Sunday, December 9, 2012

Non-IgE Mediated Food "Allergies": or “Why can’t your daughter have tortilla chips if she can have Go-Gurt?”


The intersection of a healthy immune response and idiopathological autoimmunity in an environment as complex as the gastrointestinal (GI) tract remains a wild, new frontier for immunologists, clinicians, and patients alike. I’d like to share a brief overview of my foray into atypical food allergies.

Briefly, my daughter, Indigo, was “colicky” as a newborn and infant, only sleeping for 2-3hrs at a time. After a hive-inducing administration of yogurt at 9mo of age, she was tested for a dairy allergy. The lab assayed her blood for IgE against the top eight allergies1; the result was a positive test for six of those eight allergens. An extended panel testing for IgE to 67 foods returned a positive result for 17 potentially problematic foods, though the test has a high rate of false positives 


The foods that I ate were broken down and passed to her in breastmilk which is what she was fed exclusively until ~ 5months when solids were introduced.2 Baby formula is manufactured from soy and/or dairy components---to which she had significant levels of circulating IgE. There are a handful of “hypoallergenic” elemental formulas that are composed of single amino acids--such as Elecare. These formulas would have cost us ~$1/liquid ounce--~$30/day.

Since breastmilk was her clearly her best option, suddenly an Elimination Diet was the only choice for her—and for me. This is how I found myself eating only turkey, rice, pears, apples, squash, and potatoes for six months3. We were desperate for a solution and desperate for sleep4; it was a drastic measure, but it worked. She weaned at 14 months and my diet returned to normal.

In severely allergic children, there is a tendency towards malnutrition and diminished growth due to incomplete absorption in the gut. This was never the case with us; Indigo was always a chunky baby, visibly healthy and sharp. She had some eczema on her cheeks, but it was subtle and transient. From time to time there was traces of blood in her stool, but this didn’t bother the gastroenterologist, because she was “thriving”.

Indigo is now almost five years old and annual tests have shown her IgE titers to have fallen dramatically over time. After a negative blood test for a previously offensive food, we used skin testing, another standard method for detecting IgE-mediated allergies. However, even after these came up negative she would exhibit “Screaming Tummy” (as I’ve dubbed it) when food challenged. This is a delayed reaction (4-5hrs post-exposure) evidenced by stomach pain, crying, and most especially night-waking with hysterical writhing and obvious cramping. The lingering effects include blood in her stool and render her more prone to reactions in subsequent days. 


Skin testing, 18months.
Skin testing, 3 years. Negative control on left shoulder, histamine positive control on right shoulder. These foods all tested negative. 

Allergenic foods no longer elicit hives and edema in Indigo; her symptoms have become strictly GI in nature. She has never tested positive via blood or skin test to corn, but ingestion of corn proteins prevent her from sleeping soundly at this point. It is only these proteins and sesame that are now avoided---miraculously easy compared to where we started.

As we have discussed in class, the body produces allergic reactions to proteins preferentially over sugars. I’ve spent many hours just this month trying to explain this phenomenon to her preschool. Corn is in everything5---but thankfully we just need to avoid the protein. As for the Go-Gurt? It contains high fructose corn syrup, modified corn starch, and “natural and artificial flavors”. It likely should not be fed to any children although it is mysteriously found in our fridge. 

As for a diagnosis, her symptoms mostly closely resemble eosinophilic gastritis—abnormally high numbers of eosinophils and excessive mast cell degranulation causes histamine, enzymes, and heparin to be released en masse along the lining of the GI tract resulting in localized cell damage, chronic inflammation, and recruitment of additional eosinophils that continue the cycle. (**Note that this is technically Type I Immunopathology and not true "allergy"!) We’re fortunate enough to have access to the extraordinary Gastrointestinal Eosinophilic Diseases Program –a joint venture between The Children’s Hospital and National Jewish Hospital. In a few weeks we will meet with her specialist again to discuss potential new therapies besides simple avoidance of the foods. 

First chocolate cake, age 4. 
We know that IgE is the usual suspect in allergic reactions. Clearly Indigo was an atopic child with high levels of circulating IgE---a genetic predisposition to this type of reaction. We also know that the composition of lymphocytes in the blood differs from early childhood to adulthood—the neutrophil to lymphocyte and the Th1 to Th2 ratios, for example. Her CBC at 18mo shows her lymphocyte levels below normal, but I have to wonder whether the reference ranges take into account the patient’s age—perhaps someone out there knows…? 

