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Sanders GM, Hua A, Hudson E, Troost JP, Kamada N, Kao JY, Schuler CF, El-Zaatari M. Association of myeloid cell reactivity patterns with safe food predictions in FPIES patients. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2025; 21:24. [PMID: 40400028 DOI: 10.1186/s13223-025-00968-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Accepted: 05/01/2025] [Indexed: 05/23/2025]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is an understudied non-IgE-mediated food allergy, which is distinct from and lacks diagnostic testing akin to IgE testing. FPIES affects infants and toddlers but can persist into adulthood. As there are no extant methods to identify safe foods for FPIES patients, food ingestion trials are performed at home and often lead to reactions and development of food aversions, which may lead to failure-to-thrive and gastric feeding tube requirements. We hypothesized that foods that fail to elicit responses in immune cells of FPIES patients would be safe to ingest, which could support development of a diagnostic method to headstart safe food identification in patients. METHODS We developed an ex vivo model of FPIES using food-stimulated white blood cells (WBCs) from pediatric FPIES patients and controls by defining a 9-gene panel representative of FPIES ex vivo responses and conducted a single-arm pilot clinical trial. RESULTS Myeloid cells of FPIES patients displayed variable individual-specific myeloid cell reactivity patterns (iMCRPs) to different foods. Foods that failed to elicit repsonses in patients' immune cells were safe to ingest with a negative predictive value of 98.5%. This, when utilized in prospective predictions, reduced newly introduced food reaction rates from 19.5 to 0% while increasing food repertoire diversity. CONCLUSIONS iMCRPs represent a novel and potentially useful tool that associates with safe food ingestion in FPIES patients for foods that fail to elicit immune cell reactions. Trial Registration The trial has been registered at registered at ClinicalTrials.gov # NCT04644783.
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Affiliation(s)
- Georgiana M Sanders
- Division of Allergy and Immunology, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48105, USA
- Mary H. Weiser Food Allergy Center, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48105, USA
| | - Alexandra Hua
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Hudson
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Nobuhiko Kamada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 6518 MSRB 1, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - John Y Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 6518 MSRB 1, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Charles F Schuler
- Division of Allergy and Immunology, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48105, USA.
- Mary H. Weiser Food Allergy Center, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48105, USA.
| | - Mohamad El-Zaatari
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, 6518 MSRB 1, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Baker MG, Wong LSY, Konstantinou GN, Nowak-Wegrzyn A. Food allergy endotypes revisited. J Allergy Clin Immunol 2025:S0091-6749(25)00459-2. [PMID: 40306493 DOI: 10.1016/j.jaci.2025.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Revised: 03/31/2025] [Accepted: 04/14/2025] [Indexed: 05/02/2025]
Abstract
In the last century, food allergy has become recognized as an increasingly prevalent and heterogeneous condition. Advances in biomedical technology have revealed complex genetic, environmental, immune, and metabolic pathways underlying the pathogenesis of food-allergic disorders. These findings permit classification of distinct food allergy endotypes with unique pathophysiologic features. In this review, we suggest that these endotypes of food-allergic disorders should be defined on the basis of (1) whether or not the allergic antibody IgE plays an essential role in disease pathogenesis, (2) the molecular features of the allergen (protein vs carbohydrate), and (3) the molecular markers associated with prognosis, severity, or clinical presentation. Beyond these broad categories, additional subtypes with unique mechanistic characteristics are discussed.
