Food, drug, insect sting allergy, and anaphylaxis
Clinical features and resolution of food protein–induced enterocolitis syndrome: 10-year experience

https://doi.org/10.1016/j.jaci.2014.04.008Get rights and content

Background

Food protein–induced enterocolitis syndrome (FPIES) is a non–IgE-mediated food allergy. FPIES diagnosis is frequently delayed because of the absence of classic allergic symptoms and lack of biomarkers.

Objective

We sought to characterize the clinical features and resolution of FPIES in patients evaluated in our practice.

Methods

Subjects 6 months to 45 years of age with FPIES were prospectively recruited for oral food challenges (OFCs). Medical records were searched to identify the subjects who did not participate in OFCs.

Results

Among 160 subjects, 54% were male; median age at diagnosis was 15 months. We performed 180 OFCs to 15 foods in 82 subjects; 30% of the study population had FPIES confirmed based on OFC results. The most common foods were cow's milk (44%), soy (41%), rice (22.5%), and oat (16%). The majority (65%) reacted to 1 food, 26% reacted to 2 foods, and 9% reacted to 3 or more foods. The majority were atopic, and 39% had IgE sensitization to another food. Thirty-nine (24%) subjects had positive specific IgE levels to the food inducing FPIES. Among children with specific IgE to cow's milk, 41% changed from a milk FPIES to an IgE-mediated phenotype over time. The median age when tolerance was established was 4.7 years for rice, 4 years for oat, and 6.7 years for soy. Median age when milk tolerance was established for subjects with undetectable milk-specific IgE levels was 5.1 years, whereas none of the subjects with detectable milk-specific IgE became tolerant to milk during the study (P = .003).

Conclusion

FPIES typically resolves by age 5 years. Milk FPIES, especially with detectable food-specific IgE, can have a protracted course and eventually transition to acute reactions.

Section snippets

Study population

The research protocol was approved by the Mount Sinai Institutional Review Board. Written informed consent was obtained before enrollment. This study includes a mixed prospective and retrospective method of patient ascertainment. Subjects aged from 6 months to 45 years with FPIES were prospectively recruited for OFCs under the natural history of the FPIES protocol from the Mount Sinai Allergy and Immunology Clinic patient population (New York, NY) between 2001 and 2011. All subjects with

Subjects' characteristics

Subjects' characteristics and the offending foods are summarized in Table I and Fig 1. One hundred sixty subjects were enrolled. Eighty-six 86 (54%) were male, and the median age at diagnosis was 15 months (25% to 75% interquartile range [IQR], 9-24 months). Among those 160 patients, 82 (51%) were enrolled prospectively, and 78 were identified through the retrospective chart review. Thirteen (8%) subject received a diagnosis after 5 years of age; 5 of them had FPIES to fish or shellfish with

Discussion

We report data from a large cohort of subjects with FPIES and the largest number of OFCs performed for FPIES to date. In this cohort 24% had detectable specific IgE antibodies to the food that triggered the FPIES, and 39% had concomitant IgE sensitization to other foods; to our knowledge, this latter observation has not been reported previously. Among children with specific IgE to cow's milk, 41% changed from the milk FPIES phenotype to an IgE-mediated phenotype over time. We confirmed that the

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    Supported in part by UL1 TR-000067 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health. L.S.F. was supported by the Jaffe Foundation Fellowship Award, and K.M.J. was supported in part by the Leff Family Grant.

    Disclosure of potential conflict of interest: J. C. Caubet is employed by Geneva University Hospitals. L. S. Ford has received research support from the Jaffe Foundation. K. M. Järvinen has received research support from the National Institutes of Health and has received royalties from UpToDate. S. H. Sicherer is a member of the American Board of Allergy and Immunology, has received consultancy fees from Food Allergy Research and Education (FARE) and Novartis, has received research support from the National Institute of Allergy and Infectious Diseases (NIAID) and FARE, and has received royalties from UpToDate. H. A. Sampson has received research support from the NIAID/National Institutes of Health and from FARE (including funding supporting clinical trials in milk and wheat allergy); is Chair of the PhARF Award Review Committee; has received consultancy fees from Allertein Therapeutics, Regeneron, and the Danone Research Institute; and has received lecture fees from Thermo Fisher Scientific, UCB, and Pfizer. A. Nowak-Węgrzyn has received research support from Nestlé, the NIAID, FARE, Merck (DSMB), Nutricia, and Stallergens; has received royalties from UpToDate; and has received lecture fees from Thermo Fisher Scientific. L. Sickles declares that she has no relevant conflicts of interest.

    These authors contributed equally to this work.

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