IIA&Food&Allergy&

Definition!of!Adverse!Reaction!to!Food:!
! Intolerance:! Reproducible!reaction!to!a!food/ingredient!which!occur!even!in!a!DBPCFC!
! ! ! ! ! DBPCFC:! Double!Blind!PlaceboTControlled!Food!Challenges!
! Allergy:! ! A!form!of!food!Intolerance!associated!with!Hypersensitive!Immune!response!
! Aversion/Phobia:!A!bodily!reaction!caused!by!food!which!can!Not!be!reproduced!by!DBPCFC!
Allergy!&!Heredity:! No!Parental!Hx:!! ! ! ! 13T18%!
! ! ! ! 1!Parent!with!Allergy:! ! ! ! 20T38%!
! ! ! ! Both!Parents!with!Allergy:! ! ! 40T58%!
! ! ! ! Both!Parents!with!identical!disease:! >70%!chance!child!will!have!same!disease!
! ! ! ! Onset!of!Allergy!earlier!in!Parents!with!FHx!of!Allergy!(80%!within!1!year)!
Eczema:! ! ! Has!been!proposed!as!Cutaneous!manifestation!of!a!Systemic!disorder,!
! ! ! ! ! also!give!rise!to!Asthma,!Food!Allergy!&!Allergic!Rhinitis!
Atopic!Dermatitis!(AD,!aka!Atopic!Eczema):!
! Natural!Hx:! 60%!Pt!develop!AD!by!1!year!of!age!
! ! ! ! 85%!Pt!develop!AD!by!age!5!
! ! ! ! Earlier!onset!often!indicate!more!Severe!course!
! ! ! ! Many!cases!Resolve!by!age!2,!Improvement!by!Puberty!is!common!
! ! ! ! ! 1/3!Children!with!Eczema!&!Food!Allergy!will!outgrow!their!Food!Allergy!in!1T3!years!
! ! ! ! ! Less!likely!to!lose!reactivity!to!Peanut,!Nut,!Fish,!Shellfish!
! ! ! ! ! Should!reTchallenge!every!1T2!years!
! ! ! ! 80%!Occupational!Skin!disease!occur!in!Atopics!
! ! ! ! It!is!Rare!to!see!AD!after!age!50!
! ! ! ! 50T60%!Pt!develop!Respiratory!‘Allergies’!
! Diagnostic!Clinical!features:!
! ! Essential:! Atopy:! Personal!Hx/FHx!of!Eczema,!Hay!Fever,!Asthma!
! ! ! ! ! Polygenic!Immunologic!aberrations!
! ! ! ! ! Th1/Th2!Imbalance!(Transitory)!
! ! ! ! ! NB!:! ↑IgE!Ab!Production,!Eosinophilia,!HyperTreleasable!Basophils!(&!Mast!cells)!
! ! ! ! ! ↑ETSelectin,!VCAMT1,!&!ICAM!levels!
! ! ! ! Pruritus:!
! ! ! ! ! Probably!the!‘Primary’!Sx!of!AD!
! ! ! ! ! Mildest!Mechanical!stimulation!of!Atopic!Skin!is!perceived!as!‘Itch’!
! ! ! ! ! Alloknesis!(TouchTevoked!Itch):!
! ! ! ! ! ! Once!Itching!has!started,!Likelihood!of!Surrounding!Skin!to!Itch!↑!
! ! ! ! ! Questionably!induced!by!Histamine!!(AntiHistamines!Minimally!Effective)!
! ! ! ! ! Trigger!of!Itch:! Irritants:! Wool,!Soaps/Detergents,!Disinfectants,!‘Occupational’,!
Tobacco!
! ! ! ! ! ! ! ! Xerosis!(Dry!Skin)!
! ! ! ! ! ! ! ! Microbial!agents:! S.!aureus,!Viral!infection,!?!Dermatophytes!
! ! ! ! ! ! ! ! Heat/Sweating!

! Page!334!
Food! Allergy!
! ! ! ! ! ! ! ! Contactants!including!Dust!Mites!
! ! ! ! ! ! ! ! Psychological!
! ! ! ! ! ! ! ! Foods!(IgETinduced)!&!those!having!Vasodilatory!properties!
! ! ! ! ! ! ! ! Aeroallergens!
! ! ! ! ! ! ! ! Hormones!
! ! ! ! ! ! ! ! Climate!
! ! ! ! Eczema!(Spongiosis):!Acute,!Subacute,!Chronic!
! ! ! ! (Vascular!Instability)!
! ! NonTEssential:!
! ! ! ! Xerosis,!Keratosis!Pilaris,!Pityriasis!alba,!Allergic!Shiners,!MorganTDennie!Lines,!
! ! ! ! Palmar/Plantar!Hyperlinearity,!Anterior!Capsular!Cataracts,!Keratoconus!
Relationship!of!Food!Allergy!&!AD:!
! Lab:! ! ! ↑FoodTspecific!IgE!Ab!
! ! ! ! Food!proteinTreactive!Cutaneous!T!cells!
! ! ! ! Skin!Mast!cells!activated!after!Food!ingestion!
! ! ! ! ↑Histamine!releasing!factors!with!Continued!ingestion!
! Clinical!studies:!Oral!challenge!elicit!Skin!Sx!(40%!children!with!Eczema!reacted!to!≥1!foods!after!DBPCFC)!
! ! ! ! Dietary!Elimination!aid!Resolution!(eg.!Studies!in!70s:!Mild!&!EggTfree!diet)!
Food!Allergic!Sensitization!&!Allergic!Match:!

! ! ! ! !
! ! ! ! Demonstration!of!FoodTallergenTspecific!IgE!in!Infancy!is!Predictive!Not!only!of!Eczema!
Severity,!
! ! ! ! ! but!of!Eczema!Persistence!&!Intriguingly,!the!Allergic!Airway!disease!Later!in!Childhood!
Epithelial!Skin!Barrier!as!a!Route!for!Allergic!Sensitization:!
! ! ! ! Emergence!of!Genes!regulating!Epidermal!Barrier!function!(eg.!FLG,!SPINK5)!
! ! ! ! LossTofTfunction!Mutations!widely!replicated!as!Major!RF!for!Eczema,!
! ! ! ! ! in!a!subset!with!Severe!Eczema,!Multiple!Atopic!Sensitization!&!CoTexisting!Asthma!

! Page!335!
Food! Allergy!
! ! ! ! !
Food!Allergy!as!a!Consequence!of!Eczema:!
! ! ! ! Broken!Skin>!Allergens!breach!Skin!barrier!to!reach!Systemic!circulation!
Food!&!Inhalant!Allergens!penetrating!Epidermis!are!taken!up!by!FcεRITbound!IgE!lead!to!Polarization!of!Naïve!T!into:!
! ! ! ! Acute!lesions!<3d:!
! ! ! ! ! Th2!
! ! ! ! ! ↑ILT4,!ILT5!
! ! ! ! Chronic!lesions!(with!Skin!Remodeling):!
! ! ! ! ! Th1!
! ! ! ! ! ↓ILT4,!ILT13!
! ! ! ! ! ↑IFNTγ,!TNFTα,!ILT5!
! ! ! ! ! ↑IgE!bearing!Langerhans!cell!&!Inflammatory!Dendritic!cells!
Biphasic/LateTphase!Reaction:!
! ! ! ! Cellular!Infiltrates!3T6h!(LPR)!

! ! ! ! !
Food!Allergy!=!an!ImmunologicallyTmediated!Reaction!against!Food!
! ! ! ! IgETmediated!
! ! ! ! Others…!(Less!evidence)!
! ! ! ! ! CellTmediated!reactions/NonTIgETmediated!(T!lymphocytes!–!Delayed!onset)!
! ! ! ! ! Mixed!types!(Atopic!Dermatitis)!
! ! ! ! ! Other!mechanisms!
Dx!of!Food!Allergy:! 1.!IgETmediated!Food!Allergy:! SPT!(Skin!Prick!Test)!–!IgE!

