L Allergia Alimentare

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Eleonora Franco
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1 L Allergia Alimentare Elena Lionetti Dipartimento di Scienze Mediche e Pediatriche Università di Catania

2 L allergia alimentare: Le linee guida NIAID Guidelines, J Allergy Clin Immunol 2010 WAO Guidelines, Ped Allergy Immunol 2010 NICE guidelines, nice.org.uk.guidance 2011 ESPGHAN guidelines, JPGN 2012

given food NIAID Guidelines, J Allergy Clin Immunol 2010 WAO Guidelines, Ped

3 L allergia alimentare: definizione Food allergy is an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food NIAID Guidelines, J Allergy Clin Immunol 2010 WAO Guidelines, Ped Allergy Immunol 2010 NICE guidelines, nice.org.uk.guidance 2011 ESPGHAN guidelines, JPGN 2012

4 L allergia alimentare: classificazione NIAID Guidelines for the Diagnosis and Management of Food Allergy, J Allergy Clin Immunol 2010

5 L allergia alimentare 1. Epidemiologia

6 Epidemiologia 3% 12% Sacherer S et al, J Allergy Clin Immunol 2011

7 Sicherer S et al. JACI 2014 Tan T. et al. Clin Experimental Allergy 2012 Eziopatogenesi 1. Clustering familiare 2. Prevalenza in familiari >5 pop. generale 3. Concordanza in monozigoti del 65% ambiente 15m 24m 36m Tot geni

8 Sicherer S et al. JACI 2014 Tan T. et al. Clin Experimental Allergy 2012 Eziopatogenesi 15m 24m 36m Tot Food allergy HLA class II FOXP3 STAT6 TNF SPINK5 IL13 CD14 IL10

9 Sicherer S et al. JACI 2014 Tan T. et al. Clin Experimental Allergy 2012 Eziopatogenesi ambiente Deficit vitamina D Ridotto consumo di antiossidanti e omega 3 Esposizione al fumo Aumentata igiene Obesità Utilizzo di anticidi 15m 24m 36m Timing di introduzione dei Tot cibi geni

10 Eziopatogenesi Sicherer S et al. JACI 2014 Tan T. et al. Clin Experimental Allergy 2012

11 Gli allergeni alimentari Uova, latte, arachidi, noci, soia, grano, crostacei, pesce

12 Gli allergeni alimentari Schoemaker AA, et al. Allergy 2015

13 Storia naturale dell allergia alimentare Schoemaker AA, et al. Allergy 2015

14 Storia naturale dell allergia alimentare Saarinen KM et al. JACI 2005

15 Fattori di rischio per allergia persistente Meccanismo IgE-mediato Elevata positività SPT (>6-8 mm) IgE specifiche anti-epitopi lineari Severa sintomatologia cutanea Sintomatologia respiratoria (rinite/asma) Co-sensibilizzazione ad altri aero-trofoallergeni Fiocchi A. Ann Allergy Asthma Immunol 2008 Jarvinen KM et al. JACI 2002

16 L allergia alimentare 2. Quadro clinico

17 Allergia alimentare: quadro clinico

Allergia alimentare: quadro clinico Manifestazioni gastro-intestinali Sindrome orale allergica Reflusso gastro-esofageo Esofagite eosinofila Enteropatia Enterocolite Proctite/proctocolite Stipsi

18 Allergia alimentare: quadro clinico Manifestazioni gastro-intestinali Sindrome orale allergica Reflusso gastro-esofageo Esofagite eosinofila Enteropatia Enterocolite Proctite/proctocolite Stipsi Gastroenterite eosinofila Coliche del lattante Manifestazioni cutanee Eczema atopico Orticaria-Angioedema Sindrome orale allergica Manifestazioni respiratorie Rinite Asma Manifestazioni sistemiche Anafilassi

19 Allergia alimentare: timing

20 Reazioni IgE mediate vomito, dolore addominale spesso crampiforme, nausea, diarrea.

21 Reazioni cellulo-mediate Enteropatia Enterocolite Proctocolite Proctite

22 Reazioni cellulo-mediate: Dietary protein proctocolitis In 50% of cases due to breast-feeding, but also to cow milk, soy, hydrolyzed formula Start: 2-6 weeks Satisfactory growth No vomiting, no abdominal distention Rectal bleeding mild Rarely clinically important anemia Rectosigmoidoscopies and biopsies lead to diagnosis in cases which do not respond to the removal of the protein. Affectation of the colon tends to be patchy, with areas of edematous mucosa and possible superficial erosions or ulcers. In rectal biopsies, there is infiltration by more than 20 eosinophils/hpf in the thickness of the mucosa and lamina propria Scand J Gastroent 2010

23 Reazioni IgE mediate e cellulo-mediate (miste) Esofagite Gastrite

24 Reazioni non-ige mediate: FPIES Non-IgE-mediated gastrointestinal food hypersensitivity It manifests as profuse, repetitive vomiting, often with diarrhea, leading to acute dehydration, hypotension and lethargy (or weight loss and failure to thrive if chronic) Family history of atopy in 40-80% Oral food challenge, in doubtful cases Skin prick test negative and IgE negative Endoscopy:rectal alteration and bleeding Hystology: villous atrophy, tissue edema, crypt abscess and increased lymphocytes, eosinophils and mast cells Exclusion of other causes Fiocchi A et al. J Allergy Clin Immunol Pract. 2013

