Orange Juice Can Trigger Dangerous Syndrome

Fran Lowry

ANAHEIM, California — Food protein-induced enterocolitis syndrome (FPIES) was triggered by orange juice in a 2-year-old boy, according to a poster presented here at the American College of Allergy, Asthma & Immunology 2012 Annual Scientific Meeting.

FPIES and its triggers (most commonly cow's milk, rice, and soy) can be difficult to diagnose, lead researcher Tara Federly, MD, a fellow at the Children's Mercy Hospital and the University of Missouri in Kansas City, told Medscape Medical News.

FPIES is not mediated by immunoglobulin (Ig)E, "so it's not the immediate hypersensitivity reaction that you see with peanut or milk or other allergy," Dr. Federly explained. "The exact mechanism is not known, but it's basically an inflammation of the GI tract that is triggered by certain foods. The interesting thing is that it happens hours after ingestion, instead of being a more immediate IgE-mediated reaction," she said.

In the case reported by Dr. Federly and her colleagues, which they describe as the first report of orange juice being the causative agent in FPIES, a 2-year-old boy presented with lethargy and severe vomiting that required hospitalization and the administration of intravenous fluids. This occurred on 5 occasions.

The episodes occurred without associated rash, angioedema, respiratory symptoms, fever, or contact with other sick children.

Each time, "the emergency department thought that he had viral gastroenteritis, and he returned to normal after intravenous fluid replacement," Dr. Federly reported.

On further questioning, the child's mother implicated orange juice as an apparent trigger because the reaction usually occurred a couple of hours after he drank it.

The possibility of an IgE-mediated food allergy was ruled out on the basis of negative skin-prick testing to orange extract and fresh orange juice. In addition, IgE specific to orange was less than 0.1 kU/L, Dr. Federly said.

The researchers performed an FPIES oral food challenge, using the recommended total challenge dose of 0.06 g of protein/kg divided into 3 feedings over 45 minutes.

The intended duration of observation was 4 hours, but within 90 minutes of the final dose, the child began vomiting every 10 to 15 minutes for 2 hours. He did not develop urticaria, rhinorrhea, wheezing, or other symptoms of anaphylaxis.

His absolute neutrophil count was elevated, from 1920 cells/µL to 3420 cells/µL.

The child became tachycardic and lethargic after his vomiting episodes and was given normal saline. After vigorous hydration, he responded very well and returned to normal.

Other Fruits Implicated

"This response goes along with FPIES," Dr. Federly said.

"Other fruits have been implicated in FPIES, such as apple, pear, and banana, but not orange juice. When he stopped eating oranges, he had resolution of his vomiting episodes," she explained.

The message for physicians is to think about the possibility of FPIES when a child comes in with recurrent episodes of vomiting and dehydration, she said.

Again, "the most typical triggers would be milk, soy, and rice, but you need to think of unusual cases, such as fruit and more solid foods. These kids should be seen by an allergist.... Doing a challenge in the clinic is the best way to determine if it is really FPIES," she noted.

"Not an Allergy"

Jay Portnoy, MD, professor of pediatrics at the University of Missouri and Mercy Children's Hospital, who was not part of the study, told Medscape Medical News that FPIES is a relatively new syndrome.

"Kids can die from [FPIES]. The reaction is delayed. It happens an hour or 2 after eating the food, so the parents don't always know what food it was; they don't even associate it with a food. It usually happens in children less than 1 year of age, young infants, so this might be responsible for crib death," Dr. Portnoy said.

"The important thing is that allergy testing doesn't help identify FPIES because it's not an allergy; it's something else, but we don't quite know what it is. It is important to be aware that this syndrome exists and that unusual foods not usually linked to food allergy can be associated with it," he said.

Dr. Federly and Dr. Portnoy have disclosed no relevant financial relationships.

American College of Allergy, Asthma & Immunology (ACAAI) 2012 Annual Scientific Meeting: Abstract P261. Presented November 11, 2011.


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