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Landaas VØ, Skjerven HO, Carlsen KCL, Størdal K, Håland G. Home-Based Double-Blind, Placebo-Controlled Challenges for Diagnosis of Delayed Gluten/Milk Hypersensitivity in Children. J Allergy Clin Immunol Pract 2024; 12:652-659.e5. [PMID: 38154555 DOI: 10.1016/j.jaip.2023.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Delayed hypersensitivity to gluten and milk protein is frequently reported but may be difficult to diagnose. OBJECTIVE We aimed to explore if a method of home-based double-blind placebo-controlled food challenges (H-FC) can identify and reduce unnecessary elimination diets in children. METHODS We included 73 of 92 children aged 1 to 17 years referred to a tertiary allergy clinic from 2011 to 2021 due to self-reported, delayed symptoms to gluten or milk. The children were randomized to H-FC, receiving gluten/milk protein or placebo for 5 to 7 days in a double-blind crossover manner, separated by 3 washout weeks. Patients/parents recorded symptoms using standardized forms. Two crossover periods were used from 2011 to 2016 and 3 periods from 2017 to 2021. A positive challenge required significantly more symptoms during the active period versus the placebo period. After the challenge, reintroduction of milk/gluten was assessed by a follow-up interview. The primary outcome was the proportion of children with a positive challenge. RESULTS The children, with a mean age of 11 years, had followed a strict gluten-free or milk-protein-free diet for a median duration of 24 months (range: 3-180 months). A positive challenge was observed in 18 of 73 children (25%), more often using 2 (35%) compared with 3 challenge periods (12%). At follow-up, 44 of 55 (80%) children with a negative challenge had successfully reintroduced milk/gluten. CONCLUSIONS H-FC may be an effective method in avoiding unnecessary elimination diets in children. Only 25% of the challenges were positive, and 80% of the children with negative challenges succeeded in reintroducing the food. Three challenge periods may be necessary to reduce false-positive outcomes.
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Affiliation(s)
- Vibeke Østberg Landaas
- Division of Child and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Håvard Ove Skjerven
- Division of Child and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Karin C Lødrup Carlsen
- Division of Child and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ketil Størdal
- Division of Child and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir Håland
- Division of Child and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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Ahuja K, Issa CJ, Nedorost ST, Lio PA. Is Food-Triggered Atopic Dermatitis a Form of Systemic Contact Dermatitis? Clin Rev Allergy Immunol 2024; 66:1-13. [PMID: 38285165 DOI: 10.1007/s12016-023-08977-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/30/2024]
Abstract
Food allergy in atopic dermatitis is mediated by complex immune interactions between genetics, diet, environment, and the microbiome. When contact between inflamed skin and food antigens occurs, contact hypersensitivity can develop. Consequently, systemic contact dermatitis (SCD) can occur after ingestion of allergenic foods or food additives in the setting of a Th2 response with CLA-positive T cells, triggering dermatitis where skin resident memory lymphocytes reside. This phenomenon explains food-triggered dermatitis. Atopy patch tests (APTs) detect sensitization to food proteins responsible for SCD, which in turn can be confirmed by oral food challenge with delayed interpretation. We summarize the literature on using APTs to identify foods for oral challenge with dermatitis as an outcome. In dermatitis patients at risk for Th2 skewing based on a history of childhood-onset flexural dermatitis, shared decision-making should include a discussion of identifying and avoiding food and food additive triggers, as well as identifying and avoiding all contact allergens, prior to initiation of systemic therapy for dermatitis.
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Affiliation(s)
- Kripa Ahuja
- Eastern Virginia Medical School, Norfolk, USA.
| | - Christopher J Issa
- Oakland University William Beaumont School of Medicine, Rochester, USA
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan T Nedorost
- Dermatologists of the Central States, Case Western Reserve University, Columbus, OH, USA
| | - Peter A Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Blumchen K, Kleinheinz A, Klimek L, Beyer K, Anagnostou A, Vogelberg C, Butovas S, Ryan R, Norval D, Zeitler S, Du Toit G. Post hoc analysis examining symptom severity reduction and symptom absence during food challenges in individuals who underwent oral immunotherapy for peanut allergy: results from three trials. Allergy Asthma Clin Immunol 2023; 19:21. [PMID: 36915184 DOI: 10.1186/s13223-023-00757-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/02/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Peanut allergy and its current management, involving peanut avoidance and use of rescue medication during instances of accidental exposure, are burdensome to patients and their caregivers and can be a source of stress, uncertainty, and restriction. Physicians may also be frustrated with a lack of effective and safe treatments other than avoidance in the current management of peanut allergy. Efficacy, determined using double-blind, placebo-controlled food challenges (DBPCFCs), of oral immunotherapy with peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; Palforzia®) was demonstrated versus placebo in children and adolescents aged 4 to 17 years in multiple phase 3 trials; continued benefit of PTAH was shown in a follow-on trial. The DBPCFC is a reproducible, rigorous, and clinically meaningful assessment