Fruit-Induced FPIES Masquerading as Hereditary Fructose Intolerance

Hereditary fructose intolerance (HFI) symptoms develop at first introduction of fruit during weaning. We report on an infant with suspected HFI who presented with repeated episodes of vomiting and hypotension after ingestion of fruit-containing meals. The first episode occurred at age 4 months. Despite negative genetic testing for HFI, strict avoidance of fruit ingestion resulted in lack of recurrence of symptoms. Oral-fructose-tolerance testing conducted with an apple mousse did not determine hypoglycemia or fructosuria but caused severe hypotension. Allergy evaluations were negative, and the history was diagnostic for fruit-induced food protein–induced enterocolitis syndrome. Because this non-immunoglobulin E–mediated gastrointestinal food hypersensitivity manifests as profuse, repetitive vomiting, often with diarrhea, leading to acute dehydration and lethargy, it may be misinterpreted as HFI. We advise pediatricians to consider food protein–induced enterocolitis syndrome in the differential diagnosis when there is a suspicion of HFI. Pediatrics 2014;134:e602–e605 AUTHORS: Alessandro Fiocchi, MD,a Carlo Dionisi-Vici, MD,b Giovanna Cotugno, MD,b Pierluigi Koch, MD,a and Lamia Dahdah, MDa Division of aAllergy and bMetabolism, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy