Sultafa Jessica, McKibbon Lundy, Roberts Hannah, Sarraj Jumana, Kim Harold
Department of Medicine, Western University, London, ON, Canada.
Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON, Canada.
Allergy Asthma Clin Immunol. 2022 Jan 31;18(1):8. doi: 10.1186/s13223-022-00651-9.
Food Protein-Induced Enterocolitis Syndrome (FPIES) is a non-IgE mediated food allergy most commonly presenting in infants. The most common food triggers include soy, cow's milk and grains. Symptoms may include intractable vomiting, diarrhea, lethargy, pallor, abdominal distention, hypotension and/or shock. Oral food challenges (OFCs) given at food protein dose of 0.06-0.6 g/kg in 3 equivalent doses administered over a few hours are recommended in guidelines to confirm a diagnosis.
The patient is a 6-month-old girl with a history of severe FPIES symptoms to egg. In our clinic, we perform OFC with 1/100 serving dose on visit 1 and then increase the dose monthly. The patient takes the tolerated dose daily at home between visits. An OFC to baked egg at 1/100 of a serving was performed and was well-tolerated on her initial visit. The patient remained on the same dose upon returning home. Within 1-week, she developed FPIES symptoms including watery diarrhea and severe emesis requiring ondansetron. She required an Emergency Department visit for one of the reactions.
Our patient had severe FPIES symptoms with a small amount of egg. We believe that administration of three large food challenge doses on one clinic visit, as guidelines currently suggest, does not allow adequate time for symptoms to appear. Our patient likely would have suffered a severe reaction. Also, this guidelines protocol does not allow for monitoring of more delayed or chronic FPIES. We propose a modified protocol to OFCs with cautious up-dosing to allow for safer OFCs and monitoring of chronic FPIES. We have implemented an OFC approach where only one food challenge dose (starting with 1/100 of final dose) is given at each visit. The up-titration of the dose is completed every 4-weeks with one dose only. When the serving sized dose is reached and tolerated, the food can be maintained in the diet.
食物蛋白诱导的小肠结肠炎综合征（FPIES）是一种非IgE介导的食物过敏，最常见于婴儿。最常见的食物诱因包括大豆、牛奶和谷物。症状可能包括顽固性呕吐、腹泻、嗜睡、面色苍白、腹胀、低血压和/或休克。指南建议通过在数小时内分3等份给予0.06 - 0.6 g/kg食物蛋白剂量的口服食物激发试验（OFC）来确诊。
该患者是一名6个月大的女孩，有对鸡蛋出现严重FPIES症状的病史。在我们诊所，首次就诊时给予1/100份剂量的OFC，然后每月增加剂量。患者在两次就诊期间在家中每日服用耐受剂量。进行了一次1/100份烘焙鸡蛋的OFC，首次就诊时耐受良好。回家后患者维持相同剂量。在1周内，她出现了FPIES症状，包括水样腹泻和严重呕吐，需要使用昂丹司琼。她因其中一次反应前往急诊科就诊。
我们的患者食用少量鸡蛋就出现了严重的FPIES症状。我们认为，按照目前指南建议在一次门诊就诊时分三次给予大剂量食物激发试验，没有给症状出现留出足够时间。我们的患者可能会发生严重反应。此外，该指南方案无法监测更延迟或慢性的FPIES。我们提出一种改良的OFC方案，谨慎增加剂量，以实现更安全的OFC并监测慢性FPIES。我们实施了一种OFC方法，每次就诊仅给予一份食物激发试验剂量（从最终剂量的1/100开始）。剂量每4周仅增加一次，直至达到一份食物的剂量并耐受后，该食物即可纳入饮食。