accepted by regulatory authorities to evaluate the level of tolerance as an endpoint for accidental exposures to peanut in real life. It also provides useful clinical and patient-relevant information, including the amount of peanut protein an individual with peanut allergy can consume without experiencing dose-limiting symptoms, severity of symptoms, and organs affected upon ingestion of peanut protein. We explored symptoms of peanut exposure during DBPCFCs from phase 3 and follow-on trials of PTAH to further characterize treatment efficacy from a perspective relevant to patients, caregivers, and clinicians. METHODS Symptom data recorded during screening and/or exit DBPCFCs from participants aged 4 to 17 years receiving PTAH or placebo were examined post hoc across three PTAH trials (PALISADE [ARC003], ARC004 [PALISADE follow-on], and ARTEMIS [ARC010]). The maximum peanut protein administered as a single dose during DBPCFCs was 1000 mg (PALISADE and ARTEMIS) and 2000 mg (ARC004). Symptoms were classified by system organ class (SOC) and maximum severity. Endpoints were changes in symptom severity and freedom from symptoms (ie, asymptomatic) during DBPCFC. Relative risk (RR) was calculated for symptom severity by SOC and freedom from symptoms between groups; descriptive statistics were used to summarize all other data. RESULTS The risk of any respiratory (RR 0.42 [0.30-0.60], P < 0.0001), gastrointestinal (RR 0.34 [0.26-0.44], P < 0.0001), cardiovascular/neurological (RR 0.17 [0.08-0.39], P < 0.001), or dermatological (RR 0.33 [0.22-0.50], P < 0.0001) symptoms was significantly lower in participants treated with PTAH versus placebo upon exposure to peanut at the end of the PALISADE trial (ie, exit DBPCFC). Compared with placebo-treated participants (23.4%), the majority (76.3%) of PTAH-treated participants had no symptoms at the exit DBPCFC when tested at the peanut protein dose not tolerated (ie, reactive dose) during the screening DBPCFC. Significantly higher proportions of PTAH-treated participants were asymptomatic at doses ≤ 100 mg in the exit DBPCFC compared with placebo-treated participants (PALISADE: 69.35% vs 12.10%, RR 5.73 [95% confidence interval (CI) 3.55-9.26]; P < 0.0001; ARTEMIS: 67.42% vs 13.95%, RR 4.83 [95% CI 2.28-10.25]; P < 0.0001); findings were similar at peanut protein doses ≤ 1000 mg (PALISADE: RR 15.56 [95% CI 5.05-47.94]; P < 0.0001; ARTEMIS: RR 34.74 [95% CI 2.19-551.03]; P < 0.0001). In ARC004, as the period of PTAH maintenance became longer, greater proportions of participants were asymptomatic at doses of peanut protein ≤ 1000 mg in the exit DBPCFC (from 37.63% after ~ 6 months of maintenance treatment [exit DBPCFC of PALISADE] to 45.54% after ~ 13 months and 58.06% after ~ 20 months of overall PTAH maintenance treatment). CONCLUSIONS PTAH significantly reduced symptom severity due to exposure to peanut, which is clinically relevant. When exposed to peanut, participants with peanut allergy treated with PTAH rarely had moderate or severe respiratory or cardiovascular/neurological symptoms. Oral immunotherapy with PTAH appears to reduce frequency and severity of allergic reactions in individuals with peanut allergy after accidental exposure to peanut and may enable them and their families to have an improved quality of life. Trial registration ClinicalTrials.gov, NCT02635776, registered 17 December 2015, https://clinicaltrials.gov/ct2/show/NCT02635776?term=AR101&draw=2&rank=7 ; ClinicalTrials.gov, NCT02993107, registered 08 December 2016, https://clinicaltrials.gov/ct2/show/NCT02993107?term=AR101&draw=2&rank=6 ; ClinicalTrials.gov, NCT03201003, registered 22 June 2017, https://clinicaltrials.gov/ct2/show/NCT03201003 ? term = AR101&draw = 2&rank = 9.
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La Vieille S, Hourihane JO, Baumert JL. Precautionary Allergen Labeling: What Advice Is Available for Health Care Professionals, Allergists, and Allergic Consumers? J Allergy Clin Immunol Pract 2023; 11:977-985. [PMID: 36682535 DOI: 10.1016/j.jaip.2022.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023]
Abstract
In most countries, the use of precautionary allergen labeling (PAL) is not governed by regulation. PAL was initially identified as a judicious risk management measure to address instances of "unavoidable" cross-contact with priority food allergens during food processing. However, PAL has gradually been devalued in part due to overuse and inconsistent application by the food industry. Currently, most food products do not contain detectable allergen residue or contain only low concentrations of residue of the allergens declared using PAL; however, occasionally, high concentrations of allergen residue are reported, rendering it an ineffective risk communication tool for allergic consumers. In this context, several reasons exist that make the consumption of products bearing a PAL statement not advisable for people with food allergies. The main reason is that the risk is generally not correlated with the statement used by manufacturers. Because of the increased use of PAL on prepackaged food products, and to maximize food choices for allergic individuals, health care professionals increasingly advise some patients considered to be "not highly allergic" to consume products bearing a PAL statement. This article explains why the consumption of products with PAL is not advisable without having a full clinical evaluation and knowledge that an allergen risk assessment has been conducted. It also discusses the perspectives for a better use of PAL on the basis of the recent Food and Agricultural Organization/World Health Organization recommendations on food allergens.
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Affiliation(s)
- Sébastien La Vieille
- Food Directorate, Health Canada, Ottawa, ON, Canada; Food Science Department, Laval University, Québec, QC, Canada.