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Affiliation(s)
- Mary Grace Baker
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lydia Su Yin Wong
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, NY; Department of Pediatrics, National University of Singapore, Singapore; Khoo Teck Puat National University Children's Medical Institute, National University Health Systems, Singapore
| | - George N Konstantinou
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Allergy and Clinical Immunology, 424 General Military Training Hospital, Thessaloniki, Greece
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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3
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Gelsomino M, Barni S, Mastellone F, Bersani G, Barbato M, Condemi C, Mori F, Vazquez-Ortiz M, Indirli GC, Miceli Sopo B, Simeone G, Miceli Sopo S. Severity Trend of Recurrence in Pediatric Food Protein-Induced Enterocolitis Syndrome. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2025; 13:842-850. [PMID: 39828136 DOI: 10.1016/j.jaip.2025.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 12/26/2024] [Accepted: 01/08/2025] [Indexed: 01/22/2025]
Abstract
BACKGROUND Reintroduction of the offending food in pediatric patients affected by food protein-induced enterocolitis syndrome (FPIES) is carried out in hospitals with an oral food challenge (OFC), which leads to a long waiting time and increases the societal burden of medical cost and human resources. OBJECTIVE To assess the severity trend of acute FPIES adverse reactions over time in the same patient for possible outpatient or home reintroduction of the offending food. METHODS All children (aged <18 years) with a diagnosis of acute FPIES referred to two Italian pediatric allergy clinics were retrospectively enrolled. To determine whether home or outpatient clinic reintroduction of trigger food was possible, a risk of severe reactions of 5% or less was arbitrarily considered acceptable. RESULTS Of202 patients enrolled, 23 (11.4%) had increasing severity from mild to moderate up to severe episodes. No variables analyzed in these patients (sex, age at onset, and the interval between the first and severe episodes) had a statistically significant influence on the risk of more severe reactions. Of all patients who initially presented with mild or moderate episodes, 15.2% and 13.9% later manifested severe episodes over time, respectively. Of patients with cow's milk FPIES that started with a mild episode, 5.5% later experienced a severe episode. CONCLUSIONS Performing OFC for acute FPIES is not safe enough at home because the probability of severe adverse reaction is greater than 5%. However, it could be considered to perform OFC in an outpatient clinic in patients with cow's milk FPIES who started with a mild episode and if a rapid transfer plan to emergency department is available.
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Affiliation(s)
- Mariannita Gelsomino
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Barni
- Allergy Unit, Anna Meyer Children's Hospital IRCCS, Florence, Italy
| | - Francesco Mastellone
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulia Bersani
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Marta Barbato
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Chiara Condemi
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesca Mori
- Allergy Unit, Anna Meyer Children's Hospital IRCCS, Florence, Italy
| | - Marta Vazquez-Ortiz
- Section of Inflammation, Repair, and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Bruno Miceli Sopo
- Faculty of Medicine, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, Rome, Italy
| | | | - Stefano Miceli Sopo
- Pediatric Allergy Unit, Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
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Sanders J, Conway AE, Kartha N, Kumar BP, Oppenheimer J, Verdi M, Anagnostou A, Abrams EM, Blatman KSH, Greenhawt M, Shaker MS. Cost-effectiveness of shared decision-making in determining challenge setting for nonsevere food protein-induced enterocolitis syndrome. Ann Allergy Asthma Immunol 2025:S1081-1206(25)00048-1. [PMID: 40088222 DOI: 10.1016/j.anai.2025.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 01/02/2025] [Accepted: 01/20/2025] [Indexed: 03/17/2025]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) affects approximately 0.5% of US children. Oral food challenges (OFCs) are frequently conducted to assess FPIES resolution in an observed setting, given the risk of severe reactions. However, it is unclear whether the observed OFC is universally cost-effective in all contexts vs gradually titrated home OFCs when caregivers are willing to accept a risk-to-benefit tradeoff. OBJECTIVE To characterize the health and economic benefits of at-home vs supervised reintroduction OFC in patients with a history of mild-moderate index FPIES. METHODS Cohort analyses evaluated the cost-effectiveness of a gradually titrated home vs clinical or hospital OFC using population simulations (n = 200,000 patients) and simulations in a rural New England population (n = 105). Severe FPIES reactions were defined as necessitating intravenous fluids. Fatality rates were defined as occurring approximately in 1/1,000,000 FPIES OFCs. Motor vehicle fatality rates were applied based on the travel distance to the OFC site. The cost-effectiveness threshold was set at $10,000,000 per fatality prevented. RESULTS In the population simulation, the supervised OFC costs reached $411,088,445, with 18,680 severe reactions occurring (per-patient mean 0.093, SD 0.025), at a cost-per-fatality prevented of $124,233,328. In a simulation of a rural New England population with FPIES, the cost per severe reaction ranged from $11,790 to $46,304. CONCLUSION A requirement for universally conducting FPIES challenges in an office-based or in-hospital setting is not cost-effective given extremely low FPIES reaction fatality rates, especially when compared with travel-based motor vehicle fatality rates. A shared decision-making approach may be appropriate to determine the challenge setting for patients with lower risk of severe reactions.
