An 8-year-old child came to our Pediatric Allergy Unit to evaluate his cow’s milk (CM) and fish allergy. During the first year of life he manifested severe atopic dermatitis and chronic diarrhea with mucorrhea and rectal bleeding and for this reason he began a CM-free diet.
The association of diarrhea with atopic dermatitis led to the exclusion from diet of foods frequently considered responsible for allergic hypersensitivity (egg, wheat, tomato and peanuts), even though skin-prick tests (SPTs) were negative, and to eliminate fish, that yielded a weakly positive response to extract from codfish. No clinical improvement was observed. At 4 years of age because of persisting anemia and chronic diarrhea, he was treated with mesalazine. Immediately he developed abdominal pain with raised serum amylase and lipase levels. Pancreatitis was diagnosed and two additional episodes occurred while off therapy.
At 8 years of age, when he came to our attention, reactivity to CM was absent (SPTs: CM, negative, histamine, 3 mm; sIgE ImmunoCAP: CM,<0.35kU/l), while weak reactivity to codfish was observed (SPTs: cod, 4 mm, sIgE ImmunoCAP: cod, 1.30kU/l). We reintroduced CM into the diet and then we performed the food challenge test (FCT) with cod that resulted negative. Nevertheless, when he ate cod again, he developed anaphylactic reaction within 5 minutes with rhinitis, asthma, stridor, urticaria and pallor. After resolution (adrenaline im, chorpheniramine iv and hydrocortisone iv), the child complained of abdominal pain; pancreatic enzyme serum levels had risen (alpha-amylase from 104 UI/L to 2559 UI/L). Ultrasonography showed findings compatible with pancreatitis (Figure 1), that resolved within 7 days after specific therapy for pancreatitis (intravenous gabexate mesilate and ranitidine); serum alpha-amylase and lipase levels significantly decreased after 72 hours of treatment (219 UI/L and 114 UI/L, respectively). Since then he has been on fish-free diet and did not experience additional pancreatitis episodes.