| | | | - Joseph L Baumert
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Neb
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Wassmann-Otto A, Heratizadeh A, Wichmann K, Werfel T. Microarray Analysis Confirms ImmunoCAP-Fluorescence Enzyme Immunoassay Results on Specific IgE in Patients with Atopic Dermatitis and Suspected Birch Pollen-Related Food Allergy. Int Arch Allergy Immunol 2022; 183:814-823. [PMID: 35378542 PMCID: PMC9533431 DOI: 10.1159/000522525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background Previous studies demonstrated that birch pollen-related foods can cause late eczematous responses in birch pollen-sensitized patients with atopic dermatitis (AD). However, suitable markers to predict birch pollen-related food allergy in patients with AD are still lacking. Objective We evaluated the correlation of the results from ImmunoCAP® fluorescence enzyme immunoassay (FEIA) singleplex and ImmunoCAP® immuno solid-phase allergen chip (ISAC) multiplex system in AD patients and investigated the diagnostic validity of allergen microarray analysis, measuring specific IgE (sIgE) with ImmunoCAP® ISAC to predict birch pollen-related food allergy in patients with AD. Methods A total of 19 children and adults with AD, existing IgE-mediated birch pollen sensitization, and suspected birch pollen-related food allergy underwent a double-blind placebo-controlled food challenge (DBPCFC) in the clinical routine. Total and sIgE levels to birch pollen, Bet v 1, Bet v 2, and birch pollen-related foods (apple, carrot, celery, and hazelnut) were determined prior to the DBPCFC by ImmunoCAP®-FEIA. Additionally, allergen microarray ImmunoCAP® ISAC analysis was performed. Data were analyzed retrospectively. Results Twelve out of 19 patients (63% responders) experienced an allergic reaction upon DBPCFC. Overall, 7 patients (37%) developed a significant deterioration of AD with a median increase of 12.4 points in the scoring of atopic dermatitis (SCORAD) index (range 10.0–15.7). Oral allergy syndrome was the predominant immediate-type symptom (n = 11/12 responders). There were no differences in sensitization frequencies regarding allergens of the pathogenesis-related protein family 10 between responders and non-responders. In all patients, correlation of IgE levels determined with ImmunoCAP® ISAC and ImmunoCAP®-FEIA, respectively, was significant with high correlation coefficients regarding birch pollen allergen extract, rBet v 1, and rBet v 2 (r<sub>s</sub> > 0.8, p < 0.001) and lower but also significant correlation coefficients regarding food allergens (r<sub>s</sub> < 0.8, p < 0.05–<0.001). Conclusion ImmunoCAP® ISAC microarray allows displaying a differentiated sensitization profile in birch pollen-sensitized patients with AD. However, IgE-mediated sensitization against birch pollen-related allergens revealed by the allergen multiplex system does not predict late eczematous reactions upon DBPCFC with birch pollen-related foods.
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Affiliation(s)
- Anja Wassmann-Otto
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Annice Heratizadeh
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Katja Wichmann
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - Thomas Werfel
- Division of Immunodermatology and Allergy Research, Department of Dermatology and Allergy, Hannover Medical School, Hannover, Germany
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Abstract
Population growth, even if coupled to economic growth, and resources, were already on a collision course, especially in Africa. The 2019 United Nations World Water Development Report provided a dramatic status of world water, however without questioning the main drivers of an imminent water crisis, that were unbounded, unequal, economic, and population growth, within the context of reducing resources in a finite world. Despite the report was a small step forward in awareness, still, it was not proposing satisfactory remedies. With business-as-usual, without acting on the drivers of water scarcity, regional water crises were inevitable in the next 3 decades, starting from Africa. Constrained by political, financial, and energy burdens, the technological improvements that have helped humanity to deal with the increased demand for water, food, and energy over the last 70 years, were likely not enough to avoid the water crisis. On top of forecast is the Covid19 pandemic. Coronavirus cases are (August 4, 2020) 18,446,065 and fatalities are 697,202 worldwide, and still growing. The containment measures enforced for Covid19 infection following the examples in the United Kingdom have already produced significant damage to the world economy. This will limit social expenditures in general, and the expenditures for the water issue in particular. The water crisis will consequently become worse in the next months, with consequences still difficult to predict. This will be true especially for Africa, where the main problem has always been poverty. There is the opportunity of significant health, food, and water crisis, especially in Africa. While the concepts of washing hands and social distancing that are difficult to apply haven't produce so far major issues with the Covid19 outbreak in Africa, borders closure, restrictions on movement, and more poverty will translate in a lack of food and water potentially much more worrying than the virus spreading.
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Affiliation(s)
- Alberto Boretti
- Prince Mohammad Bin Fahd University, Al Khobar, Saudi Arabia
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Nowak-Wegrzyn A, Berin MC, Mehr S. Food Protein-Induced Enterocolitis Syndrome. J Allergy Clin Immunol Pract 2021; 8:24-35. [PMID: 31950904 DOI: 10.1016/j.jaip.2019.08.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/14/2019] [Accepted: 08/21/2019] [Indexed: 01/01/2023]
Abstract
Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that manifests with projectile, repetitive emesis that can be followed by diarrhea and may be accompanied by lethargy, hypotonia, hypothermia, hypotension, and metabolic derangements. FPIES usually starts in infancy although onset at older ages is being increasingly recognized. FPIES is not rare, with the cumulative incidence of FPIES in infants estimated to be 0.015% to 0.7%, whereas the population prevalence in the US infants was 0.51%. FPIES diagnosis is challenging and might be missed because of later (1-4 hours) onset of symptoms after food ingestion, lack of typical allergic skin and respiratory symptoms, and food triggers that are perceived to be hypoallergenic. Diagnosis is based on the recognition of symptoms because there are no biomarkers of FPIES. The pathophysiology remains obscure although activation of the innate immune compartment has been detected. Management relies of avoidance of food triggers, treatment of accidental exposures, and periodic re-evaluations with supervised oral food challenges to monitor for resolution. There are no strategies to accelerate development of tolerance in FPIES. Here we review the most important current concepts in epidemiology, pathophysiology, diagnosis, and management of FPIES.