! Page!336!
Food! Allergy!
! ! ! ! ! ! ! ! ! ! SerumTspecific!IgE!
! ! ! ! 2.!NonTIgETmediated!Food!Allergy!(No!Good!method)!
! ! ! ! ! Elimination!Challenge!
! ! ! ! ! (Research!purpose):! Patch!test!
! ! ! ! ! ! ! ! ! In!vitro:! Cellular!markers,!Flow!study!(Cytokine!profile?)!
! ! ! ! Gold!Standard!=!DBPCFC!
! Teaching!Clinic:!Food!diary,!Elimination!diet,!Skin!Prick!test,!Blood!tests!(Serum!Specific!IgE,!RAST),!
! ! ! ! Food!Challenge!(Gold!standard!in!Children;!Difficult!in!Adults!–!Elimination!diet!more!common)!
! ! Dietary!diary:!
! ! ! ! Pt!keeps!a!record!of!the!contents!of!each!meal!&!whether!Allergic!reactions!occurred!
! ! Elimination!diet:!
! ! ! ! Under!doctor’s!direction!
! ! ! ! Pt!does!Not!eat!a!food!suspected!of!causing!the!Allergy!(eg.!Eggs),!
! ! ! ! ! and!substitutes!another!food!(eg.!Another!source!of!Protein!if!ceased!eating!Eggs)!
! ! ! ! See!if!Sx!go!away!
! ! ! ! Pt!then!resumes!eating!the!food!&!see!if!the!Sx!return!
! ! ! ! If!reaction!is!severe,!Pt!should!Not!resuming!eating!the!food!as!reTchallenge!is!risky!
! ! Skin!Prick!test:!
! ! ! ! Dilute!extract!of!suspected!food!is!placed!on!skin!of!forearm/back!
! ! ! ! Pricked!with!a!needle!&!observed!for!Swelling!&!Redness!
! ! ! ! +ve!test!indicates!that!Pt!has!IgE!specific!for!the!food!being!tested!
! ! ! ! Skin!Mast!cells!to!the!test!material!
! ! ! ! Intradermal!tests!are!Not!done!for!Food!Allergy!since!they!are!Too!Sensitive!
! ! ! ! Skin!tests!are!Rapid,!Simple,!Relatively!Safe!
! ! ! ! Pt!can!have!a!+ve!skin!test!to!a!Food!Allergen!without!having!Allergic!reaction!to!the!food!
! ! ! ! ! (Sensitization!only)!
! ! ! ! Food!Allergy!is!diagnosed!only!when!Pt!has!+ve!Skin!test!to!a!specific!Allergen,!
! ! ! ! ! Plus!Hx!suggests!an!Allergic!reaction!to!the!same!food!
! ! ! ! Skin!tests!should!Not!be!done!in!Highly!Allergic!ppl,!esp!if!they!had!Anaphylactic!reactions!
! ! ! ! Skin!tests!also!canNot!be!done!in!Pt!with!Extensive!Eczema!
! ! Blood!tests:!
! ! ! ! EIA,!previously!RAST!
! ! ! ! Measure!presence!of!FoodTspecific!IgE!in!blood!
! ! ! ! In!situations!where!Skin!tests!can’t!be!done!
! ! ! ! More!Costly!than!Skin!tests,!and!results!are!Not!available!immediately!
! ! ! ! +ve!Blood!tests!make!Dx!of!a!specific!Food!Allergy!only!when!Hx!compatible!
! ! ! ! Basophil!Activation!tests!are!Not!advocated!for!Food!Allergy!yet!
! ! Food!Challenge:!
! ! ! ! DBPCFC!is!the!Gold!standard!for!objective!allergy!testing!
! ! ! ! Challenge!materials!prepared!in!opaque!capsules!
! ! ! ! Pt!with!Hx!of!severe!reactions!should!Not!be!tested!due!to!danger!of!another!severe!reaction!

