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Sami Bahna, MD, DrPHProfessor of Pediatrics & Medicine
Chief of Allergy & Immunology Section
Louisiana State University
Health Sciences Center
Shreveport, Louisiana
WISC, Dubai, Dec 2010
• MEDICAL HISTORY: Nature & course of symptoms, feeding
history, relation of symptoms to eating or to other factors
• PHYSICAL EXAMINATION: Signs of allergy or other diseases
• INITIAL LABORATORY TESTS:
To exclude nonallergenic disease
To support allergy diagnosis (IgE; eosinophils)
• SCREENING TESTS FOR FOOD ALLERGENS:
SPT; specific IgE Ab; trials of elimination diets; diaries
• VERIFICATION : Elimination – challenge test
Food Allergy Diagnosis
Medical history± Skin testing± Specific IgE
Suspected foods
Strict elimination trial
Symptoms improved
Challenge test
Equivocal symptoms
Definite symptoms
No symptoms
OFFENDING FOOD
Symptoms not improved
Food reintroduced
No change
Symptoms worsened
INNOCENT FOOD
Single-blind Double-blindOpen
A. Open Food Challenge
• Food is given in its usual form.
• Both the observer & the patient know.
• Acceptable in infants & young children with
objective symptoms.
• Preliminary screening of foods that are at a low
level of suspicion.
B. Single-Blind Food Challenge• Food should be well disguised (color,
texture, odor, taste).
• Appropriate placebo.
• Observer knows but not the patient.
• Tests must be administered in the same way.
• Result is revealed to the patient after all
challenges are done.
• Applicable to most cases in clinical practice.
C. Double-Blind Food Challenge• Food is well disguised (color, texture, odor, taste).
• Neither observer nor patient knows.
• Food & placebo prepared & coded by a third person.
• Test substances are given in a random fashion,
exactly in the same way.
• After all challenges are done, code is opened &
results are discussed.
• Ideal for research & for some cases in clinical
practice.
How reliable is the medical history
in food allergy diagnosis?
Reactions to Foods & AdditivesEstimated Prevalence
• Claimed by 20-30% of people. These are self-diagnosed perceived reactionsto foods; highly over-estimated!
• True (confirmed) food allergy:6-7% in children1-2% in adults
Manifestations in 4 patients with confirmed
food allergy out of 23 who claimed so(Pearson et al: Lancet 1:1259, 1983)
Urticaria 4
Allergic rhinitis 4
Bronchial asthma (2 immediate & 1 late-onset) 3
Atopic dermatitis 2
Abdominal pain 2
Symptoms attributed to “food allergy” by 19 patients
in whom food allergy was not confirmed(Pearson et al: Lancet 1:1259,1983)
Symptoms No. %Lethargy or feeling unwell 16 84
Head pain or tightness 13 68
Abdominal swelling or discomfort 10 53
Depression 10 53
Bowel disturbance 9 47
Paraesthesia 9 47
Nausea 8 42
Palpitation 8 45
Abdominal pain or heartburn 7 37
Threshold
Psychiatric score in patients presenting with suspected food allergy
(Pearson et al: Lancet 1983, 1:1259)
Your problem isn’t
something you ate.
It is something you
married.
How reliable is skin testing in
food allergy?
Skin Test Reliability Compared to
Double-Blind Oral Challenge to Food
Cow Egg
Skin test reliability % Total* milk Crab white Fish Peanut Shrimp
Sensitivity (true positive test) 57.9 44.4 66.7 66.7 83.3 66.7 62.5
Specificity (true negative test) 65.2 66.7 60.0 80.0 50.0 57.1 75.0
Positive predictive accuracy 47.8 66.7 33.3 50.0 83.3 40.0 71.4
Negative predictive accuracy 73.8 44.4 85.7 88.9 50.0 80.0 66.7
* Include figures on several foods, which are not presented individually because of small numbers
Predictive SPT wheal diameter of positive
challenge to egg & milk in children______________________________________________________________________________________________________________________________________
Predictive SPT diameter (mm)
level < 1 yr > 1yr
Hen egg 90% 9.3 11.1
95% 11.2 13.3
99% 15.4 18.3
n = 26 n = 134
---------------------------------------------------------------------------
Cow milk 90% 7.9 13.2
95% 9.7 15.799% 13.5 *
n = 154 n = 149
* could not be calculated. (Modified from Verstege et al. Clin Exp Allergy 2005; 35:1220)
Skin prick test result compared with food challenge outcome.
