Food protein–induced enterocolitis syndrome in response to salmon roe and trout roe

Clinical implications herein, we describe the first case in medical literature of food protein–induced enterocolitis syndrome response to specific fish roe. Adult-onset (FPIES) is an increasingly described phenomenon.1Nowak-Wegrzyn A. Berin M.C. Mehr S. Food protein-induced syndrome.J Allergy Clin Immunol Pract. 2020; 8: 24-35Abstract Full Text PDF PubMed Scopus (67) Google Scholar FPIES presents with symptoms including profuse emesis and diarrhea without cutaneous or respiratory symptoms, which appear 1 4 hours after ingestion a culprit food.2Connors L. O’Keefe Rosenfield Kim H. Non-IgE-mediated hypersensitivity.Allergy, Asthma Immunol. 2018; 14: 1-9PubMed Scholar, 3Du Y.J. Nowak-Węgrzyn Vadas P. adults.Ann Allergy, 121: 736-738Abstract (39) 4Nowak-Węgrzyn Jarocka-Cyrta E. Moschione Castro A.P.B. Investig Allergol 2017; 27: 1-18Crossref (62) This can result significant morbidity, as subsequent volume loss may progress hypovolemia, lethargy, circulatory shock.4Nowak-Węgrzyn Although typically diagnosis childhood, common culprits for adult-onset include crustaceans.2Connors Scholar,4Nowak-Węgrzyn it has been clearly delineated that IgE sensitization not perpetrator acute reactions,2Connors precise pathophysiology remains unclear. Complicating matters, there overlap between IgE-mediated allergy, presence elevated food-specific being associated persistent beyond childhood.4Nowak-Węgrzyn In addition, have conflicting reports regarding importance T cells, well questions possibility type IV hypersensitivity playing role.4Nowak-Węgrzyn Fish roe are enveloped ovarian membrane commonly used ingredients foods such sushi.5Hickey R.W. Sea urchin (uni) anaphylaxis.Ann 2007; 98: 493-494Abstract (12) Scholar,6Mäkinen-Kiljunen Kiistala R. Varjonen Severe reactions from concomitant allergy.Ann 2003; 91: 413-416Abstract (26) documented both those preexisting allergy it,5Hickey Scholar,7Kondo Y. Kakami M. Kawamura Nakajima Tsuge I. Urisu et al.Identification salmon allergens consideration cross-reactivity chicken egg.J 2005; 10: 2005Google Scholar,8Cosme J. Spínola-Santos Bartolomé B. Pastor-Vargas C. Branco-Ferreira Pereira-Santos al.Salmon emerging allergen Western countries.J 2019; 29: 139-141Crossref (2) no published cases We 54-year-old female recurrent episodes clinically convincing secondary trout A anesthesiologist presented delayed following Her history was unremarkable, she took regular medications, had allergy. The initial episode occurred multicourse restaurant meal. meal contained multiple different proteins. At end 90-minute meal, became severely nauseated. After vomiting restroom, returned home, where experienced 3 emesis, followed by intense chills, diaphoresis, watery diarrhea. There concern angioedema, urticaria, dyspnea. She did seek care, her resolved over hours. next day. No other diners who shared developed any kind. patient then identical 18 months, all meals. husband, physicians, search arrived at suspected FPIES. husband (author this article A.B.) contacted coauthor (H.K.), concurred. However, identifying triggering protein patient's proved elusive. regularly consumes fish, shellfish, eggs, meats, dairy reaction. finally provided clear cause-and-effect relationship culprit. consumed avocado egg on toast (a issue) along added garnish. Afterward, presentation previous 5 episodes. thorough review prior meals (through personal online photos menus) identified only ingredient 6 Serum-specific potential present during were drawn, component-resolved diagnostics peanut performed (Table I). Given gluten each these meals, celiac disease workup included II). These investigations yielded slightly positive number continues eat (ie, false-positive results); negative crustaceans, mollusks; non–IgA-deficient patient.Table ISerum-specific levels total serum blood work resultsCategoryResult (kU/L)Reference range (kU/L)Total IgE154<114Milk, egg, wheat HEW level0.15<0.10Ovalbumin<0.10<0.10Ovomucoid<0.10<0.10 CM IgE<0.10<0.10 Wheat IgE0.19<0.10Legume tree nut Peanut (total)0.57<0.10Ara h1<0.10<0.10Ara h2<0.10<0.10Ara h3<0.10<0.10Ara h8<0.10<0.10Ara h90.13<0.10 Soybean Sesame IgE0.19<0.10 Walnut IgE0.13<0.10 Hazelnut IgE0.17<0.10 Cashew Almond IgE<0.10<0.10Fish, crustacean, mollusk, beef Codfish Salmon Tuna Shrimp Scallop Beef IgE<0.10<0.10Serum-specific determined using Quest Diagnostics Immunoassay. Interpretation serum-specific level (kU/L): <0.10, absent/undetectable; 0.10-0.34, very low; 0.35-0.69, 0.70-3.49, moderate; 3.50-17.4, high; ≥17.5, high. Abnormal laboratory results bolded.ARA h, Arapis hypogaea; CM, cow’s milk; HEW, hen’s white. Open table new tab Table IIResults diseaseInvestigationResultReference rangeSerum IgA level2.74 g/L<0.47-3.10 g/LTTGA level<1 U/mL<4 U/mlTTGA, Tissue transglutaminase antibody. bolded. ARA TTGA, represents unique form believed be distinct owing T-cell recognition certain allergens.2Connors debated explanation favored many, provides absence typical anaphylaxis timing reaction.1Nowak-Wegrzyn Despite prevalence small series study hypothesized vitellogenin (Oncorhynchus keta) roe, apparently non–cross-reactive also egg.7Kondo thought represent antigen itself but flesh.8Cosme addition this, quite species-specific, sporadic patients developing species roe.5Hickey One weakness our report stems lack hospital-based oral provocation testing confirm keeping proposed diagnostic criteria Nowak-Wegrzyn al, coupled 10 ingestion, pallor, lethargy.1Nowak-Wegrzyn As clinical diagnosis, setting unnecessary potentially dangerous, particularly patient’s case. physicians thus able provide exceptionally detailed history. de novo Interestingly, trout, salmon, (including masago, tobiko, ossetra caviar) complete reactivity. line aforementioned anaphylaxis, tolerate originated issue.6Mäkinen-Kiljunen members family Salmonidae,9Crête-Lafrenière Weir L.K. Bernatchez Framing salmonidae phylogenetic portrait: more picture increased taxon sampling.PLoS One. 2012; 7e46662Crossref (166) perhaps explaining relevance based its uniqueness additional further delineation mechanisms underlying reactions. It us 2 demonstrated flesh either species. could explained vitellogenin, itself, reaction linear epitope vitellogenin. poorly understood phenomenon, advance body knowledge propel forward understanding immunologic underpinning it.