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Food! Allergy!
! ! ! ! Expensive!&!Requires!a!lot!of!time,!esp!for!Pt!with!Multiple!Food!Allergy!(Only!test!1!at!a!time)!
! ! ! ! Must!be!done!under!supervision!of!a!physician!
! ! ! ! Open!Challenge!is!more!often!done!
Dx!of!AD:! ! ! Hx!&!PE!
! ! ! ! Lab!tests!Not!Routine:!
! ! ! ! ! Serum!IgE,!Serum!test!for!AllergenTspecific!IgE!(CAPTRAST)!
! ! ! ! ! Skin!Biopsy,!Skin!Culture!(Bacterial,!Viral,!Fungal)!
! ! ! ! ! Skin!Prick!test,!Patch!test!(Corticosteroids,!Aeroallergens)!
Tests:!
! IgE!Skin!testing!–!Prick:!
! ! ! ! Safe,!Multiple!Allergens!at!the!same!time!
! In!vitro!test!(RAST!–!RadioAllergoSorbent!Testing):!
! ! ! ! Quantification!of!level!of!FoodTspecific!IgE!
! ! ! ! Diagnostic!Decision!points!of!95%!PPV:!
! ! ! ! ! Cow’s!Milk!15!kU/L,! Egg!7!kU/L,! Peanut!14!kU/L,!! Fish!20!kU/L!
! Atopy!Patch!test:!
! ! ! ! Possible!Utility!in!NonTIgETmediated!Allergy!
! ! ! ! Lack!Standardization!of!Reagents,!Application!&!Interpretation!
! ! ! ! Require!Multiple!Visits!
! Diagnostic!value:! Sensitivity:! SPT!100%! ! RAST!90%! ! APT!75%!
! ! ! ! ! Specificity:! SPT!35%! ! RAST!35%! ! APT!85%!
! ! NB:! ! Skin!testing!(Prick!test!&!Patch!test)!in!Eczema!in!another!study:!
! ! ! ! ! Either!+ve:! ! Sensitivity!86%,!Specificity!72%!
! ! ! ! ! Both!+ve/–ve:! Sensitivity!24%,!Specificity!94%!
Food!Challenge:!! ‘Gold!standard’!
! ! ! ! Potentially!Dangerous!test!
! ! ! ! Safeguards:! Individual!Protocol,!Appropriate!Setting!
! Prevalence!of!Food!Allergy!in!Children!with!Eczema!proven!by!DBPCFC:!
! ! ! ! 33T63%!
! Jones!1993:! DBPCFC!in!470!children:! 74%!Cutaneous!syndrome,!27%!Skin!only,!50%!GI,!45%!Resp!
Phenotypes!of!Food!Allergy:!
! IgE:! ! ! Immediate!type!! OAS!(Oral!Allergy!Syndrome)! ! Any!time,!Peak!in!Early!life!
! Mixed:! ! Eczema! ! ! AEE,!AEG,!AEGE!! ! ! ! InfancyTAdolescence!
! ! ! ! ! ! ! ! (Allergic!Eosinophilic!Esophagitis/GE)!
! NonTIgE:! ! Eczema! ! ! FPIES,!Celiac! ! ! ! ! Usually!Infancy!
! ! ! ! ! ! ! ! (FPIES:!Food!ProteinTInduced!Enterocolitis!Syndrome)!
Food!Allergy!&!AD:!
! Children:! ! Moderate:!! Severe!AD!(1/3T2/3)!have!Food!Allergy!
! ! ! ! ↑ing!Severity!of!AD!similar!to!↑ing!Risk!of!FA!
! Adults:! ! Low!Incidence!(<2%)!
! Foods!Responsible!(~85%!cases):!

! Page!338!
Food! Allergy!
! ! ! ! Outgrown:! ! Milk,!Egg,!Soy,!Wheat!
! ! ! ! Persistent:!! Peanut,!Nuts,!Fish,!Shellfish!
Consensus!Statements!from!NICE!Guideline!on!Atopic!Eczema!for!Children!0T12!yo:!
! ! ! ! A!Dx!of!Food!Allergy!should!be!considered:!
! ! ! ! ! Hx!of!Immediate!Sx!
! ! ! ! ! ModTSevere!Not!controlled!by!Optimum!Mx!
! ! ! ! ! Particularly!associated!with!GI!Dysmotility!&!Failure!to!Thrive!
! ! ! ! <6m!
! ! ! ! A!6T8!week!trial!of!an!EHF!(Extensively!Hydrolysed!Formula)!or!AAF!(Amino!Acid!Formula)!
! ! ! ! Children!on!Elimination!Cow!Milk!>8!weeks!should!be!referred!for!Special!Dietary!advice!
! ! ! ! Unmodified/Partially!Hydrolyzed!Formula!should!Not!be!used!
Evaluation!of!Food!Allergy!in!AD:!
! Lab:! ! ! Specific!IgE!(Pharmacia!CAPTRAST!System)!
! ! ! ! ! Predictive!value!(>95%!reaction!rate)!in!Children!
! ! ! ! ! ! Egg,!Milk,!Peanut,!Codfish!
! Clinical:! ! Elimination!Diets!
! ! ! ! Oral!Food!Challenges:! Physician!supervised!
! ! ! ! ! ! ! ! ! Open,!Single!Blind,!DoubleTBlind,!PlaceboTcontrolled!
Review!of!Dietary!Intervention!studies!in!Eczema:!
! ! ! ! 15!out!of!16!studies!report!Improvement!
! ! ! ! No!MetaTanalysis!
! ! ! ! Interventions!most!Effective!in!Infants!
! ! ! ! Successful!Interventions!include!Egg,!Milk!&!Wheat!Avoidance!

! ! ! ! !
Dx!Algorithm:! ! Persistent!ModerateTSevere!AE!
! ! ! ! >!Hx!of!Possible!Food!Allergy,!SIgE,!SPT!(APT)!
! ! ! ! >!Diagnostic!Elimination!Diet!over!a!period!of!some!weeks!(eg.!4T6!weeks)!
! ! ! ! >!1st!step!of!OFC!in!Stable!phase!of!disease,!Evaluation!of!Eczema!Score!before!OFC!
! ! ! ! >!1st!titrated!Oral!Food!Challenge!
! ! ! ! >!Evaluation!of!NonTEczematous!Sx!during!Titration!&!following!2h!
! ! ! ! >!Evaluation!of!Eczema!Score!for!at!least!16T24h!after!OFC!