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Affiliation(s)
- Anna Nowak-Wegrzyn
- Department of Pediatrics, New York University Langone Health, New York, NY; Department of Pediatrics, Gastroenterology and Nutrition, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland.
| | - M Cecilia Berin
- Precision Immunology Institute, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sam Mehr
- Department of Allergy and Immunology, Royal Children's Hospital, Melbourne, VIC, Australia
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Xepapadaki P, Christopoulou G, Stavroulakis G, Freidl R, Linhart B, Zuidmeer L, Lakoumentas J, van Ree R, Valenta R, Papadopoulos NG. Natural History of IgE-Mediated Fish Allergy in Children. J Allergy Clin Immunol Pract 2021; 9:3147-3156.e5. [PMID: 33866031 DOI: 10.1016/j.jaip.2021.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Fish allergy is not uncommon, especially in countries with high fish consumption, it can frequently be severe and may affect dietetic and lifestyle choices. Nevertheless, data on its clinical course and natural history are scarce. OBJECTIVE To describe the natural history of immunoglobulin E-mediated fish allergy and the potential differential reactivity to various fish species and identify prognostic markers in children with confirmed disease. METHODS Clinical history, specific immunoglobulin E, and skin prick tests to various fish were recorded in 126 children with confirmed immunoglobulin E-mediated fish allergy. Immunoglobulin E reactivity was also evaluated by immunoblotting. Eligible participants proceeded to a series of food challenges to tuna, swordfish, and codfish. In total, 234 challenges were performed. RESULTS Fifty-eight children (9.7 ± 3.9 years) were included in the analysis. Age at first reaction was 0.5 to 5 years (median, 1.3 years). Thirteen children (22%) tolerated all fish tested, including cod, 1 to 14 years (mean, 8.2 ± 4.2 years) following their first reported reaction. Complete fish tolerance increased with age, ranging from 3.4% in preschool children to over 45% in adolescents (95% confidence interval, 26.3%-79.7%). Most children were able to tolerate swordfish (94%) and tuna (95%). Prechallenge specific immunoglobulin E to cod greater than 4.87 kUA/L was the best positive predictive marker for fish allergy persistence (94%), followed by skin prick tests to sardine greater than 6.5 mm (92%). CONCLUSIONS A considerable proportion of fish-allergic children develop tolerance around adolescence. Most fish-allergic children can consume tuna and swordfish, which, thus, provide safe alternatives for a balanced diet.
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Affiliation(s)
- Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia Christopoulou
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - George Stavroulakis
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Raphaela Freidl
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
| | - Birgit Linhart
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria
| | - Laurian Zuidmeer
- Department of Experimental Immunology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - John Lakoumentas
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Ronald van Ree
- Department of Experimental Immunology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands; Department of Otorhinolaryngology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Rudolf Valenta
- Department of Pathophysiology and Allergy Research, Medical University of Vienna, Vienna, Austria; NRC Institute of Immunology FMBA of Russia; Laboratory for Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First, Moscow State Medical University, Moscow, Russia; Laboratory for Immunopathology, Department of Clinical Immunology and Allergy, Sechenov First Moscow State Medical University, Moscow, Russia; Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece; Division of Infection, Immunity, and Respiratory Medicine, The University of Manchester, Manchester, United Kingdom.
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Kansen HM, van Erp FC, Knulst AC, Ehlers AM, Lyons SA, Knol EF, Meijer Y, Otten HG, van der Ent CK, Le TM. Accurate Prediction of Peanut Allergy in One-Third of Adults Using a Validated Ara h 2 Cutoff. J Allergy Clin Immunol Pract 2020; 9:1667-1674.e3. [PMID: 33248282 DOI: 10.1016/j.jaip.2020.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The diagnostic value of peanut components is extensively studied in children, but to a lesser extent in adults with suspected peanut allergy. The use of peanut components in daily practice may reduce the need for double-blind placebo-controlled food challenges (DBPCFCs); however, validation studies are currently lacking. OBJECTIVE To evaluate the diagnostic value of (combined) peanut components and validate a previously found Ara h 2 cutoff level with 100% positive predictive value (PPV) in adults with suspected peanut allergy. METHODS Adults who underwent a peanut DBPCFC were included: 84 patients from a previous study (2002-2012) and 70 new patients (2012-2019). Specific IgE (sIgE) to peanut extract, Ara h 1, 2, 3, 6, and 8 was measured using ImmunoCAP. Diagnostic value was assessed with an area under the curve (AUC) analysis. RESULTS In total, 95 (62%) patients were peanut allergic. sIgE to Ara h 2 and Ara h 6 were the best predictors with an AUC (95% confidence interval) of 0.85 (0.79-0.91) and 0.85 (0.79-0.92), respectively. The Ara h 2 cutoff level with 100% PPV (≥1.75 kUA/L) was validated in the 70 new patients. Thirty percent of all included patients could be classified correctly as peanut allergic using this validated cutoff level. CONCLUSION sIgE to Ara h 2 and Ara h 6 have equally high discriminative ability. Peanut allergy can be predicted accurately in one-third of adults using a validated cutoff level of sIgE to Ara h 2.
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Affiliation(s)
- Hannah M Kansen
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands; Department of Pediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, Utrecht, the Netherlands.