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Affiliation(s)
- Jason Sanders
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Navya Kartha
- Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Brinda Prasanna Kumar
- Section of Allergy and Immunology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marylee Verdi
- Dartmouth College Student Health, Hanover, New Hampshire
| | - Aikaterini Anagnostou
- Division of Allergy and Immunology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Karen S Hsu Blatman
- Section of Allergy and Immunology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Marcus S Shaker
- Section of Allergy and Immunology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
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Nowak-Wegrzyn A, Sicherer SH, Akin C, Anvari S, Bartnikas LM, Berin MC, Bingemann TA, Boyd S, Brown-Whitehorn T, Bunyavanich S, Cianferoni A, du Toit G, Fortunato JE, Goldsmith JD, Groetch M, Leonard SA, Rao M, Schultz F, Schwaninger JM, Venter C, Westcott-Chavez A, Wood RA, Togias A. Current status and future directions in food protein-induced enterocolitis syndrome: An NIAID workshop report of the June 22, 2022, virtual meeting. J Allergy Clin Immunol 2025; 155:336-356. [PMID: 39521282 DOI: 10.1016/j.jaci.2024.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/10/2024] [Accepted: 10/17/2024] [Indexed: 11/16/2024]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated gastrointestinal food allergy characterized by delayed, protracted vomiting and accompanied by lethargy and pallor, usually 1 to 4 hours after ingesting the food allergen. The pathophysiology of FPIES remains unknown, and currently there are no diagnostic biomarkers available to assess disease activity or its resolution. Over the last 2 decades, FPIES has become increasingly recognized in both pediatric and adult patients. Forty years after the initial FPIES description, the first FPIES code appeared in the International Classification of Diseases, Tenth Revision (ICD-10), and the first international consensus guidelines for the diagnosis and management of FPIES were published. On June 22, 2022, the National Institute of Allergy and Infectious Diseases (NIAID) held its first virtual multidisciplinary workshop on FPIES. Various clinical and translational aspects of FPIES as well as important areas of unmet needs were discussed as priorities for future research during this 2-day virtual workshop. Our report provides a summary of content of the workshop, including updated literature on the topic areas, and also provides critical commentary on the state of FPIES.
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Affiliation(s)
- Anna Nowak-Wegrzyn
- Department of Pediatrics, Hassenfeld Children's Hospital, NYU Grossman School of Medicine, New York, and the Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland; Department of Pediatrics, Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Scott H Sicherer
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Cem Akin
- Department of Medicine, University of Michigan, Division of Allergy and Clinical Immunology, Ann Arbor, Mich
| | - Sara Anvari
- Division of Immunology, Allergy and Retrovirology, Texas Children's Hospital, Baylor College of Medicine, Houston, and Texas Children's Hospital, William T. Shearer Center for Human Immunobiology, Houston, Tex
| | - Lisa M Bartnikas
- Department of Medicine, Division of Immunology, Boston Children's Hospital, Boston, and Harvard Medical School, Boston, Mass
| | - M Cecilia Berin
- Department of Medicine, Division of Allergy/Immunology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Theresa A Bingemann
- Department of Allergy, Immunology and Rheumatology and the Department of Pediatric Allergy and Immunology, University of Rochester School of Medicine, Rochester, NY
| | - Scott Boyd
- Stanford University School of Medicine, Palo Alto, Calif
| | - Terri Brown-Whitehorn
- Division of Pediatric Allergy and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Supinda Bunyavanich
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Antonella Cianferoni
- Division of Pediatric Allergy and Immunology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - George du Toit
- Department of Women and Children's Health (Paediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, and the Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - John E Fortunato
- Gastroenterology, Hepatology and Nutrition, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Jeffrey D Goldsmith
- Department of Pathology, Boston Children's Hospital, Boston, and Harvard Medical School, Boston, Mass
| | - Marion Groetch
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephanie A Leonard
- Division of Pediatric Allergy & Immunology, Rady Children's Hospital San Diego, University of California, San Diego, Calif
| | - Meenakshi Rao
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, and Harvard Medical School, Boston, Mass
| | - Fallon Schultz
- Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health, Rockville, Md
| | | | - Carina Venter
- Children's Hospital Colorado, University of Colorado, Denver, Colo
| | | | - Robert A Wood
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Alkis Togias
