Jack is a 26 month old male who returns to your clinic after an ER visit for food allergy. He ate a piece of a granola bar that was produced on a line with peanut and tree nuts. Fifteen minutes later he developed hives on his arms, legs, and trunk. His mother next noticed periorbital edema and wheezing. He was taken to a nearby ER and was treated with IM epinephrine, diphenhydramine, steroids, and one albuterol nebulized treatment. He was observed in the ER and then discharged home that evening. He was sent home with a prescription for an epinephrine auto-injector.
Jack has a history of eczema that is well controlled with topical emollients and occasional topical steroid use. He has no prior history of wheezing. His parents do not report any previous exposure to peanuts. He eats eggs, milk, soy and wheat with no symptoms of food allergy. He has never eaten tree nuts, fish, or shellfish.The parents are concerned about other potential signs of food allergy. Other signs may include:
Explanation to Question 1
There is a wide range of manifestations of food allergy. Food allergy has been reported in up to 35% of patients referred to an allergist or dermatologist for atopic dermatitis. Evaluation should be considered in infants and children with moderate to severe atopic dermatitis or if there is a history of exacerbation when eating specific foods. If food allergy is diagnosed, the atopic dermatitis often improves after dietary elimination of that particular food. The causes of acute urticaria vary and include infection, drug reaction, and food allergy. Acute urticaria is a common symptom present with food allergy. In contrast, chronic urticaria is very rarely related to food allergy. Food allergy testing is rarely indicated for chronic urticaria since most cases are idiopathic.
Multiple nasopharyngeal symptoms occur with food allergy, including acute rhinitis, but the rhinitis is typically associated with other oropharyngeal symptoms such as pruritus of the throat and angioedema. However, chronic rhinitis is not a manifestation of food allergy.
The correct answer is D, both atopic dermatitis and acute urticaria may be signs of food allergy.
Sources:
1. Burks W. Skin Manifestations of Food Allergy. Pediatrics 2003; 111:1617-24.
2. Kulthan K. Prevalence and relevance of the positivity of skin prick testing in patients with chronic urticaria. J Dermatol 2008; 35:330–35.
