A possible unexpected link: Could wheat elimination trigger food protein-induced enterocolitis syndrome in a celiac disease patient?

Food protein-induced enterocolitis syndrome after involuntary gluten transgression in celiac children: A new increasingly common complication?

Among the possible adverse reactions to gluten, celiac disease, non-celiac gluten sensitivity, and IgE-mediated wheat allergy have been classically described. A non-IgE-mediated reaction similar to food protein-induced enterocolitis syndrome (FPIES) after inadvertent gluten ingestion in a celiac patient was recently reported. We present three children affected by celiac disease with exquisite control, including appropriate adherence to an exclusion diet, who suffered a severe adverse food reaction after unappreciated outdoor ingestion of gluten, meeting the criteria for a definitive diagnosis of FPIES. The strict and prolonged exclusion of gluten from the diet is postulated as the possible trigger for this serious entity after an involuntary transgression. Although the first published cases are recent, we might be witnessing an increase in the frequency of presentation. Therefore, we believe emergency services must be alert to the possibility of diagnosis of FPIES in celiac patients due to involuntary transgressions. The determination of gluten glycoimmunopeptides in urine or stool samples may be useful for certifying the inadvertent consumption of wheat as the cause of FPIES.

Wheat-Triggered Food Protein-Induced Enterocolitis Syndrome in Celiac Children on Gluten-Free Diet: A New Clinical Association

INTRODUCTION

The association between food protein-induced enterocolitis syndrome (FPIES) and wheat ingestion in children with celiac disease is unknown at this time.

METHODS

We present seven cases of children with celiac disease who presented with symptoms of wheat-triggered acute FPIES (a-FPIES). An oral food challenge (OFC) with wheat allergen followed by 4 h of observation was performed. Activation of innate system cells was measured at baseline (T0), during symptoms (Ts), and 4 h after symptom onset (Ts + 4). A panel of human inflammatory cytokines was also performed.

RESULTS

All patients reacted to the first allergen dose. Three patients experienced a decrease of 30 mm Hg in systolic blood pressure and tachycardia and required hemodynamic resuscitation. Neutrophilia and a decrease in eosinophil count were evident at 4 h after symptom onset. At 4 h after symptom onset, cytokines (IL-6 and IL-8, and to a lesser degree, IL-10) were elevated.

CONCLUSION

In a small sample of celiac patients with wheat exposure in an OFC, symptoms and acute immunological changes in serum inflammatory cytokine profile were consistent with a-FPIES.