| | - Francine C van Erp
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - André C Knulst
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands; Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Anna M Ehlers
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands; Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Sarah A Lyons
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Edward F Knol
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands; Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yolanda Meijer
- Department of Pediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Henny G Otten
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Cornelis K van der Ent
- Department of Pediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Thuy-My Le
- Department of Dermatology and Allergology, University Medical Center, Utrecht University, Utrecht, the Netherlands; Center of Translational Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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Tye-Din JA, Daveson AJM, Goldstein KE, Hand HL, Neff KM, Goel G, Williams LJ, Truitt KE, Anderson RP. Patient factors influencing acute gluten reactions and cytokine release in treated coeliac disease. BMC Med 2020; 18:362. [PMID: 33239013 PMCID: PMC7690153 DOI: 10.1186/s12916-020-01828-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/27/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with coeliac disease (CD) commonly report a variety of adverse symptoms to gluten, but descriptions of the symptomatic response in the literature may have been confounded by the presence of food components such as fermentable carbohydrates (FODMAPs) causing symptoms of irritable bowel syndrome independent of gluten. In recent unmasked and masked low FODMAP gluten challenge studies in small groups of treated CD patients, nausea and vomiting were shown to be the key symptoms associated with serum interleukin (IL)-2 release. Our objective was to utilise a large and diverse cohort of people with CD undertaking a standardised gluten food challenge to characterise the demographic, genetic and clinical factors influencing the severity and timing of acute gluten reactions and IL-2 production. METHODS A total of 295 adults treated for CD were observed for 6 h after an unmasked food challenge consisting of 10 g vital wheat gluten (low in FODMAPs) in 100 ml water. Assessments included patient-reported outcomes, serum IL-2 and adverse events. Responses were analysed according to patient characteristics, HLA-DQ genotype, duodenal histology and response to a second gluten challenge. RESULTS Peak symptom severity was at 3 h (median severity 5/10). Peak IL-2 was at 4 h (median 4 pg/ml, range undetectable to 1028 pg/ml). Older age, older age at diagnosis, HLA-DQ2.5 positivity and homozygosity for HLA-DQB1*02 were each significantly associated with IL-2 elevations after gluten. Patients positive for HLA-DQ2.5, DQ8, DQ2.2 or DQ7 showed elevated IL-2 after gluten. Patient factors were not significantly associated with severity of digestive symptoms, but symptoms were correlated to one another and serum IL-2. Gluten challenge after 5 months caused more vomiting and higher IL-2 levels, but responses correlated with the first. CONCLUSIONS Gluten-induced symptoms and cytokine release is common in adults with treated CD. Age, genetics and previous response to gluten predict these acute reactions to gluten challenge. Structured symptom assessment and serum IL-2 after standardised gluten challenge may inform on patient diagnosis, the role of gluten in symptomatology and the need for adjunctive treatment. TRIAL REGISTRATION ClinicalTrials.gov , NCT03644069 Registered 21 May 2018.
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Affiliation(s)
- Jason A Tye-Din
- Immunology Division, The Walter and Eliza Hall Institute, Parkville, VIC, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, Australia.,Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - A James M Daveson
- Coral Sea Clinical Research Institute, Suite 7, 76 Willetts Road, North Mackay, QLD, 4740, Australia.,University of Queensland, Brisbane, QLD, Australia
| | | | | | | | | | | | | | - Robert P Anderson
- ImmusanT Inc., Cambridge, MA, USA. .,Wesley Medical Research, PO Box 499, Toowong, QLD, 4066, Australia.
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11
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Abstract
Food challenges are the criterion standard for establishing the presence or absence of food allergy. However, they remain underused because of their resource-intensive nature, inadequate reimbursement, and concern for the risk of anaphylaxis. Here, we review indications for performing food challenges, including scenarios of uncertain diagnosis, quality-of-life effects following food challenges, and the impact on office practice including coding and reimbursement issues. Demand for food challenges is likely to increase and allergists should be capable of providing this service to their patients when indicated.
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12
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Ballmer-Weber BK, Lidholm J, Lange L, Pascal M, Lang C, Gernert S, Lozano-Blasco J, Gräni N, Guillod C, Wangorsch A, Hanschmann KM, Pontoppidan B, Tjäder L, Bartra J, Vieths S. Allergen Recognition Patterns in Walnut Allergy Are Age Dependent and Correlate with the Severity of Allergic Reactions. J Allergy Clin Immunol Pract 2019; 7:1560-1567.e6. [PMID: 30708144 DOI: 10.1016/j.jaip.2019.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/19/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Walnut is an important elicitor of food allergy in children and adults with a high rate of severe reactions. Multicenter studies using a common clinical protocol and a comprehensive allergen are lacking. OBJECTIVE To investigate potential correlations between molecular sensitization patterns and clinical characteristics of walnut-allergic patients. METHODS A total of 91 walnut-allergic subjects and 24 tolerant controls from Switzerland, Germany, and Spain were included. Walnut allergy was established by food challenge in all but anaphylactic subjects. Specific IgE (sIgE) to walnut extract, rJug r 1 (2S albumin), rJug r 3 (nonspecific lipid transfer protein 1), nJug r 4 (11S globulin), rJug r 5 (PR-10 protein), 2 vicilin fractions, profiling, and cross-reactive carbohydrate determinant was determined by ImmunoCAP. A threshold of 0.10 kUA/L was used for positivity. RESULTS Sensitivity of sIgE to walnut extract was 87% and increased to 96% for the sum of all walnut components. sIgE to walnut extract and all walnut components, except rJug r 5, was significantly higher in patients younger than 14 years at inclusion. Stratification by age at onset of walnut allergy led to similar results. All patients younger than 14 years had severe reactions, whereas 38% of patients 14 years or older were mild reactors. Severe reactors (n = 70) had higher sIgE levels than did mild reactors (n = 21) to walnut extract (P < .0001), rJug r 1 (P < .0001), nJug r 4 (P = .0003), and both vicilin fractions (P < .0001), but not to Jug r 3 and Jug r 5. CONCLUSIONS Sensitization to walnut storage proteins is acquired in childhood and correlates with severe reactions. sIgE levels to storage proteins Jug r 1 and Jug r 4 and vicilin fractions, but not to nonspecific lipid transfer protein and PR-10 proteins, correlate with systemic reactions to walnut.
