Food protein induced enterocolitis syndrome caused by rice beverage
© Caminiti et al.; licensee BioMed Central Ltd. 2013
Received: 26 March 2013
Accepted: 7 May 2013
Published: 14 May 2013
Food protein-induced enterocolitis syndrome (FPIES) is an uncommon and potentially severe non IgE-mediated gastrointestinal food allergy. It is usually caused by cow’s milk or soy proteins, but may also be triggered by ingestion of solid foods. The diagnosis is made on the basis of clinical history and symptoms. Management of acute phase requires fluid resuscitation and intravenous steroids administration, but avoidance of offending foods is the only effective therapeutic option.
Infant with FPIES presented to our emergency department with vomiting, watery stools, hypothension and metabolic acidosis after ingestion of rice beverage. Intravenous fluids and steroids were administered with good clinical response. Subsequently, a double blind placebo control food challenge (DBPCFC) was performed using rice beverage and hydrolyzed formula (eHF) as placebo. The “rice based formula” induced emesis, diarrhoea and lethargy. Laboratory investigations reveal an increase of absolute count of neutrophils and the presence of faecal eosinophils. The patient was treated with both intravenous hydration and steroids. According to Powell criteria, oral food challenge was considered positive and diagnosis of FPIES induced by rice beverage was made. Patient was discharged at home with the indication to avoid rice and any rice beverage as well as to reintroduce hydrolyzed formula. A case of FPIES induced by rice beverage has never been reported. The present case clearly shows that also beverage containing rice proteins can be responsible of FPIES. For this reason, the use of rice beverage as cow’s milk substitute for the treatment of non IgE-mediated food allergy should be avoided.
KeywordsAllergy Enterocolitis Rice beverage Proteins
Food allergies are prevalent in the first 2 years of life and are usually IgE-mediated hypersensitivity reactions. Food protein-induced enterocolitis syndrome (FPIES) is a relatively rare and severe form of non IgE-mediated gastrointestinal food hypersensitivity reaction. It is frequently misdiagnosed and unrecognized at the initial presentation. Typical form of FPIES is characterized by a clinical onset before nine-month of age with food-induced severe vomiting, bloody diarrhoea, abdominal distension, dehydration, lethargy, pallor and metabolic acidosis. Symptoms occur 1 – 5 hours after ingesting the offending food. While the most common provoking foods are cow’s milk and soy protein based formula, FPIES was also documented with other foods such as rice, fish, wheat and poultry. To some extent children with FPIES reacted to more than one food[2, 3]. Diagnosis is based on history, clinical symptoms and exclusion of other causes, i.e. metabolic, toxicologic and intestinal etiologies.
Oral food challenge with 0.3 – 0.6 g/Kg of the suspected allergen can be used to establish diagnosis when history is unclear and to determine whether FPIES has resolved. The majority of children will outgrow their FPIES by about three to four years of age. Avoidance of the offending food is currently the only specific treatment of FPIES.
Management of acute episode requires continued fluid resuscitation and intravenous steroids. Epinephrine is not recommended but it should be useful for potential hypotension and shock.
In this report, we describe the case of a Caucasian 8 month-old male who developed FPIES after administration of rice beverage.
Criteria of positivity for oral food challenge according to Powell []
Observe/test for criteria*
Emergency therapies in place (i.e. intravenous access)
Verify normal weight gain and lack of symptoms while avoiding potential causal protein
Faecal blood (frank or occult)
Baseline and follow-up stool samples
Baseline peripheral blood PNM count
Repeat peripheral blood PNM count 6 h after ingestion
Increase of neutrophils >3.500/mm3
FPIES related to rice is a well recognized entity. Pediatricians should be aware that rice beverage not only has the potential to cause FPIES, but also that such reactions tend to be severe as those caused by cow’s milk or soy. A case of FPIES induced by rice beverage has never been reported. The present case clearly shows that also beverage containing rice proteins can be responsible of FPIES. Foods that may perceived as hypoallergenic are thought no triggers of FPIES; on the other hand rice is a common cause of FPIES and the use of rice beverage as cow’s milk substitute for the treatment of non IgE-mediated food allergy should be avoided. Of note, both early diagnosis and correct management of disease would ensure that appropriate dietary advice is given to families, thereby reducing the risk of repeated reactions, inappropriate interventions, and frequent hospitalizations. Moreover, rice beverages are “formulas” with low content of proteins, therefore children feeding only this food are at risk of low protein intake.
Rice is considered a trigger of FPIES and a reaction to rice beverage should be considered as a possibility.
Written informed consent was obtained from the parents of the patient for publication of this Case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
food protein induced enterocolitis
double blind placebo controlled food challenge.
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