- Allergy, Immunology and Transplantation, NIAID, National Institutes of Health, Rockville, Md
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6
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Perriere A, Garcette K, Kalach N, Tounian P, Lemoine A. Food protein induced enterocolitis syndrome: French practices assessment in children. Arch Pediatr 2025; 32:114-119. [PMID: 39875216 DOI: 10.1016/j.arcped.2024.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 09/23/2024] [Accepted: 12/08/2024] [Indexed: 01/30/2025]
Abstract
BACKGROUND Food protein-induced enterocolitis syndrome (FPIES) is a specific non IgE-mediated food allergy. The international consensus guidelines defined diagnosis criteria and management plan in 2017. OBJECTIVES To assess practices regarding FPIES in France and in French-speaking countries, according to those guidelines. METHODS AND SETTING We carried out a 22-question online survey to assess practices of specialised physicians (paediatricians, allergists, gastroenterologists, members of 2 French-speaking learning societies and/or working at hospitals in paediatric allergy units) following patients with FPIES between August 2019 and February 2022. RESULTS We received 92 replies to our survey, mostly from hospital practitioners following less than 10 patients with FPIES. Oral rehydration solution and/or Ondansetron were largely prescribed in the emergency kit (61/72, 84.7 % and 47/72, 65.3 % respectively). 20 practitioners declared never prescribing an emergency kit. There was some confusion when distinguishing between FPIES and an IgE-mediated food allergy, as suggested by the unnecessary prescription of an antihistamine (18/72, 25.0 %) and/or epinephrine (11/72, 15.3 %) in the emergency kit. An explanatory FPIES emergency management letter to physicians in case of allergic reactions was provided in 83.7 % (77/92) of patients. Oral food challenge (OFC) practices varied greatly concerning doses: most respondents used several doses (52/92, 56.5 %) during the same day (33/52, 63.4 %). Eleven responders (12.0 %) used the same protocol as for an IgE-mediated food allergy. CONCLUSION Our survey showed that practices of FPIES management in France are generally aligned with the international consensus guidelines. There are still pending issues to be standardised, such as the emergency kit prescription and its contents, as well as OFC management strategies. This work confirms the need for continuous training of physicians regarding FPIES management. Further guidelines are needed to improve standardisation of FPIES management.
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Affiliation(s)
- Amélie Perriere
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Karine Garcette
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France; CMSEA, 11 rue Froment, 75011 Paris, France.
| | - Nicolas Kalach
- Paediatric Department, Saint Antoine Paediatric Clinic, Saint Vincent de Paul Hospital, Catholic University of Lille, boulevard de Belfort, BP 387, 59020 Lille Cedex, France.
| | - Patrick Tounian
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
| | - Anaïs Lemoine
- Sorbonne Université, Paediatric Nutrition and Gastroenterology Department, APHP-Trousseau Hospital, 26 avenue du Dr Arnold Netter, 75012 Paris, France.
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Beaudoin M, Mehra A, Wong LSY, Vazquez-Ortiz M, González-Delgado P, Nowak-Wegrzyn A. An Algorithm for the Diagnosis and Treatment of Food Protein-Induced Enterocolitis Syndrome (FPIES), 2024 Update. Allergy 2025; 80:362-365. [PMID: 39655844 DOI: 10.1111/all.16432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 10/28/2024] [Accepted: 12/01/2024] [Indexed: 01/12/2025]
Affiliation(s)
- Michele Beaudoin
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
| | - Ashna Mehra
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
| | - Lydia Su Yin Wong
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Pediatrics, National University of Singapore, Singapore, Singapore
| | | | - Purificación González-Delgado
- Allergy Service, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- Clinical Medicine Department, University Miguel Hernández, Alicante, Spain
- Allergy Section, Alicante General University Hospital Dr. Balmis, Alicante, Spain
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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8
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Hung L, Zientara B, Berin MC. Contribution of T cell subsets to different food allergic diseases. Immunol Rev 2024; 326:35-47. [PMID: 39054597 DOI: 10.1111/imr.13368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Food allergies occur due to a lack of tolerance to the proteins found in foods. While IgE- and non-IgE-mediated food allergies have different clinical manifestations, epidemiology, pathophysiology, and management, they share dysregulated T cell responses. Recent studies have shed light on the contributions of different T cell subsets to the development and persistence of different food allergic diseases. This review discusses the role of T cells in both IgE- and non-IgE-mediated food allergies and considers the potential future investigations in this context.
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Affiliation(s)
- Lisa Hung
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brianna Zientara
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - M Cecilia Berin
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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9
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Hayashi D, Yoshida K, Akashi M, Kajita N, Tatsumoto C, Ishii T, Koike Y, Horimukai K, Kinoshita M, Hamahata Y, Nishimoto H, Sakihara T, Arakaki Y, Hara M, Noguchi E, Morita H. Differences in Characteristics Between Patients Who Met or Partly Met the Diagnostic Criteria for Food Protein-Induced Enterocolitis Syndrome (FPIES). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1831-1839.e1. [PMID: 38492664 DOI: 10.1016/j.jaip.2024.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/24/2024] [Accepted: 03/09/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Some patients with food protein-induced enterocolitis (FPIES)-like allergy do not completely fulfill the diagnostic criteria of the international consensus guideline for FPIES. However, it is unclear whether such FPIES-like patients represent a completely different population from FPIES. OBJECTIVE This study aimed to clarify differences in characteristics between patients with FPIES who fully met diagnostic criteria and those who partly met them. METHODS This was a cross-sectional study using data at the time of registration in multicenter, prospective studies of patients with FPIES in Japan. Children who had delayed emesis within 1 to 4 hours and/or diarrhea within 5 to 10 hours after ingestion of food were recruited between March 2020 and February 2022. We examined their compatibility with the diagnostic criteria of the international consensus guideline and their detailed clinical characteristics, including trigger foods, the serving size that elicited symptoms, and antigen-specific IgE antibody titers. RESULTS Of the 225 patients with FPIES, 140 fully met the diagnostic criteria whereas 79 patients did not fully meet them but demonstrated reproducible symptoms. The frequencies of pallor, lethargy, and diarrhea were significantly higher in those who met the criteria fully, whereas the age at onset, trigger foods, comorbidity, and perinatal information were comparable. Analysis of patients with FPIES to hen's egg revealed significantly higher levels of egg white- and egg yolk-specific IgE in patients who partly met criteria, whereas the serving size eliciting symptoms was comparable. CONCLUSIONS Patients who partly met the diagnostic criteria may have a milder phenotype of FPIES, but this needs to be validated in further studies using biomarkers reflecting the pathophysiology.
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Affiliation(s)
- Daisuke Hayashi
- Department of Pediatrics, Tsukuba Medical Center Hospital, Ibaraki, Japan; Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Koichi Yoshida
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masayuki Akashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Kajita
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Tomo Ishii
- Department of Pediatrics, NHO Tochigi Medical Center, Tochigi, Japan
| | - Yumi Koike
- Department of Allergy, Nagano Children's Hospital, Nagano, Japan
| | - Kenta Horimukai
- Department of Pediatrics, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Misako Kinoshita
- Department of Pediatrics, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Yuko Hamahata
- Department of Pediatrics, Saitama City Hospital, Saitama, Japan
| | - Hajime Nishimoto
- Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | | | - Yohei Arakaki
- Department of Pediatrics, Naha City Hospital, Okinawa, Japan
| | - Monami Hara
- Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Emiko Noguchi
- Department of Medical Genetics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Allergy Center, National Center for Child Health and Development, Tokyo, Japan.
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Anvari S, Ruffner MA, Nowak-Wegrzyn A. Current and future perspectives on the consensus guideline for food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:188-195. [PMID: 38326194 DOI: 10.1016/j.alit.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 01/06/2024] [Indexed: 02/09/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy presenting with delayed onset of projectile vomiting in the absence of cutaneous and respiratory symptoms. The pathophysiology of FPIES remains poorly characterized. The first international consensus guidelines for FPIES were published in 2017 and provided clinicians with parameters on the diagnosis and treatment of FPIES. The guidelines have served as a resource in the recognition and management of FPIES, contributing to an increased awareness of FPIES. Since then, new evidence has emerged, shedding light on adult-onset FPIES, the different phenotypes of FPIES, the recognition of new food triggers, center-specific food challenge protocols and management of acute FPIES. Emerging evidence indicates that FPIES impacts both pediatric and adult population. As a result, there is growing need to tailor the consensus guidelines to capture diagnoses in both patient groups. Furthermore, it is crucial to provide food challenge protocols that meet the needs of both pediatric and adult FPIES patients, as well as the subset of patients with atypical FPIES. This review highlights the evolving clinical evidence relating to FPIES diagnosis and management published since the 2017 International FPIES Guidelines. We will focus on areas where recent published evidence may support evolution or revision of the guidelines.