25 Reazioni non-ige mediate: FPIES Differential diagnosis of FPIES Fiocchi A et al. J Allergy Clin Immunol Pract. 2013

26 L allergia alimentare 3. Diagnosi

27 7 colonne per una diagnosi corretta I. Sintomatologia clinicca compatibile II. Esclusione difetti anatomici, patologie metaboliche, infettive, etc III. Chiara relazione temporale con assunzione di un particolare cibo IV. Segni di atopia (DA, asma, IgE/SPT) V. Scarsa risposta clinica al trattamento convenzionale per reflusso, stipsi, etc.. VI. Chiara risposta clinica alla dieta di eliminazione VII. Test di provocazione orale positivo Sampson HA, JPGN 2000

28 Algoritmo diagnostico ESPGHAN guidelines, JPGN 2012

29 APLV: diagnosi If oral food challenge required for IgE mediated allergy do only food challenge and no other tests. High pretest probability: No food challenge use SPT with 3 mm cut-off to diagnose FA. Average pretest probability - do only food challenge and no other tests to diagnose or rule out FA. Low pretest probability: No food challenges use SPT < 3 mm to rule out FA

30 I test allergologici: performance diagnostica Sicherer S et al. Pediatrics 2012 Berni Canani R, et al. Allergy 2007

31 I test allergologici Screening panels of food allergens without previous consideration of the history is not recommended, because sensitization without clinical allergy is common. A negative SPT or serum sige test result does not entirely exclude a diagnosis of a food allergy. Caution is needed when tests are negative when a specific food allergy history is convincing; a medically supervised oral food challenge may be needed. Cross-reactivity among homologous proteins of aeroallergens and food allergens may result in positive tests to foods, often without clinical allergy (eg, birch pollen with hazelnut, peanut, soy; grass pollen with wheat, peanut; dust mite with shrimp). Strong positive test results correlate with increasing probability of clinical allergy, and particularly high values may indicate a high degree (>95%) of likely allergy; however, there are few studies correlating outcomes to test results, and results vary by age, disease, and other factors. The routine use of measuring total serum IgE should not be used to make a diagnosis of FA. APT should not be used in the routine evaluation of FA. Component resolved diagnostic test are not currently reccomended for the routine diagnosis of FA. NIAID Guidelines for the Diagnosis and Management of Food Allergy, J Allergy Clin Immunol 2010 Sicherer S et al. Pediatrics 2012

32 Durata della dieta di eliminazione diagnostica Lattanti con reazione clinica immediata (es. Orticaria acuta o ostruzione bronchiale entro 2 ore): 3-5 giorni Lattanti con reazione clinica ritardata (es. Esacerbazione dell eczema nei giorni successivi): 1-2 settimane Lattanti con alcune reazioni gastrointestinali (es. Diarrea cronica, ritardo di crescita): 2-4 settimane, talvolta più a lungo Koletzko S. et al. J Pediatr Gastroenterol Nutr 2012

33 Test da non eseguire per la diagnosi

34 L allergia alimentare 4. Terapia

35 Allergia alimentare: Terapia Dieta di Eliminazione

36 Allergia alimentare: cross-reattività

37 Allergia alimentare: Terapia (APLV) Idrolisati spinti delle proteine del latte vaccino (caseina o sieroproteine) Amminoacidi elementari Soya Idrolisati delle proteine di riso Idrolisati parziali del latte vaccino Latte di capra, pecora, asina, etc

38 Allergia alimentare: Terapia (APLV) Idrolisati spinti delle proteine del latte vaccino (caseina o sieroproteine) Amminoacidi elementari NIAID Guidelines, J Allergy Clin Immunol 2010 WAO Guidelines, Ped Allergy Immunol 2010 NICE guidelines, nice.org.uk.guidance 2011 ESPGHAN guidelines, JPGN 2012

39 Allergia alimentare: terapia In children with IgE-mediated cow s milk allergy at high risk of anaphylactic reactions (prior history of anaphylaxis and currently not using extensively hydrolysed milk formula), we suggest amino acid formula rather than extensively hydrolysed milk. In children with IgE-mediated cow s milk allergy at low risk of anaphylactic reactions (no prior history of anaphylaxis or currently on extensively hydrolysed milk formula), we suggest extensively hydrolysed milk formula over amino acid formula. In children with IgE-mediated cow s milk allergy, we suggest extensively hydrolysed milk formula rather than soy formula.

40 Dieta senza proteine del latte vaccino Problematiche nutrizionali (differente pattern amminoacidico, deficit ac. folico, zinco, calcio, ferro) Costi elevati Palatabilità Scarsa compliance

41 Prospettive future 1. Immunoterapia Oral immunotherapy (OIT) Sublingual immunotherapy (SLIT) Epicutaneneus immunotherapy (EIT) 2. Immunonutrizione Trattamento termico Probiotici

42 Prospettive future Obiettivi 1. Ridurre il rischio di reazioni gravi 2. Migliorare la qualità della vita

44 Forme miste: Allergic esofagitis/gastritis eosinophilic Caratterizzato da infiltrazione eosinofila mucosa (esofago, stomaco); eosinofilia in circa il 50 % dei pazienti Forma più comune: RGE (esofagite eosinofila) Disfagia, pirosi, epigastralgia, dolori addominali, scarsa crescita 8 settimane per risoluzione dei sintomi e 12 settimane per la normalizzazione istologica. Sicherer S. Pediatrics 2007

45 Algoritmo diagnostico NIAID Guidelines for the Diagnosis and Management of Food Allergy, J Allergy Clin Immunol 2010

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