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Affiliation(s)
- Barbara K Ballmer-Weber
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland; Clinic for Dermatology and Allergology, Kantonsspital St Gallen, Switzerland.
| | | | - Lars Lange
- Department of Pediatrics, St Marien Hospital, Bonn, Germany
| | - Mariona Pascal
- Servei d'Immunologia, CDB, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Claudia Lang
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | | | - Jaime Lozano-Blasco
- Department of Pediatric Allergy and Clinical Immunology, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat (Barcelona), Barcelona, Spain
| | - Nora Gräni
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Caroline Guillod
- Allergy Unit, Department of Dermatology, University Hospital, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | | | | | | | | | - Joan Bartra
- Secció d'Allèrgia, Servei de Pneumologia, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain
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13
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Kalic T, Morel-Codreanu F, Radauer C, Ruethers T, Taki AC, Swoboda I, Hilger C, Hoffmann-Sommergruber K, Ollert M, Hafner C, Lopata AL, Morisset M, Breiteneder H, Kuehn A. Patients Allergic to Fish Tolerate Ray Based on the Low Allergenicity of Its Parvalbumin. J Allergy Clin Immunol Pract 2019; 7:500-508.e11. [PMID: 30471362 DOI: 10.1016/j.jaip.2018.11.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/13/2018] [Accepted: 11/09/2018] [Indexed: 11/21/2022]
Abstract
Background Clinical reactions to bony fish species are common in patients with allergy to fish and are caused by parvalbumins of the β-lineage. Cartilaginous fish such as rays and sharks contain mainly α-parvalbumins and their allergenicity is not well understood. Objective To investigate the allergenicity of cartilaginous fish and their α-parvalbumins in individuals allergic to bony fish. Methods Sensitization to cod, salmon, and ray among patients allergic to cod, salmon, or both (n = 18) was explored by prick-to-prick testing. Clinical reactivity to ray was assessed in 11 patients by food challenges or clinical workup. IgE-binding to β-parvalbumins (cod, carp, salmon, barramundi, tilapia) and α-parvalbumins (ray, shark) was determined by IgE-ELISA. Basophil activation tests and skin prick tests were performed with β-parvalbumins from cod, carp, and salmon and α-parvalbumins from ray and shark. Results Tolerance of ray was observed in 10 of 11 patients. Prick-to-prick test reactions to ray were markedly lower than to bony fish (median wheal diameter 2 mm with ray vs 11 mm with cod and salmon). IgE to α-parvalbumins was lower (median, 0.1 kU/L for ray and shark) than to β-parvalbumins (median, ≥1.65 kU/L). Furthermore, α-parvalbumins demonstrated a significantly reduced basophil activation capacity compared with β-parvalbumins (eg, ray vs cod, P < .001; n = 18). Skin prick test further demonstrated lower reactivity to α-parvalbumins compared with β-parvalbumins. Conclusions Most patients allergic to bony fish tolerated ray, a cartilaginous fish, because of low allergenicity of its α-parvalbumin. A careful clinical workup and in vitro IgE-testing for cartilaginous fish will improve patient management and may introduce an alternative to bony fish into patients’ diet.
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14
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Abstract
PURPOSE OF REVIEW This review incorporates findings from studies of oral food challenges (OFC) over the last decade and highlights the latest innovations and understanding of the procedure. RECENT FINDINGS PRACTALL guidelines are widely used in OFC research, but there is still no international consensus on the OFC protocol in clinical practice. Guidelines for performing OFC in clinical practice have been updated to include oral food challenges for infants. There have been advances in predictive models for outcomes and severity of reaction during OFC that take into account multiple clinical data as well as newer laboratory modalities. Low-dose OFC and eliciting threshold dose determination are being examined for additional diagnostic and therapeutic use in the management of food allergy. Quality-of-life considerations have also been reviewed, as well as post-OFC assessment and care. The OFC remains an important diagnostic tool in the management of food allergy and in clinical research. Advances in the field should improve safety and broaden the clinical applications of this essential procedure.
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15
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Makita E, Yanagida N, Sato S, Asaumi T, Ebisawa M. Increased ratio of pollock roe-specific IgE to salmon roe-specific IgE levels is associated with a positive reaction to cooked pollock roe oral food challenge. Allergol Int 2018; 67:364-370. [PMID: 29242143 DOI: 10.1016/j.alit.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Anaphylaxis and immediate-type fish roe allergies have been reported worldwide, and, in Japan, fish roe is the sixth most common food allergen. No oral food challenges (OFCs) have used pollock roe (PR), which is reported to have high cross-reactivity with salmon roe (SR). Therefore, we administered an OFC using cooked PR to evaluate PR- and SR-specific immunoglobulin E (IgE) levels and allergic reactions in patients with PR sensitivity. METHODS This retrospective study evaluating patient characteristics and responses to OFCs was conducted with 10-20 g of cooked PR, between April 2006 and November 2016. RESULTS We assessed 51 patients (median age: 6.8 years). All had PR sensitization, 6 (12%) with a history of immediate reactions to PR, and 18 (35%) of immediate reactions to SR. Median PR-specific and SR-specific IgE values were 3.4 kUA/L and 9.9 kUA/L, respectively. Seven patients (14%) had a positive OFC. There was no anaphylaxis. Induced symptoms were mild and included localized urticaria, throat pruritus, intermittent cough, and mild abdominal pain. We treated one patient with mild abdominal pain with oral antihistamines. There were no significant differences in history of immediate reaction to PR and PR-specific IgE titers between OFC-positive and OFC-negative patients, although significant differences were found for PR-specific IgE titers adjusted for SR-specific IgE (p = 0.025) and PR-specific IgE/SR-specific IgE ratio (p = 0.009). CONCLUSIONS Increased PR-specific IgE/SR-specific IgE ratio or PR-specific IgE levels adjusted for SR-specific IgE levels were risk factors for OFC positivity.
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Affiliation(s)
- Eishi Makita
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan
| | - Tomoyuki Asaumi
- Department of Pediatrics, Sagamihara National Hospital, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Kanagawa, Japan.