Are there other observations/thoughts/explanations you might have? Do you recall that food allergies are most common in surburban, Caucasian, singlets with microbiologist mothers? 
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1) These “top eight allergens”—peanut, tree nut, milk, egg, wheat, soy, fish, and shellfish--account for ~90% of food allergic reactions and are part of required labeling by the FDA on ingredient lists. You’ll see other iterations of this list (“Top 10” includes sesame and gluten as separate from wheat or include coconut; “Top 7” will lump together fish and shellfish, etc. etc.) http://www.foodallergy.org/section/allergens

2) This is supposed to help protect from food allergies---bathing her intestines in mother’s IgA confers natural, passive immunity. 

3) I eventually added olive oil, sunflower, and Chipotle Tabasco sauce for variety.

4) She did not sleep through the night once until 11 mo. old, intermittently from 1 to 2yrs and then less than a dozen times between age 2 years and 3 years. During that interim period of 1-2yrs, it seems she developed a completely new allergy to corn that was undetected until age 3.

5) The usual suspects include “...Whole corn or maize, popcorn, corn flour, corn starch, corn meal, corn alcohol, corn gluten, corn sweetener, corn sugar, corn syrup and corn oil…Derivatives of corn include: dextrose, dextrin, dextrate, maltodextrin, caramel, malt syrup…Corn starch is added to most confectioner’s sugar and baking powder to keep them from caking or clumping...modified food starch, vegetable gum, or vegetable starch may or may not be derived from corn…(and) other foods that might contain corn (include): distilled white vinegar, bleached white flour, (and) iodized table salt.” 

We’re not through yet: “Corn oil might be used in emollient creams and toothpastes. Corn syrup is often used as a texturizer and carrying agent in cosmetics. Corn may be present in adhesives for envelopes, stamps, and stickers. Plastic wrap, paper cup, and paper plates can be coated with corn oil...Some of the most commonly encountered corn-contain medications include the following: aspirin, throat lozenges, ointments, suppositories, vitamins, laxatives, (and) bath powders contain corn starch. “--summariezed from Joneja, Janice Vickerstaff et al. “Dealing With Food Allergies in Babies and Children”. Bull Publishing Company. Boulder, CO. 2007. ISBN 978-1-633503-05-9 

8 comments:

  1. That Go-Gurt, it shows up everywhere. I suppose there's no percentage in trying to convince her that she won't be able to drink bourbon when she's older, because of the corn?

    I didn't think so. :)

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  2. That is a really fascinating story. Its a good thing she was able to be breastfed for so long, and an even better thing that she can tolerate corn carbohydrates. I am lactose intolerant so I have learned to look for lactose in unlikely places, but at least I don't need to worry about my envelopes and paper plates being coated in it. I wonder what the incidence of type I hypersensitivity of corn carbohydrate is.

    Your post got me thinking about the Travelan IgA from Australia for traveler's diarrhea. Maybe it could be made for corn proteins as well, and it could allow her to eat corn containing things on rare occasions. Even better, maybe they could find a way to preferentially stimulate her IgA production over IgE production against corn proteins, so corn would be bound up by IgA before it could elicit an allergic response. Maybe someday.

    About the CBC reference range in toddlers. I used to work at Boulder Community Hospital's clinical lab, and I know that the reference ranges given on an individual patient's CBC are tailored to the individual patient, integrating information such as age, sex, and even whether the blood was from a capillary puncture or from venous blood. However, not all labs do this and I am not sure if University Hospital does this tailoring (they most likely do but I don't know for sure). It is easy to find CBC reference ranges for an 18 month old on the internet. Here are two different sites with pediatric age-specific reference ranges:

    https://www.pediatriccareonline.org/pco/ub/view/Pediatric-Drug-Lookup/153930/0/normal_laboratory_values_for_children

    http://www.childrensmn.org/manuals/lab/hematology/018981.asp

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    1. Thanks for your insight into the CBC, that's helpful.

