ALLERGOLOGY Removals Review By Alec Maquiling

OUTLINE I. Adverse Food Reactions II. Anaphylaxis III. Urticaria and Angioedema C4. Cross-reactivity: when an antibody reacts not only with the original allergen but also with a similar allergen -NOTE: LATEX cross reacts with banana, avocado, kiwi, and chestnuts C5. Correlation with other diseases - FA coexists with asthma, atopic dermatitis, eosinophilic esophagitis, and exercise-induced anaphylaxis -Coexistence of FA and ASTHMA is a risk factor for asthma exacerbations - Exercise-induced anaphylaxis: it happens when you eat a certain food (most common triggers: shellfish, alcohol, tomatoes, cheese, celery), then you exercise. The food triggers mentioned can be eaten WITHOUT symptoms in the absence of exercise. - 75% of patients who experience this are females! C6. Natural History of Food Allergy - Most FA will tolerate milk, egg, soy and wheat (but time course varies and may occur as late as teenage years) - A higher initial level of serum IgE against a certain food is associated with a lower rate of resolution C7. Types of Food Allergy (REMEMBER THIS) C7.1 IgE-MEDIATED FOOD ALLERGY C7.1.1 Clinical Features: -RAPID onset (within 1-2 hours) -Resolve quickly (within minutes to few hours) -Several symptoms involved: MOST COMMONLY INVOLVED: SKIN, 2nd most commonly involved: Gastrointestinal C7.1.2 Examples Allergy of IgE-Mediated Food

I. ADVERSE FOOD REACTIONS Definition: ANY reaction following the ingestion of a food. A. ORAL FOOD TOLERANCE: suppression of adverse immune responses to nonharmful food antigens. A1. Mechanisms: 1. Mucosal Barrier (Intestinal Intraepithelial cells, secretory IgA, Regulatory T cells, Commensal Flora) 2. Balance of Th1 and Th2 cells B. FOOD INTOLERANCE: adverse WITHOUT a clear immune mechanism event

B1. HOST factors: enzyme deficiencies, GI disorders, idiosyncratic reaction, psychologic, migraines B2. FOOD factors: infectious organisms (S. aureus, E. coli, C. difficile), toxins (scombroid poisoning [histamine]), pharmacologic agents, contaminants C. FOOD ALLERGY (FA): a reaction WITH an immune mechanism C1. Prevalence - 2.5% of newborn infants have hypersensitivity to COW MILK in the FIRST year of life. -About 1.5% of young children are allergic to EGGS. C2. Common food allergens (in the Philippines) - Seafood, fish, eff, milk, soy, peanuts (Note: Chicken allergy is NOT common) - PEANUT allergy: most common cause of anaphylaxis in children leading to an ER consultation. - REMEMBER: PROTEIN component is responsible for causing food allergy C3. Genetics (chance of getting food allergy) - If both parents both have food allergy: 50-80% - If both parents are atopic: 40-60% - If one of the parents have food allergy: 40% - If neither parent has food allergy: 15%

1. Oral Allergy Syndrome -aka POLLEN-associated FA syndrome (because it also commonly affects those who are allergic to pollens) -allergy usually to RAW fruits and vegetables - confined to LIPS, MOUTH, THROAT 2. Acute Urticaria - rapid onset after ingestion of food characterized by round or irregular shaped PRURITIC WHEALS

ALLERGOLOGY Removals Review By Alec Maquiling

3. Angioedema -often occurs in combination with urticaria -NON-pitting, NON-pruritic, well-defined edematous swelling that involves subcutaneous, abdominal organs or upper airway. C7.1.3 Examples of Non-IgE-Mediated Food Allergy 1. Food Protein-Induced Allergic Proctocolitis -in healthy infants who have visible specks or streaks of blood with mucus in the stool -many infants present while being breast-fed 2. Food Protein-Induced Enterocolitis Syndrome - presents as chronic emesis, diarrhea, failure to thrive - in young people, most common cause are milk and soy protein -in adults, most often related crustacean shellfish ingestion. C7.1.4 Mixed Conditions (both IgE and NonIgE-mediated) 1. Eosinophilic Esophagitis - LOCALIZED inflammation of the esophagus 2. Esophageal Gastroenteritis -pathologic infiltration of the GI tract by eosinophils 3. Atopic Dermatitis - skin barrier dysfunction - mutation on the protein FILAGGRIN - Atopic March (Atopic Dermatitis then Asthma then Allergic Rhinitis) C8. Diagnosis of Food Allergy -FA should be considered in patients with anaphylaxis or any combination of symptoms that occur within minutes to hours of ingesting food. - Although History and PE can aid in the diagnosis, they CANNOT be considered diagnostic of FA. Moreover, parent and patient reports must be CONFIRMED because 50 to 90% of presumed FAs are not allergies. - IgE-mediated Skin Prick Test: cannot be diagnostic BUT can be used to confirm ABSENCE of IgE-mediated reaction - Double Blind Placebo Controlled Oral Food Challenge (Gold Standard) C9. Management of Food Allergy - currently NO CURE exists - standard of care: STRICT ALLERGEN AVOIDANCE -NOTE: VERY IMPORTANT to memorize Labels that Indicate Egg Protein (particularly ALBUMIN, binder, coagulant, egg white, egg yolk, emulsifier, globulin, lecithin, livetin, lysozyme, OVALBUMIN, OVAMUCIN, OVOVITELLIN, powdered egg, vitellin, whole egg) and food that may contain egg protein (baked goods, baking mixes, boullion, breakfast cereals, cake flours, candy, cookies, egg noodles, French toast, ice cream, macaroni, cocoa, marshmallows, MEATBALLS, SAUSAGES,