(Nolan et al: Ped Allergy Immunol 2007,18:224)
Positive challenge
Negative challenge
How reliable is sIgE testing in
food allergy?
sIgE (RAST) Reliability Compared to
Double-Blind Oral Challenge to Foods
Cow Egg
RAST reliability % Total* milk Crab white Fish Peanut Shrimp
Sensitivity (true positive test) 58.3 55.6 66.7 33.3 100 75.0 62.5
Specificity (true negative test) 33.4 66.7 40.0 40.0 0.0 28.6 37.5
Positive predictive accuracy 43.7 71.4 25.0 14.3 71.4 37.5 50.0
Negative predictive accuracy 67.4 50.0 80.0 66.7 0.0 66.7 50.0
* Include figures on orange, tomato and soy, which are not presented individually because of small numbers
Predictive Value of Food-Specific IgE
by CAP-FEIA in Children with
Atopic Dermatitis(Sampson & Ho: JACI 1997; 100:444)
Food PPV 90% PPV 95%
Egg 2 KU/L 6 KU/L
Peanut 9 KU/L 15 KU/L
Fish 9.5 KU/L 20 KU/L
Milk 23 KU/L 32 KU/L
Soy Best PPV was 50%, at 65 IU/ml
Wheat Best PPV was 75%, at 100 IU/ml
Probability curves for food reaction according to sIgE
immunoCAP in a prospective vs a retrospective study (1997)(Sampson : JACI 2001; 107:891)
Probability curves for food reaction according to sIgE immunoCAP
in a prospective vs a retrospective study (Sampson & Ho1997)(Sampson : JACI 2001; 107:891)
6
Probability curves for food reaction according to sIgE immunoCAP
in a prospective vs a retrospective study (Sampson & Ho1997)(Sampson : JACI 2001; 107:891)
32
Probability curves for food reaction according to sIgE immunoCAP
in a prospective vs a retrospective study (Sampson & Ho1997)(Sampson : JACI 2001; 107:891)
15
Probability of positive egg challege according to sIgE (ImmunoCAP) in
children (0.2-14.6yr); mostly AD (74%)(Komata et al: JACI 2007;119:1272)
Egg
Probability of positive milk according to sIgE (ImmunoCAP) in
children (0.2-14.6yr); mostly AD (74%)(Komata et al: JACI 2007;119:1272)
Milk
sIgE levels with 95% predictability of
positive challenge by age (Komata et al: JACI 2007, 119:1272)
Age Egg Milk
< 1 yr 13 KU/L 5.8 KU/L
1 to < 2 yr 23 KU/L 38.6 KU/L
2 yr + 30 KU/L 57.3 KU/L
(sIgE by Immuno-CAP system)
What is the best cut-off of milk-sIgE level?(Garcia-Ara et al, J Allergy Clin Immunol, 2001)
Specific IgE interpretation
Factors to be considered:
• Total IgE level
• Patient’s age
• Type of allergy manifestation
• Severity of allergy manifestation
• Food allergen
• Degree of exposure to the food
• Duration of avoidance of the food
Why Food Challenge?
• Verification of the diagnosis of food allergy.
• Identification of the truly offending food(s).
• Limiting the dietary elimination, which would:
- Improve the quality of life.
- Enhance the compliance with diet.
- Prevent potential mal- or under-nutrition.
• Exclusion of food allergy would allow further
investigation for other causes of the symptoms.
Positive Double-Blind Food Challenge in 10 Studies
Author Population Children Adults
Positive DBFC
Foods Patients May ’76
Aas ’78
Ford & Fergusson ’80
Sampson ’87
Bock ’86
Sampson ’88
Bernestein et al ’82
Atkins et al ’85
Onoreto et al ’86
Bahna & Gandhi ’87
Range
Average
X
X
X
X
X
X
X
X
X
X
X
X
14/70
119/446
26/54
22/104
96/431
180/514
13/46
12/71
13/35
38/107
533/1878
(20%)
(27%)
(26%)
(21%)
(22%)
(35%)
(28%)
(17%)
(37%)
(36%)
(17-37%)
(28%)
11/38
-
26/40
14/26
81/206
98/160
10/22
10/24
11/20
36/61
297/597
(29%)
-
(65%)
(54%)
(39%)
(61%)
(45%)
(42%)
(55%)
(59%)
(29-65%)
(50%)
(Modified from Pastorello et al. Allergy Proceeding 1991;12:319)
Should food allergy be always
confirmed by challenge?
In instances where a specific food has
caused a life-threatening reaction,
particularly if more than once,
food challenge in any form is
contraindicated.
(If necessary, skin or labial contact may be done)
Let’s get out of here.