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Food! Allergy!
! ! ! ! >!–ve!reaction:! Repeat!Challenge!with!Average!Daily!intake!x!few!days!
! ! ! ! ! ! ! Evaluate!Eczema!Score!x!1!week!
! ! ! ! >!At!least!on!Challenge!Free!day!4T7!days!
! ! ! ! >!Next!step!of!OFC!
Varying!Rate!of!Food!Allergy!in!the!World:!
! ! ! ! HK:! Shellfish,!Egg,!Peanut,!Beef!
Food!Allergy!in!Adults:!
! ! ! ! Most!common!Foods:!
! ! ! ! ! Shellfish!(eg.!Shrimp,!Crayfish,!Lobster,!Crab),!Nuts!from!Trees!(eg.!Walnuts),!
! ! ! ! ! Fish,!Eggs,!Peanuts!
! ! ! ! In!Highly!Allergic!ppl,!even!minute!amounts!of!peanut!can!evoke!an!allergic!reaction!
! ! ! ! ! Less!Sensitive!ppl!may!be!able!to!tolerate!small!amounts!
! ! ! ! Compared!with!Children:!
! ! ! ! ! Most!common!Food!Allergy!in!Children:! Eggs!(Med!2007!MCQ!45),!Milk,!Peanuts!
! ! ! ! ! Children!sometimes!outgrow!their!Allergy,!but!Adults!usually!do!Not!
! ! ! ! ! Children!are!more!likely!to!outgrow!allergies!to!Cow’s!milk/Soy!formula!
! ! ! ! ! ! than!allergies!to!Peanuts,!Fish,!Shrimp!
! ! ! ! Adults!&!Children!tend!to!react!to!those!foods!they!eat!more!often!
! ! ! ! ! Eg.!Rice!allergy!in!Japan!&!Codfish!allergy!in!Scandinavia!more!common!than!elsewhere!
CrossTreactivity:! ! Occurrence!of!Allergic!reactions!to!foods!that!are!chemically/otherwise!related!
! ! ! ! Eg.!Shrimp!Allergy:!Also!allergic!to!Crab!
! Oral!Allergy!syndrome:!
! ! ! ! Another!type!of!CrossTreactivity!
! ! ! ! When!Pt!Highly!Sensitive!to!Ragweed/Birch!pollen!eat!certain!fruits!like!melons!&!apples!
! ! ! ! Rapid!onset!of!Itching,!Irritation,!Mild!Swelling!in!Lips,!Tongue,!Palate,!Throat!
! ! ! ! Aka!PollenTFood!Allergy!syndrome;!Due!to!Fruit!proteins!that!cross!react!with!Pollen!Proteins!
! ! ! ! Occurs!in!up!to!50%!of!those!who!have!Allergic!Rhinitis!caused!by!pollen!
! ! ! ! Fresh/Uncooked!foods;!Cooked!fruits!&!vegetables!usually!do!Not!cause!the!reaction!
! ! ! ! Resolves!usually!within!minutes,!although!up!to!10%!will!develop!Systemic!Sx,!
! ! ! ! ! and!1T2%!may!experience!Anaphylactic!Shock!
Ddx!of!Food!Allergy:! Food!Poisoning!
! ! ! ! Reactions!to!certain!chemicals!in!food,!eg.!Histamine/Food!additives!
! ! ! ! Lactose!intolerance!
! ! ! ! Celiac!disease!
! ! ! ! Other!GI!diseases:! PU,!Gallstones,!NonTulcer!dyspepsia,!Crohn’s!disease,!Cancer,!
! ! ! ! ! ! ! ! Eosinophilic!GE!(May/May!Not!be!IgETmediated)!
! ! ! ! Psychological!
Summary:!! ! Foods!are!capable!of!initiating!Cutaneous!NonTEczematous!&!Eczematous!responses,!
! ! ! ! ! associated!with!↑!in!Plasma!Histamine,!
! ! ! ! ! Activation!of!Eosinophils!&!Clonal!Expansion!of!Allergen!–!Specific!Skin!Homing!T!cells!
! ! ! ! Foods!frequently!induce!Biphasic!response!in!Skin,!