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16
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Srisuwatchari W, Vichyanond P. Oral food challenges: result of a 16-year experience at a major teaching hospital in Thailand. Asia Pac Allergy 2018; 8:e21. [PMID: 29732297 PMCID: PMC5931928 DOI: 10.5415/apallergy.2018.8.e21] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 04/25/2018] [Indexed: 01/22/2023] Open
Abstract
Background Prevalence of food allergy is increasing all over the world including in Asia. Diagnosis of food allergy in Asia is usually made after family complaints or by elimination and/or reintroduction foods. This could lead to an inaccurate diagnosis and to incorrect information on epidemiology of food allergy. We, herein, reported results of a 16-year experience (1996–2012) of oral food challenge (OFC) performed in pediatric patients at a major teaching hospital in Thailand. Objective The major objectives of this report are to review types of foods selected for oral challenges, frequency of positive/negative challenges to these foods and the clinical reactions during challenges among these children. Methods Medical records of 206 children underwent OFC between 1996 and 2012 for various indications at the Allergy clinic of Pediatric Department, Siriraj Hospital, Mahidol University (age range, 4 months to 17 years) were retrospectively reviewed. Data including clinical data, skin prick test results and specific IgE levels were analyzed with respect to challenge results (positive/negative). During the period of the study, 2 separate investigations on shrimp allergy and wheat allergy were conducted. Results Sixty of 206 children (29%) had positive OFC, whereas 84 out of 306 OFC (27.5%) were positive. The most common food giving positive challenges in this study was shrimp (40%). Among children less than 3 years of age, the most common food with positive challenge was wheat (70%) whereas among children 3 years of age or older, shellfish was the most common food (42%). Cutaneous reactions were the most common reactions observed. Conclusion Only 1 out of 3 children underwent OFC in this study had positive challenges. Shrimp was the most common food causing challenge in this study especially among children older than 3 years of age. Wheat has become another leading food besides cow's milk and egg in causing positive OFC in younger children in Thailand.
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Affiliation(s)
- Witchaya Srisuwatchari
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pakit Vichyanond
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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17
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Abstract
Food allergies are common and seem to be increasing in prevalence. Preventive measures have become far more evident in the public arena (schools, camps, sports venues, and so forth). Evaluation and management of food allergies has evolved such that primary care practitioners may choose to provide initial diagnostic and treatment care or refer to allergists for similar care. Food allergies, once considered incurable, are now being diminished in intensity by new strategies.
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Affiliation(s)
- Samuel N Grief
- Department of Family Medicine, University of Illinois at Chicago, 1919 West Taylor Street, Suite 143, Chicago, IL 60612, USA.
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18
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Van Erp FC, Knulst AC, Kok IL, van Velzen MF, van der Ent CK, Meijer Y. Usefulness of open mixed nut challenges to exclude tree nut allergy in children. Clin Transl Allergy 2015; 5:19. [PMID: 26034579 PMCID: PMC4450451 DOI: 10.1186/s13601-015-0062-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/04/2015] [Indexed: 01/08/2023] Open
Abstract
Background To minimize the risk of accidental reactions, atopic children with multiple sensitizations to tree nuts are advised to avoid all nuts. Multiple food challenges would be needed to confirm the clinical relevance, but are too burdensome to be practical. The usefulness of open mixed nut challenges in terms of safety, reactions during challenge, tolerance of the challenge material, effect on the elimination diet and satisfaction of the parents was evaluated. Findings Open mixed nut challenges were performed in 19 children with a previous negative hazelnut challenge and long term elimination diet for tree nuts. Challenges were negative in 13 (68 %) children, in four (21 %) children (non-severe) allergic symptoms were observed. The challenges were well accepted, safe and efficient. We were able to avoid multiple nut challenges in 15 (79 %) children. Conclusions Open mixed nut challenge can efficiently exclude multiple tree nut allergies in children with a lifelong nut free diet and low suspicion of clinical allergy.
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Affiliation(s)
- Francine C Van Erp
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, 3508 AB, P O Box 85090, Utrecht, The Netherlands
| | - André C Knulst
- Department of (Paediatric) Dermatology and Immunlogy, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Irene L Kok
- Department of Dietetics, Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maartje F van Velzen
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, 3508 AB, P O Box 85090, Utrecht, The Netherlands
| | - Cornelis K van der Ent
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, 3508 AB, P O Box 85090, Utrecht, The Netherlands
| | - Yolanda Meijer
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, 3508 AB, P O Box 85090, Utrecht, The Netherlands
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19
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van Erp FC, Knulst AC, Meijer Y, Gabriele C, van der Ent CK. Standardized food challenges are subject to variability in interpretation of clinical symptoms. Clin Transl Allergy 2014; 4:43. [PMID: 25493173 PMCID: PMC4260179 DOI: 10.1186/s13601-014-0043-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 11/12/2014] [Indexed: 11/10/2022] Open
Abstract
Background Food challenge tests are the gold standard in diagnosing food allergy. Guidelines provide scoring systems to classify symptoms during challenge and typically recommend that challenges are considered positive when objective symptoms occur. However, currently no standard criteria for the definition of a positive challenge outcome exists and interpretation of food challenges mainly depends on clinical judgment. This study aims to assess inter- and intra-observer variability in outcomes of routinely performed peanut challenges in children. Methods All complete food challenge score sheets of double blind placebo controlled peanut challenges performed in 2008-2010 in an academic hospital were included. Score sheets were reassessed independently by three clinical experts including double reassessment in a subset of score sheets. Inter- and intra-observer variability was evaluated using kappa statistics. Results We included 191 food challenge score sheets. Inter-observer agreement on overall challenge outcome was moderate (κ = 0.59-0.65) and was fair (κ = 0.31-0.46) on challenges with symptoms. Intra-observer agreement on overall challenge outcome was good (κ = 0.63-0.77) but was moderate (κ = 0.50-0.60) on challenges with symptoms. Subjective symptoms (oral symptoms, abdominal complaints, food aversion) were significantly associated with disagreement between observers. Conclusions We demonstrate that, despite strict adherence to guidelines, there is a considerable amount of variability in reassessment of symptoms recorded on food challenges sheets between and within well trained clinicians, especially when subjective symptoms occur.
