Q:

7/23/2013
I have a 5 year-old patient who I follow for food allergies. He has new complaints of GI intolerance (immediate onset nausea, sometimes with emesis) of canned fruit (all different fruits) and canned chicken. He tolerates regular fresh fruit (including pre-packaged in a plastic cup), all other kinds of chicken, and other canned foods (ie vegetables and tuna). He has similar GI symptoms with sunflower butter--but he tolerates plain sunflower seeds. His skin testing (histamine 5mm wheal with flare) was positive for canned peaches (prick-prick method into a can of peaches, 9mm wheal with flare) and sunflower seed extract (11mm wheal with flare). I didn't test chicken extract.

GI complaints alone seem less consistent with a true allergy, but there's evidence of food-specific IgE. I'm also confused by tolerance of fresh versions of the foods but intolerance of prepared versions (seems like it should be the opposite).

As an aside, but possibly pertinent, he also has a growth curve <5% but is tracking with an appropriate velocity. He frequently complains to his mother of belly pain and sometimes burning in his chest. He has occasional seemingly random episodes of emesis that self-resolve and are short-lived.

I've sent him to Peds GI for further evaluation of his abdominal complaints, wondering specifically about GERD or even a possible EGID. Regarding his acute symptoms to the above listed foods, would you recommend any further evaluation or consideration of other potential diagnoses besides a food allergy? I recommended that he continue to eat the versions of those foods he can tolerate, avoiding the canned versions. Would you recommend any differently? Obviously my recommendations might change depending on his GI evaluation.

I've not previously come across this scenario (tolerance of fresh food, intolerance of canned food) in my practice, and I couldn't find anything in a MEDLINE search... I'll be interested to hear your thoughts! Thank you kindly.

A:

Thank you for your inquiry.

I am referring your question to Dr. Scott Sicherer who is an international expert in food allergy. As soon as we receive his response, we will forward it to you.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D.

We received a response from Dr. Sicherer regarding your Ask the Expert inquiry. Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

Response from Dr. Scott Sicherer:
I provide my answers or comments in the context of each point you make in the history and so I have recapitulated most of your text:

"He has new complaints of GI intolerance (immediate onset nausea, sometimes with emesis) of canned fruit (all different fruits) and canned chicken."

Not to get too deep into a semantic argument, but if it is an "intolerance", you would be thinking something like fructose malabsorption or a metabolic disorder in the category of carbohydrate metabolism. Symptoms can be dose dependent. So if the relationship is "real" corn syrups are higher in fructose and so if when eating the canned fruits in corn syrup results in a lot of the syrup being eaten, maybe more than in the plastic cups (mentioned later), that could be a variable of interest. However, the chicken does not fit since it should be in water. You might also expect some more evident issues with fruits such as apple and melons when not canned. However, you later worry about allergy instead of intolerance, so read on.

"He tolerates regular fresh fruit (including pre-packaged in a plastic cup), all other kinds of chicken, and other canned foods (ie vegetables and tuna)."

You present this additional data that contrasts canning of different foods, suggesting that canning itself is not the cause. Metal "allergy" such as to nickel has been implicated in canned foods but the symptom is generally dermatitis. In any event, you are ruling out an allergy to the can/canning here, not that I ever have heard of such a concern.

"He has similar GI symptoms with sunflower butter--but he tolerates plain sunflower seeds."

As you also mention later, you are correct that immediate nausea and vomiting can be an IgE mediated acute reaction and here I would wonder if the difference is in relation to the amount of protein ingested. It is likely that eating the butter results in a much larger dose of protein than the seeds eaten separately.

"His skin testing (histamine 5mm wheal with flare) was positive for canned peaches (prick-prick method into a can of peaches, 9mm wheal with flare) and sunflower seed extract (11mm wheal with flare). I didn't test chicken extract."

I would be interested to know if he tolerates raw peach and presumably he does, and to know what the canned versus raw skin tests show. As you indicate later, and I agree, canning (heating) usually reduces allergenicity of the proteins in fruits. It may alter solubility and some ratios of the components of the fruit, but I am not aware of that creating a more allergenic form. Having a positive prick test, however, does not necessarily mean the response is an allergic reaction.

"I'm also confused by tolerance of fresh versions of the foods but intolerance of prepared versions (seems like it should be the opposite)."

I generally agree. Some foods are more allergenic with heated or processed, but not typically fruits.

"As an aside, but possibly pertinent, he also has a growth curve <5% but is tracking with an appropriate velocity. He frequently complains to his mother of belly pain and sometimes burning in his chest. He has occasional seemingly random episodes of emesis that self-resolve and are short-lived."

His having random emesis raises a common issue in situations where unusual things are noted-do we feel certain of the relationships mentioned above? You may have already queried, but I would be very interested to know much, much more about this child-what are his other food allergies? How much is eaten when symptoms occur? What else is eaten with meals? How does he do with eating in general (fast, slow, complaints of pain). Any other bowel complaints? How consistent is the relationship of ingestion of the problem foods to adverse reactions? What other allergies does he have? What other illnesses does he develop? Does he show pickiness and food preferences? The answers to these and other queries may lead me to question the relationship or look for other triggers, and think about the differential diagnosis as you mention next.

"I've sent him to Peds GI for further evaluation of his abdominal complaints, wondering specifically about GERD or even a possible EGID."

I agree this is important and they would presumably also think about intolerance.

"Regarding his acute symptoms to the above listed foods, would you recommend any further evaluation or consideration of other potential diagnoses besides a food allergy? I recommended that he continue to eat the versions of those foods he can tolerate, avoiding the canned versions."

I agree with the idea of eating what is tolerated and avoiding things that caused problems. I already mentioned some "non-allergy" issues and additional simple tests. However, if it is truly a mystery, and if nuances of the history suggested ambiguity, it would be possible to do blinded food challenges to confirm or refute the observed unusual relationships. The equivalent amount of fruit can be fed from the different forms under observation if it is deemed worthwhile.

Scott H. Sicherer, MD
Professor of Pediatrics
Jaffe Food Allergy Institute

AAAAI - American Academy of Allergy Asthma & Immunology