! Page!340!
Food! Allergy!
! ! ! ! ! with!Acute!Pruritic!lesions!followed!by!Eczematous!lesions!several!hours!later!
! ! ! ! Food!Allergy!is!present!in!about!1/3!Children!with!ModTSevere!Eczema,!
! ! ! ! ! and!up!to!2/3!Infants!<2!yo!with!Severe/Refractory!Eczema!
! ! ! ! Food!Allergy!affect!only!10%!Infants!with!Mild!Eczema!
! ! ! ! Appropriate!Early!Intervention!can!impact!significantly!on!
! ! ! ! ! Eczema!Severity,!Infant!Growth!&!QOL!
! ! ! ! +ve!Dx!empower!Pt!&!his!families!
! ! ! ! –ve!test!lift!Unnecessary!Restriction!

! Page!341!
Food! Allergy!
Other!Allergy:!
Allergic!Rhinoconjunctivitis:!
! ! ! ! Peak!age!of!onset!at!36!months!
! ! ! ! Eyes:!! Red,!Itchy,!Swollen!
! ! ! ! Nose:! Nasal!congestion,!Itching,!Sneezing,!Rhinorrhea!
! ! ! ! Mouth!breathing:! Malocclusion!&!Abnormal!Facial!development!
! ! ! ! Poor!sleep!with!chronic!tiredness,!poor!concentration,!bad!temper!etc!
Common!Resp!Allergens:!
! ! ! ! Seasonal:! ! Tree/Grass/Weed!pollens!
! ! ! ! Perennial:!! Dust!mite,!Mold!spores,!Cockroach,!Animal!dander!
! ! ! ! Occupational:! Isocyanates,!Colophony,!Chromium,!Plicatic!acid,!Latex,!Organic!dust,!
! ! ! ! ! ! ! Animal!dander!
Mx:! Dust!Avoidance:!
! ! ! ! Remove!Carpets,!Heavy!Curtains,!Upholstery,!Stuffed!toys!
! ! ! ! Encase!Mattress,!Pillows!&!Quilt!in!impermeable!covers!
! ! ! ! Hotwash!(>55°C)!all!sheets!once!a!week!
! ! ! ! HEPA!filter!for!Vacuum!cleaner!
! ! ! ! Chemical!Tx!has!limited!efficacy!
! Drug!Tx:! ! Cromolyn!eyedrops,!nose!spray!&!inhaler!
! ! ! ! Topical!Steroid!nasal!spray!&!inhaler!
! ! ! ! AntiHistamine:! Topical!&!Systemic!
! ! ! ! In!very!severe!cases,!a!short!course!of!Systemic!Steroid!may!be!needed!
Anaphylaxis:! ! Most!common!S/S!(2010!MCQ!14):! Urticaria/Angioedema!(Flushing!is!less!common)!
Dx:! ! ! ! Serum!Tryptase!level!↑!for!several!hours!after!anaphylaxis;!Low!Sensitivity!(Window!too!Short)!
! ! ! ! Skin!tests!to!Ag!such!as!Food,!Aeroallergens,!Drugs!
! ! ! ! RAST,!MAST,!CAP!tests!
! ! ! ! Basophil!Histamine!release!assay!
! ! ! ! Challenge!testing:! Physical!challenge,!Drug!challenge,!etc!
Tx:! ! ! ! Acute:!Adrenaline,!IV!fluid,!Steroid,!Maintain!Airway!
! ! ! ! Avoid!inciting!Ag/Physical!stimuli!
! ! ! ! AntiHistamines!may!be!of!some!use!in!Prevention!
! ! ! ! Long!term!Systemic!Steroid!for!Recurrent!Idiopathic!Anaphylaxis!
! ! ! ! Desensitization!for!Insect!stings,!Aspirin!sensitivity,!etc!
FoodTdependent,!ExerciseTinduced!Anaphylaxis:!
! ! ! ! Distinct!subset!of!ExerciseTinduced!Anaphylaxis!
! ! ! ! Anaphylaxis!develops!only!if!Physical!activity!occurs!within!few!hours!after!eating!a!specific!
food!
! ! ! ! Most!commonly!implicated:! Wheat,!Shellfish,!Tomatoes,!Peanuts,!Corn!
! ! ! ! Others:! Fruits,!Seeds,!Milk,!Soybean,!Lettuce,!Peas,!Beans,!Rice,!Various!Meats!
