary care with appropriate interest and training. Despite the high and increasing numbers of patients with allergy and the ease with which the majority of symptoms can be controlled, many doctors in primary care are reluctant to take a more proactive approach to managing allergic conditions. This appears to be due to concerns about overburdening an already busy service, but may also be due to recommendations from allergy specialists which have implied that high quality allergy care is not possible without identification of specific allergic triggers using skin prick tests or blood tests. In reality, symptoms can usually be controlled using pharmacotherapy, although a working knowledge of the appropriate guidelines is helpful. In this paper, we propose minimum levels of knowledge for all practitioners in order to raise the standards of primary care allergy management, and provide recommendations for training for those wishing to manage successfully more difficult allergy cases and allergy diagnosis.