      As for boosted IgA production, it seems that this might be a good therapy in very young children with an unpopulated GI tract that are prone to "leaky gut"...?

      I don't know what the relative titers are for IgA to IgE, but I think the larger obstacle would be the potential for quick saturation of all potentially binding antibodies with a quick bite of polenta. I'm imagining the quantity of antigen on a a grain of cornmeal and thinking it's be hard to bind up in large "doses".

      I do like this idea of binding the reactive IgE, but I wonder if that plays a role in the tolerance therapies (repeated administration of the offending food).

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  3. Also, I am interested in how they arrived at the diagnosis of eosinophilic gastritis. It makes sense based on the symptoms, but did they do some sort of gastric lavage during an episode that was found to be rich in eosinophils? Is it something that can be visualized on an endoscopy?

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    1. Good question!! :) Because of her age and the "you can't do anything about it anyways" factor, they have not yet biopsied her for a formal diagnosis.

      Dr. Furuta at Nat'l Jewish was part of a panel and first author on a 1997 paper in Gastroenterology entitled, "Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment." which convened 31 specialists to review cases and establish diagnostic criteria. They concluded the following in their paper:

      "(1) Symptoms including but not restricted to food impaction and dysphagia in adults, and feeding intolerance and GERD symptoms in children;

      (2) > or = 15 eosinophils/HPF; (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD.

      (3) Exclusion of other disorders associated with similar clinical, histological, or endoscopic features, especially GERD."

      Recall that eosinophils are not normally found in large numbers in the intestinal mucosa. And yes, he's talking about eosinophilic esophagitis (EoE) not gastritis which is further along in the body.

      I am brimming with hope that new therapies might be within grasp in will (after the end of the semester has ended, admittedly) report back if anything interesting arises.

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  4. First I am so happy Indigo is doing well!! This blog was a joy to read, you are a gifted writer.

    I did find it interesting that she has a sensitivity to corn proteins which made me begin to think of all the possible new "allergies" we may begin to see as the long term and generational affects of GMO's begin. I had the pleasure of taking a course in my undergrad with one of my most favorite professors around these topics. She is a proponent of GMO's and we still argue around the potential issues. She is a molecular scientist and would beat into my head that these modified foods are safe and will be the only way to sustain the exponential population growth. I am always wary on changing foods of any sort in any way since there has been such negative side effects when we do. It will be interesting to see as time continues since as you mentioned the vulnerable population is wealthy, suburban families who are the typical ingest-ors of these types of food. Gogurt may not be our only problem.

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  5. I share your hesitation about GMOs, and it actually crossed my mind while reading the post since most corn products are GM in the states. The standard to get FDA approval for drugs, which a small subset of the population will consume in most cases, is so much stricter than for GMOs, which pretty much every American consumes every day. I don't know, that just doesn't seem right to me. Sometimes really small chemical changes have unexpected effects.

    I can't say that I have really explored the research on GM foods, but I have heard about 1 or 2 animal studies that make me wonder about their safety. I know that GM foods are purported to be a solution to world hunger, but I have a hard time trusting the charitable notions of large companies like Monsanto. In practice it seems like GM crops just allow farmers to use more and more pesticides, which doesn't seem great for the environment or us.

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  6. There are so many possible explanations for our spike in food allergies, and I thought GMO's were a bogus culprit for the longest time. One idea alone stands out to me as a valid explanation what all of the fuss is about: the insertion of one gene in just the wrong place can do a lot of harm....in the notes JJ Cohen shares the news stories of gene therapies gone horribly wrong ("Gene Therapy Link to Cancer Cases", in the 10/30/12 Immunodeficiency notes) wherein two children with SCID with a retrovirus were unlucky in the location where the virus inserted itself. They developed leukemia and retroviral trials were halted.

    So what happens when we randomly insert anti-pest, pesticide resistance, drought resistance/tolerance genes into corn? I wonder if there's an increase risk when we put multiple genes into zea mays....? I'd love to read real science about that rather than just hysterics; the GMO opposition sure has a lot of volume and a lot of sketchy science, but maybe there is something to it.

    One more thought: if we were getting some decrease in food allergies from refusing GMO foods and eating organic, wouldn't we be seeing it in the urban/suburban affluent populations shopping at Whole Foods...???

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