! ! ! ! Less!severe!allergy:! Urticaria,!Asthma,!Abdominal!Pain!
! ! ! ! Tx:! Not!eating!at!least!2h!before!Exercise!
! Page!342!
Food! Allergy!
! WheatTdependent!ExerciseTinduced!Anaphylaxis!(WDEIA):!
! ! ! ! Best!characterized!form!of!FoodTdependent,!ExerciseTinduced!Anaphylaxis!
! ! ! ! Provocation!tests:! 60%!Pt!+ve!
! ! ! ! Recent!study:! Specific!IgE!to!omegaT5Tgliadin!(Tri!a!19):! Sensitivity!80%!with!High!Specificity!
! ! ! ! ! Tri!a!19!is!a!storage!protein!
! ! ! ! ! Test!by!recombinant!wheat!allergens!
Peanut!Allergy:!
Clinical:! ! ! S/S!occurs!in!a!few!min!to!1h!after!ingestion!
! ! ! ! Skin:!! Hives,!Redness,!Swelling!
! ! ! ! GI:! ! Itching/Tingling!in/around!mouth!&!throat,!Diarrhea,!Stomach!Cramps,!N/V!
! ! ! ! Resp:! Tightening!of!throat,!SOB,!Wheezing,!Runny!nose!
! ! ! ! Anaphylaxis:!
! ! ! ! ! Any!of!above!plus:!
! ! ! ! ! ! Constriction!of!Airways,!Throat!Swelling,!Shock/Hypotension,!Dizziness/Fainting!
! ! ! ! Peanut!is!the!most!common!cause!of!Food!induced!Anaphylaxis!
RF:! Age:! ! ! Food!Allergy!are!most!common!in!Young!Children,!esp!Toddlers!&!Infants!
! Other!Food!Allergy!
! FHx:! ! ! ↑Risk!of!Peanut!Allergy!if!other!Allergy!esp!other!types!of!Food!Allergy!are!common!in!Family!
! Other!Allergic!diseases:!
! ! ! ! Allergic!Rhinitis,!Atopic!Eczema!
Dx!involving!Allergen!components:!
! ! ! ! Major!Peanut!allergens:! Ara!h1,!Ara!h2,!Ara!h3!
! ! ! ! Ara!h2:! Resistant!to!Heat!&!Gastric!denaturation!&!Plays!a!major!role!in!diagnostics!
! ! ! ! Ara!h8:! Isolated!Positivity!indicates!Tolerance!to!Peanuts!
! ! ! ! More!Accurate!Lab!Dx!can!↓!Need!of!Food!Challenge!
Tx:! No!definite!Tx!for!Peanut!Allergy:!
! ! ! ! Immunotherapy!by!giving!↑ing!doses!of!Peanut!Flour/Peanut!Extract!over!time!
! ! ! ! ! Results!are!promising!but!more!study!is!needed!
! As!with!any!Food!Allergy:!
! ! ! ! Avoid!ingesting!Peanut!
! ! ! ! Learn!to!relieve!Minor!Sx!(AntiHistamines)!
! ! ! ! Learn!how!to!identify!&!react!to!a!severe!reaction!(Adrenaline,!SelfTinject!or!in!A&E)!
! ! Avoiding!Peanut:!
! ! ! ! Never!assume!a!food!doesn’t!contain!Peanuts!
! ! ! ! ! Always!read!labels!on!manufactured!food!
! ! ! ! ! Check!label!every!time!because!ingredients!may!change!
! ! ! ! Don’t!ignore!a!label!that!says!a!food!was!produced!in!a!factory!that!processes!peanuts!
! ! ! ! When!in!doubt,!Avoid!
! ! ! ! Avoiding!foods!that!often!contain!Peanuts:!
! ! ! ! ! Ground/Mixed!Nuts,!Baked!goods!(eg.!Cookies!&!Pastries),!
! ! ! ! ! Ice!cream!&!Frozen!desserts,!Energy!bars,!Cereals!&!Granola,!Grain!breads!
! Page!343!
Food! Allergy!
Natural!Hx!of!Peanut!Allergy:!
! ! ! ! Some!Children!may!outgrow!it!
! ! ! ! Some!may!appear!to!have!outgrown!it!but!recur!
! ! ! ! Most!are!Persistent!
!