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Affiliation(s)
- Sara Anvari
- Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; William T. Shearer Center for Human Immunobiology, Texas Children's Hospital, Houston, TX, USA
| | - Melanie A Ruffner
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anna Nowak-Wegrzyn
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, NYU Grossman School of Medicine, New York City, NY, USA; Department of Pediatrics Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
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Akashi M, Kaburagi S, Kajita N, Morita H. Heterogeneity of food protein-induced enterocolitis syndrome (FPIES). Allergol Int 2024; 73:196-205. [PMID: 38553113 DOI: 10.1016/j.alit.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/13/2024] [Indexed: 04/02/2024] Open
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy with gastrointestinal symptoms such as vomiting and diarrhea. The development of international consensus guidelines for the diagnosis and management of FPIES in 2017 enabled us to compare patients worldwide, regardless of geographic variation in disease features. As a result, it has become clear that there is heterogeneity among patients with FPIES or that there are cases that partly fit the diagnostic criteria for FPIES but have different characteristics. This review highlights the heterogeneity in FPIES characteristics in terms of trigger foods, the age of onset, differences in geographic regions, and symptoms; it further proposes four disease entities, including acute FPIES in children, acute FPIES in adults, chronic FPIES, and early-onset neonatal FPIES, depending on the age of onset and presumed pathophysiology. The major symptoms at onset and trigger foods differ in acute FPIES in children, acute FPIES in adults, and chronic FPIES, whereas the disease entities may share a similar pathophysiology. Early-onset neonatal FPIES may have a different pathophysiology than acute or chronic FPIES, and may not necessarily fulfil the full diagnostic criteria for acute or chronic FPIES described in the international consensus guidelines. Due to the similarity in symptoms, early-onset neonatal FPIES may sometimes be misdiagnosed as necrotizing enterocolitis. We aim to increase awareness of FPIES among medical staff in pediatrics, neonatology, and internal medicine and promote research, to gain a better understanding of the heterogeneity and pathophysiology of FPIES.
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Affiliation(s)
- Masayuki Akashi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Sachiko Kaburagi
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Kajita
- Department of Allergy, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hideaki Morita
- Department of Allergy and Clinical Immunology, National Research Institute for Child Health and Development, Tokyo, Japan; Allergy Center, National Center for Child Health and Development, Tokyo, Japan.
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Shah S, Grohman R, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome (FPIES): Beyond the guidelines. JOURNAL OF FOOD ALLERGY 2023; 5:55-64. [PMID: 39022754 PMCID: PMC11250192 DOI: 10.2500/jfa.2023.5.230014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Background Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) cell mediated food allergy that can cause severe symptoms and is considered an allergic emergency. Objective To describe FPIES epidemiology and appraise the approach to diagnosis and management. Methods A review of the relevant articles published in the peer-reviewed journals since the publication of the First International FPIES Consensus Guidelines in 2017. Results FPIES is estimated to affect 0.51-0.9% of children and 0.22% of adults in the United States. It typically presents with protracted, projectile vomiting, which occurs within 1-4 hours of ingesting culprit foods, sometimes followed by diarrhea within 24 hours of ingestion. In ∼15-20% of severe cases, patients go into hypovolemic or distributive shock. In chronic FPIES, infants may have failure to thrive and weight loss. The most common triggers include cow's milk, oat, rice, and avocado, with egg and peanut being more frequently reported. Examples of other common fruit and vegetable triggers include banana, apple, and sweet potato. FPIES can be classified into acute, chronic, adult-onset, or atypical subtypes. FPIES is associated with comorbid atopic conditions of IgE-mediated food allergy, atopic dermatitis, asthma, allergic rhinitis, and eosinophilic esophagitis. The natural history of infantile FPIES is generally favorable, with the exception of fish FPIES. Seafood FPIES in adults has low rates of resolution over 3-5 years. Correctly identifying FPIES can be challenging because there are no specific biomarkers for diagnosis and the constellation of symptoms may mimic those of infectious enteritis or sepsis. Management relies on dietary food avoidance, periodic re-evaluations for tolerance with oral food challenges, and management of acute reactions with rehydration and antiemetic ondansetron. Although the pathophysiology of FPIES remains poorly understood, underlying mechanisms such as cytokine release, leukocyte activation, and impaired gastrointestinal mucosal barrier function may act as cornerstones for further research. Conclusion Prevention, laboratory diagnostic testing, and strategies to accelerate tolerance development are urgent unmet needs in FPIES.
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Affiliation(s)
- Sohini Shah
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Rebecca Grohman
- Department of Pediatrics, Hassenfield Children’s Hospital, Children’s Hospital at Montefiore/Montefiore Medical Center, Bronx, New York
| | - Anna Nowak-Wegrzyn
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York, and
- Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
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