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Cátia Alves1, Ana Margarida Romeira1, Paula Leiria Pinto1

1-Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE, Lisboa

Congress of the European Academy Allergology Clinical Immunology - Poster

Milk allergy is usually IgE mediated, with immediate symptoms (cutaneous, respiratory, gastrointestinal or anaphylaxis). Cow’s milk oral tolerance induction (OTI) is an effective treatment option for persistent IgE-mediated milk allergy.
Food protein-induced enterocolitis syndrome (FPIES) is a non-immunoglobulin E (IgE) mediated gastrointestinal food hypersensitivity that manifests as profuse vomiting and often with diarrhea. Cow’s milk or soy proteins are frequently the cause.

Case Report
We describe the clinical case of a boy, nowadays 10-years-old, referred to the Immunoallergology Department when he was 1,5 months of age due to rectal bleeding and vomiting after milk formula intake. Skin prick tests (SPT) for milk and protein fractions were negative and there was resolution of the symptoms with milk eviction and use of an extensively hydrolyzed formula. SPT became positive for milk at 19 months. Specific IgE (sIgE) were evaluated at 3 months of age and were positive for milk, alpha-lactalbumin and beta-lactoglobulin. sIgE were evaluated twice and afterwards once a year and they remained similar along the years (milk 2,12 KUA/L, alpha-lactalbumin 1,32 KUA/L, beta-lactoglobulin 0,57 KUA/L and casein 0,47 KUA/L, at 7-years-old). We performed two cow’s milk oral food challenge (OFC), at 12 months and 4-years-old. In both, he developed incoercible vomiting, dehydration and prostration, more than 2h after the beginning of the intake. He also had 2 similar episodes (6-years-old), 1,5 to 2,5h after accidental ingestion of cow’s milk. No respiratory or cutaneous symptoms were observed in any of the milk allergic reactions. It was decided to begin OTI for milk when he was 8-years-old. During the process, he had symptoms with the ingestion of milk – vomiting, abdominal pain and nausea – in 2 or 3 appointments, with spontaneous resolution. After 6 visits, the procedure was completed with the daily ingestion of 200 ml of milk. Today, 21 months after the end of the procedure, he ingests 200 ml of milk per day and 3 times per week another food with cow’s milk protein, without symptoms.

A small subset of infants fulfilling the clinical diagnostic criteria for FPIES has or develops IgE antibodies to the trigger food. These patients are referred to as having atypical FPIES. The OTI performed in this case of atypical FPIES was successful, also for the gastrointestinal symptoms with a late onset (probably more related with a non IgE mechanism).

Palavras Chave: milk allergy; oral tolerance induction; non-IgE mediated food allergy