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Food! Allergy!
 Resp&Cystic&Fibrosis&
Cystic!Fibrosis:! ! Disease!of!Exocrine!gland!function!that!involves!multiple!organ!systems!
! ! ! ! Chiefly!results!in!Chronic!Resp!Infections,!Pancreatic!Insufficiency,!and!asso.!Cx!in!untreated!Pt!
! ! ! ! Pulmonary!involvement!occurs!in!90%!Pt!surviving!Neonatal!period!
! ! ! ! EndTstage!Lung!disease!is!main!cause!of!death!
Genetic:! ! ! AR!
! ! ! ! Cystic!Fibrosis!Transmembrane!conductance!Regulator!(CFTR)!gene!mutation!
! ! ! ! ! Most!common!mutation!is F508!at!Chr!7q31.2!
! ! ! ! Occur!among!All!races;!Predominance!in!Northern!Europeans!with!incidence!of!~1!in!2500!
! ! ! ! GenotypeTPhenotype!correlation!is!weak!for!Lung!manifestations!
Pathophysiology:! Defective!CFTR!protein>!↓Secretion!of!Cl,!↑Reabsorption!of!Na!&!Water!
! ! ! ! >!↓Hydration!of!Mucus>!↑Viscosity,!ie.!Stickier!to!Bacteria!
Organ!involvement:! Major!Phenotypic!Features:!
! ! ! ! ! Progressive!Pulmonary!disease,!Exocrine!Pancreatic!Insufficiency,!
! ! ! ! ! Obstructive!Azoospermia,!↑Sweat!chloride,!Growth!failure,!Meconium!Ileus!(IO)!
! Resp:!
! ! Nasal!Polyp!
! ! Sinusitis!
! ! Lung:! Recurrent/Chronic!Infection,!initially!with!S.!aureus/H.!influenzae,!
! ! ! ! ! subsequently!Pseudomonas/Burkholderia!
! ! ! ! Bronchiectasis!develops!in!Young!Child!
! ! ! ! In!Older!Child,!may!have!Allergic!BronchoPulmonary!Aspergillosis,!other!Cx!like!
Pneumothorax…!
! GI:! Bowel:! IO:! Meconium!Ileus!at!Birth,!Distal!IO!syndrome!in!Later!life!
! ! ! ! Rectal!Prolapse:!
! ! ! ! ! Onset!usually!Age!1T5!in!Paedi!
! ! ! ! ! Ddx:! Idiopathic!
! ! ! ! ! ! Chronic!Constipation,!Diarrhea,!Intestinal!Parasites,!Ulcerative!Colitis!
! ! ! ! ! ! Cystic!Fibrosis,!Pertussis!
! ! ! ! ! ! Meningocele!
! ! Pancreas:! Pancreatic!Exocrine!Insufficiency>!Failure!to!thrive,!Steatorrhea,!FatTsoluble!Vitamins!
deficiency!
! ! ! ! ! Frequent!Bulky!Malodorous!Greasy!stools!with!Excessive!Flatus!
! ! ! ! DM!can!occur!as!a!Cx!(often!IDDM)!
! ! Liver:! Biliary!Cirrhosis,!Gallstones!
! Genital:!
! ! Male!Subfertility:!
! ! ! ! >95%!have!Azoospermia!(Mainly!due!to!Congenital!Absence!of!Vas!deferens)!
! ! ! ! ! But!Fertility!may!still!be!possible!with!Assisted!Reproductive!Techniques!
! ! ! ! Also!↑Incidence!of!Inguinal!Hernia,!Hydrocele,!Undescended!Testis!
! ! Female!Subfertility:!

! Page!345!
Cystic! Fibrosis!
! ! ! ! 20%!may!have!Secondary!Amenorrhea!due!to!Severe!Malnutrition!or!Pulmonary!disease!
! ! ! ! Cervical!mucus!also!more!tenacious!
! Skin:!Excessive!Salt!Loss:!
! ! ! ! Parents!may!notice!Salk!‘Frosting’!of!skin!or!Salty!taste!when!kiss!child!
! ! ! ! Predispose!to!Dehydration/Salt!depletion!(may!present!with!HypoCl!Alkalosis)!in!Hot!weather!
Dx:! Sweat!Test:! Cl↑!
! DNA!Test:!! CFTR!gene!defect!
Mx:! Resp:! ! Chest!Physiotherapy,!Postural!Drainage!
! ! ! ! Antibiotic!Prophylaxis,!eg.!Flucloxacillin!
! ! ! ! Mucolytic:!Dornase!alfa!(Pulmozyme),!a!recombinant!DNase!
! ! ! ! ! ! Nebulized!Hypertonic!Saline!
! ! ! ! BD,!Macrolide,!etc!
! Nutritional:! Pancreatic!enzyme!supplements!(oral!entericTcoated,!taken!with!meals)!
! ! ! ! Multivitamins!(FatTsoluble!Vitamins)!
!

! Page!346!
Cystic! Fibrosis!