ALLERGY

RECALL:

First contact:

1. Dietary proteins taken up by a variety of cells before being processed

and presented as fragments to nave T helper( T0 )cells.
2. The nave T cells are stimulated to differentiate into Th cells, either:
Th1 or Th2, elaborating cytokines along the way.
3. If the response is destined to be allergic, the Th2 cell population is
expanded and Th2 type cytokines are produced.
4. These cytokines will influence B cells to mature
into IgE bearing plasma cells and will produce a
specific IgE antibody response (they make a lot of
IgEs)
5. The IgEs attach themselves to receptors on
membranes of mast cells and basophils. They are
now ready for the second exposure

Second contact:

1. On second contact with the same food antigen,

the IgE antibodies are cross linked and mast cell
activation occurs.
2. Mast cell degranulation occurs and there is an
elaboration of mast cell mediators: histamine and
others e.g. leukotriene which have their
downstream effects
3. The patient will then have the allergic response.

SIGNS OF ALLERGIC REACTION

Swelling of lips, face, eyes

Hives or welts
Tingling mouth
Abdominal pain, vomiting (tend to be insect
related)

SIGNS OF ANAPHYLAXIS

Anaphylactic agents are avoided for life. Following are in

the exam!!!!

Difficult or noisy breathing stridor or wheeze

Tongue swelling ( not just lips)
Swelling or tightness of throat, unable to swallow saliva
Wheeze/persistent cough
Difficulty talking/hoarse voice
 Persistent

dizziness or cough
Pale and floppy (young children)

CAUSES

Major allergenic foods (>85% of allergy) in:

o Children: milk, egg, soy, wheat, other depending on geographical area
o Adult: peanut, nuts, shellfish, fish
Most people with a food allergy have a single food (or related) allergy, which is
more common that multiples food allergies
 For many of the food allergens we know understand the epitopes (epitope: part of
the antigen that is recognised by the IgE antibodies and by B cells and T cells)
o Most of these epitopes are 3D. They have a linear and a conformational
epitope the way they are folded will bring certain molecules into close
positioning with each other, forming the epitope
o The state in which the person is exposed to the epitope influences their
reaction
Often a recognised conformational epitope can be tolerated in a
cooked state (e.g. egg) because the conformation is undone with
cooking (the more we cook it, the more it undoes)
Those who recognise the epitope in a linear form, it is conserved
with cooking so patient cant tolerate it

Peanut doesnt get better, is unchanged by cooking and is a legume. Milk and egg allergy
can be followed up with skin prick tests as they tend to get better with age

What can be done?

Breastfeed until 6 months

Exposure to proteins needs to be in a critical early window to produce oral
tolerance (probably 4-6 months in humans, which is a similar timing to gut
colonisation. E.g. to prevent peanut sensitisation, introduce peanut butter at <6
months, with regular reintroduction through childhood
Communicate with the patient or parent
o Explain the ASCIA action plan (opposite)
o Epipen show parent and explain how to use this
o Regular immunologic follow-up

MANAGEMENT

Anaphylaxis

Use the DRS ABCD algorithm

Remove trigger
If patient has respiratory or cardiac arrest:
o Basic and advanced life support
o Adrenaline: 10 mcg/kg
IM if respiratory arrest
IV if cardiac arrest

Mild to moderate allergic reactions

Non-sedating antihistamines are first line therapy

Can be used with or without short course oral steroids

WHAT PROTECTS US AGAINST ALLERGY?

Bugs! Bugs may skew away from parasitic response experiments show that germ-free
mice become more readily allergic. Children born by Caesarian Section are more likely to:

Report wheezing
Report asthma diagnosis
Be allergic
Hunter gatherer mothers commonly chew infant food, and children whose mum
cleaned dummy by sucking it were less likely to have:

Asthma
Eczema
Allergic sensitization at 18 months

Vaginal delivery and parental dummy sucking appear to yield independent additive
protective effects against eczema. There is some reversal of effect of sterile delivery by
supplementing with probiotics, while early antibiotics increase allergy. Dirt in the house
and exposure to bugs also causes less asthma and allergic sensitisation.

Food allergy

We can look at food allergy as a continuum of

immunopathogenetic mechanisms.

On one side we have typical IgE mediated

reactions
o Rhinitis/ asthma
o Urticaria/angioedema; urticaria is one of
the commonest manifestations of food
allergy in its most dramatic form we see
anaphylaxis)
o Oral allergy syndrome occurs in patients with Class 2 allergen symptoms;
most common clinical manifestation is immediately on ingestion of the
vegetable/fruit, there is itching and tingling of the lips, oral cavity,
oropharynx and GIT symptoms (may manifest as nausea, vomiting,
diarrhoea)
o In ~20% of people, if they eat enough of the food despite the early
warnings, they will develop anaphylaxis (but this is not as common in Class
2 allergens because it gives immediate warnings on contact with oral
mucosa, so as long as they stop eating it wont become a full blown
systemic reaction). Most children with allergy to Type 1 dont get the oral
warning, so they may develop anaphylaxis because they continue eating it
Mixed cellular responses and IgE responses
o Atopic dermatitis
o Eosinophilic GIT problems, e.g. eosinophilic oesophagitis, eosinophilic
gastroenteritis
Cellular responses
o Seen in response to some of the more complex food allergy syndromes e.g.
Coeliac disease
o These people may have IgE mediated response also, but it is not the driver
of the disease
o Similar process for the protein induced enteropathies seen in infants and
young children

History from the mother is vital!

IgE mediated Non-IgE mediated

Diagnostic Specific IgE Elimination diet followed by reintroduction
tests Skin prick test
Food challenge
Examples Acute urticaria Food protein induced proctocolitis
 Angioedema Food protein induced enterocolitis
Anaphylaxis Food protein induced enteropathy

SKIN PRICK TEST

Opposite shows a skin prick test. The skin is pricked,

some antigen is introduced into the prick. This size of
the wheal (the raised bit the flare refers to the
reddened bit) is then measured.

TYPES OF FORMULAE

Standard
o This is modified cows milk, available in supermarket. Cows milk and baby
formulae consist of protein, fat and carbohydrate (disaccharides: lactose,
glucose, fructose)
o AR = Anti-reflux
Single modifications are lactose free formulas. This is helpful after a
gastroenteritis, as the lactases on the small intestinal brush border get a bit
screwed up after the initial illness, and these formulas prevent exacerbation of the
temporary lactose intolerance that follows (lasts about a week)
Modified formula
o Extensively hydrolysed formulae Used in CMPI
Example is Pepti-junior, where proteins are broken down into small
chains of amino acids.
o Amino acid formulae
Neocate/elecare this is formulae which is even more highly
modified than the Pepti-junior, in which the protein is broken down
into amino acids, the fat is broken down from triglycerides into
monoglycerides, the carbohydrate disaccharides are broken down
into monosaccharides. This ensures the breakdown of the allergenic
part of the formula (the protein). Obviously this is super expensive
around $200 a tin. Can only prescribed by paediatric
gastroenterologists.
Junior formulae pediasure

DONT restrict your childs diet unless you have to!! It isnt natural!