Q:

8/30/2012
Healthy 4 year old girl with previous tolerance to milk, wheat, and soy. Two recent anaphylactic reactions - abdominal cramping, emesis, intense rhinorrhea, urticaria, periocular swelling - fairly shortly after eating 1) a boxed macaroni and cheese - noodles plus the rehydrated sauce packet and 2) a dry, packaged noodle (without any accompanying sauce package).

I am led to believe it is the noodles themselves causing anaphylaxis. Will be skin testing her to the noodles from both products but trying to find a culprit ingredient, nothing is obvious from labeling. My only thought thus far is soy - she has tolerated soy sauce but has not been given concentrated soy products in the past, could a soy cross-contaminant or minor food ingredient be surpassing some sort of threshold for reaction in this child? OR some kind of FAEIA, to wheat? Other wheat products have caused no symptoms.

A:

Thank you for your inquiry.

I am referring your inquiry to Dr. David Fleischer, who is an expert in food allergy. When I hear from Dr. Fleischer, I will forward his response to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

Dr. David Fleischer requested additional information and clarification regarding your Ask the Expert inquiry. Please see his note copied below.
 
Thank you,
Phil Lieberman, M.D.
 
Request for additional information/clarification from Dr. David Fleischer: I need a little more information. I am not clear from this history if this 4 yo child has a history of any food allergy.
 
Previous tolerance of milk, wheat, and soy means exactly what here - does she have a history of food allergy? Or has she always been tolerant of milk, wheat, and soy?
 
What does “fairly shortly” after ingestion of these foods mean as well? If it was more than 2 hours after ingestion of these foods, then it was not the foods.
 
If there is no history of food allergy, then a 4 yo girl does not suddenly develop food allergy to milk, soy or wheat unless she is a transplant patient on immune suppression. Has she eaten wheat since this reaction and exercised? FAEIA rare.

Does the child tolerate other legumes such as green beans, peas, peanut butter? If she does, even though she has not had concentrated soy, I doubt she is allergic to soy.

Has skin testing to milk, wheat, and soy been done? Fine to do a fresh skin test to the noodles as well. But if she has been eating milk and wheat her whole life, I doubt food is the culprit here. If skin tests are negative to the foods, I would recommend graded food challenges to the foods under observation.

I would consider idiopathic anaphylaxis, as food may be being blamed, and food is not the cause at all (especially if negative skin tests, negative food challenges, reactions occurred more than 2 hours after eating the culprit foods, or she has no history of food allergy and has been tolerant to these foods all along).

David Fleischer

Response to Dr. Fleischer's request for additional information/clarification. See replies embedded below in caps.  
 
Q.  I am not clear from this history if this 4 yo child has a history of any food allergy at all.
A.  NONE. YOUNGER SIB HAS PNA.
 
Q.  Previous tolerance of milk, wheat, and soy means exactly what here - does she have a history of food allergy? Or has she always been tolerant of milk, wheat, and soy?
A.  ALWAYS TOLERANT SINCE INTRODUCTION OF THESE FOODS.
 
Q.  What does “fairly shortly” after ingestion of these foods mean as well? If it was more than 2 hours after ingestion of these foods, then it was not the foods.
A.  RIGHT AWAY. LET'S SAY MORE OR LESS AT THE END OF THE MEAL.

Q.  If there is no history of food allergy, then a 4 yo girl does not suddenly develop food allergy to milk, soy or wheat unless she is a transplant patient on immune suppression.
A.  YES, THATS WHY I FIND THIS SO ODD.
 
Q.  Has she eaten wheat since this reaction and exercised? FAEIA rare.
A.  WHEAT IS FINE. ONE NOODLE MEAL WAS LUNCH and ONE SUPPER. EXERCISE HAD ARGUABLY OCCURRED WITHIN FEW PRECEDING HOURS AS SHE IS A HEALTHY FOUR YEAR OLD.

Q.  Does the child tolerate other legumes such as green beans, peas, peanut butter? If she does, even though she has not had concentrated soy, I doubt she is allergic to soy.
A.  HAS EATEN PEANUT BUTTER IN THE PAST BUT NOT GIVEN REGULARLY BECAUSE YOUNGER SIB DEVELOPED PNA AND THUS HOME IS NUT FREE. HAS EATEN SOY SAUCE.

Q.  Has skin testing to milk, wheat, and soy been done?
A.  NO. CONTINUES TO EAT MILK/PRODUCTS AND WHEAT. SOY NOT A REGULAR PART OF DIET.

Q.  Fine to do a fresh skin test to the noodles as well. But if she has been eating milk and wheat her whole life, I doubt food is the culprit here. If skin tests are negative to the foods, I would recommend graded food challenges to the foods under observation.
A.  BOTH TIMES RIGHT AFTER A KOSHER PASTA PRODUCT. STRONGLY TEMPORALLY LINKED TO THE MEALS.

Q.  I would consider idiopathic anaphylaxis, as food may be being blamed, and food is not the cause at all (especially if negative skin tests, negative food challenges, reactions occurred more than 2 hours after eating the culprit foods, or she has no history of food allergy and has been tolerant to these foods all along).
A.  NOT QUITE RIGHT... UNDER 2 HOURS. NO HX OF FOOD ALLERGY BUT REVIEWING MY NOTES, A YOUNG ONSET SEASONAL ALLERGIC CONJUNCTIVITIS (AGE 4) WITH BAD SPRINGTIME EYES.

Might I mention that at first meal Mom had simultaneously been eating almonds so I blamed almonds. Skin test neg to almond extract. Declined fresh almond skin test due to fear of systemic reaction. Sent for immunoserology to almond but not done yet. Second reaction - no almonds to blame, just...noodles. Again. Kosher noodles!

Final response from Dr. Fleischer:
I still have a hard time blaming this on foods, especially if she has eaten almost every ingredient from that meal again in some other form from that meal, i.e. milk, wheat and let say so, as she is tolerant to peanut. If she continues to consume milk and wheat, she cannot be allergic to milk or wheat.

If you need to convince yourself, you can challenge her to the meals that she ate that day though.

If she is negative to almond, I doubt she will be positive to fresh almond, and I have not had a patient have anaphylaxis from a fresh food skin test ever. A systemic reaction is possible from an intradermal skin test, but extremely unlikely to a fresh test. Dr. Dan Atkins and I do fresh tests all the time here at National Jewish and it has not happened yet. If she herself did not eat almond though, I do not think you can blame these reactions on almond (i.e. just from a contact reaction from mother).
 
I would do food challenges to all the foods this child at that day if you have to convince yourself and the mom that foods are not the cause to the reactions this child had that day if skin tests are all negative, which it seems like they are.

It sounds to me like these reactions are likely due to idiopathic anaphylaxis if you don't find another cause, and unfortunately she will need to have an Epipen around but can at least not need to avoid foods unnecessarily.
 
Let me know the outcome or if you have more questions.
 
David M. Fleischer, M.D.
Associate Professor of Pediatrics
Division of Pediatric Allergy and Immunology National Jewish Health

AAAAI - American Academy of Allergy Asthma & Immunology