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Affiliation(s)
- Francine C van Erp
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, P O Box 85090, 3508 AB Utrecht, The Netherlands
| | - André C Knulst
- Department of (Paediatric) Dermatology and Allergology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Yolanda Meijer
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, P O Box 85090, 3508 AB Utrecht, The Netherlands
| | - Carmelo Gabriele
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, P O Box 85090, 3508 AB Utrecht, The Netherlands
| | - Cornelis K van der Ent
- Department of Paediatric Pulmonology and Allergology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, P O Box 85090, 3508 AB Utrecht, The Netherlands
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Merras-Salmio L, Salo S, Pelkonen AS, Kuitunen M, Aronen ET, Mäkelä MJ, Kolho KL. How mothers interact with children with suspected cow's milk allergy symptoms. Acta Paediatr 2013; 102:1180-5. [PMID: 24033685 DOI: 10.1111/apa.12408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 08/05/2013] [Accepted: 08/23/2013] [Indexed: 12/17/2022]
Abstract
AIM To characterize mother-child interaction in children with suspected gastrointestinally manifested cow's milk allergy (GI-CMA) and to explore factors associated with the parentally perceived symptoms. METHODS We invited a randomly selected group of children with suspected GI-CMA and their mothers to take part in a video recording of them playing together. The mother-child interaction was rated using the Emotional Availability Scales (EAS, 4th edition) and compared with national normative data. RESULTS Video recordings were conducted with 24 patients (15 girls and nine boys) with a median age of 10.1 months (range 2.1-20.5 months) undergoing a double-blind, placebo-controlled food challenge for cow's milk allergy. The EAS profile in the challenge negative group (17/24) was significantly different from the normative data. The scores for maternal sensitivity (p = 0.0049) and nonintrusiveness (p = 0.0192), together with child responsiveness (p = 0.0053) and involvement of mother (p = 0.0085), were all significantly lower when compared to the normative data. The dimensions of maternal nonhostility and structuring, as well as the scores of the challenge positive group, did not differ from the normative data. CONCLUSION Dysfunctional mother-child emotional interaction was frequent in young children with suspected GI-CMA ruled out by the cow's milk challenge. Appropriate psychological support should be considered.
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Affiliation(s)
- Laura Merras-Salmio
- Division of Pediatric Gastroenterology; Children's Hospital; Helsinki University Central Hospital; Helsinki Finland
| | - Saara Salo
- Department of Child Psychiatry; Helsinki University Central Hospital; Helsinki Finland
| | - Anna S Pelkonen
- Department of Allergology; Helsinki University Central Hospital; Helsinki Finland
| | - Mikael Kuitunen
- Department of Allergology; Helsinki University Central Hospital; Helsinki Finland
| | - Eeva T Aronen
- Department of Child Psychiatry; Children's Hospital; Helsinki University Central Hospital and University of Helsinki; Helsinki Finland
| | - Mika J Mäkelä
- Department of Allergology; Helsinki University Central Hospital; Helsinki Finland
| | - Kaija-Leena Kolho
- Division of Pediatric Gastroenterology; Children's Hospital; Helsinki University Central Hospital; Helsinki Finland
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Klemans RJB, Broekman HCHP, Knol EF, Bruijnzeel-Koomen CAFM, Otten HG, Pasmans SGMA, Knulst AC. Ara h 2 is the best predictor for peanut allergy in adults. J Allergy Clin Immunol Pract 2013; 1:632-8.e1. [PMID: 24565711 DOI: 10.1016/j.jaip.2013.07.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/08/2013] [Accepted: 07/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Specific IgE (sIgE) to Ara h 2 as a clinical predictor for peanut allergy in children has a diagnostic value comparable with a prediction model that contains sex, skin prick test (SPT), sIgE to peanut extract, and total IgE minus sIgE. In adults, the diagnostic value of peanut components has not yet been studied. OBJECTIVE To validate a pediatric prediction model in an adult population; to define the diagnostic value of sIgE to peanut components. METHODS Validation was performed by discrimination with an area under the receiver operating characteristic curve (AUC) and calibration with the Hosmer-Lemeshow test. The diagnostic value of the peanut components was assessed with the AUC. RESULTS Validation of the pediatric model in 94 adults showed poor discrimination (AUC, 0.64) but good calibration (P = .48); sIgE to Ara h 2 was the best diagnostic predictor (AUC, 0.76). By using a cutoff value with a 100% positive predictive value (≥1.75 kU/L), 28% of patients could be diagnosed with 100% accuracy. The highest negative predictive value was 63%. A higher negative predictive value could not be calculated for any other test. Although sIgE to Ara h 2 was significantly correlated with severity, it did not discriminate between mild and severe allergy in individual patients (AUC < 0.65). CONCLUSION sIgE to Ara h 2 has the best discriminative ability of all diagnostic tests. It can accurately diagnose peanut allergy in 28% of patients but cannot be used to exclude a peanut allergy in an adult population.
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Affiliation(s)
- Rob J B Klemans
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Henrike C H P Broekman
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Edward F Knol
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Henny G Otten
- Department of Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Suzanne G M A Pasmans
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands; Center for Paediatric Allergology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Pediatric Dermatology, Children's Hospital Erasmus University Medical Center-Sophia, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - André C Knulst
- Department of Dermatology and Allergology, University Medical Center Utrecht, Utrecht, The Netherlands
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