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"Child`s Health" 4 (64) 2015

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Gastrointestinal allergy in the practice of the pediatrician and allergist

Authors: Okhotnikova O.M., Chernysh Yu.R. - National Medical Academy of postgraduate education named after P.L.Shupyk, Kyiv, Ukraine

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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The questions of diagnosis of clinical manifestations that occur in response to food in children is actual today [1,2]. The clinical manifestations are characterized by polymorphism: skin, respiratory and gastrointestinal syndromes.  Gastrointestinal form ranks second in the  overall clinical manifestations of food the allergy (48 - 67%) [1,3,4]. It because  the gastrointestinal tract  is constantly in direct contact with allergens, and allergic inflammation can develop in different areas along its entire length (directly in the mucosa). The most important food allergens in children are: cow's milk protein, fish and seafood, eggs, cereals, meat, soybeans [1, 4, 5]. Food allergy is one of the risk factors for atopic dermatitis, especially in young children (up to 3 years - 75.7%) [3]. So the question of interaction of food allergy and atopic dermatitis is actual, and the problem of diagnosis of allergic lesions of the gastrointestinal tract (especially invasive methods), particularly in children with atopic dermatitis, is still open [3].

We offer a clinical case of gastrointestinal allergy (allergic gastroduodenitis), which confirmed by biopsy of mucosa of the esophagus, stomach and duodenum in  the child with atopic dermatitis.

Boy N.A, 23.08.2010 year of birth (2 years 9 months) enrolled in the department for younger children. The complaints are rashes the skin of the feet, knees, behind auricles,  the dry  and itchy skin , bloating, frequent episodes of diarrhea.

History of the disease: He had the eczematous rash, intestinal colic, bloating and diarrhea, dysbiosis, delayed physical development from the age of 2 months.  Atopic dermatitis was diagnosed at the age of 2.5 months. Constantly received  therapy: H1-antihistamines, sorbents, local therapy (ointment Elokоm).  Skin syndrome did not disappear completely. Periods of remission were about two months in the summer. In 2011 - consultation of the allergist and gastroenterologist;  diagnosis: Atopic dermatitis,  widespread form, continuously relapsing course, the period of exacerbation; malabsorption syndrome. The received therapy: ketotifen, fenkarol, galstena; locally - sinoflan.  Some improvement was noted: a manifestation of skin syndrome only on the hands and feet. In the future aggravation of skin syndrome occur on the  foods such as: cow's milk, egg, wheat, rye, rice, potatoes, red vegetables and fruits, citrus. At the age 1 year, 8 months - analysis of  antibodies to transglutaminase of tissue was negative. Аngioedema (Kwinke swelling) was after the first eating fish at age 2 years 8 months. 21.05.13  was diagnosed: Atopic dermatitis, children form bounded moderately severe flow. Stunted growth. Secondary fermentopathy, intestinal dysbiosis. Celiac disease? Primary fermentopathy? was sent  for  examination, treatment in "OKHMATDET" clinic.

History of life: Child from pregnancy III, the threat of termination with 4 weeks, the mother received Duphaston. Birth at 39 weeks, physiological. Weight at birth - 3410 g, length - 56 cm. The period of adaptation newborn was normal. Discharged home on the third day. Breastfeeding was under 1 year 7 months. Vaccinated according to age without complications. Postponed disease: acute respiratory infections to 5 - 6 times a year, in the first year of life suffered obstructive bronchitis; 2 years 4 months - chicken pox. Injuries and operations were not. Allergic reactions to drugs are not mentioned.

Family history: mother, 28 years old - chronic gastritis; father, 28 years old - skin rashes occur in spring; brother 5 years - almost healthy.

Objective examination: the state of moderate severity, irritable, weight - 12.3 kg, height - 89.5 cm. The  temperature of body is 36,7 ° C. The skin is dry, excoriations, the eczematous and a maculopapular rash on the skin of feet, knees, behind auricles. Nasal breathing is difficult. Respiratory rate is 26 per minute. Percussion - a clear lung sounds; auscultation - hard breathing, wheezing does not listen. Abdominal distension, palpation is painless. Liver is palpable from the costal arch of 2 cm. Watery стул, 2 times a day, without pathological impurities. Urination free, enough. During stay in clinic was short abdominal spastic pains, unstable stool, without violating the overall condition.

Examination: Complete blood count, biochemical analysis of blood are normal.

 IgE - 579,5 IU/ml N- 0,100-200,0IU/ml). IgG – 15,73 g/l (N - 4,53-9,16 g/l); IgA – 0,35 g/l (N - 0,20-1,00 g/l);  IgM – 0,58 g/l (N - 0,19-1,46 g/l).

Immunological study of cellular immunity: The total number of white blood cells - 6,4 х 109 / L (normal - 6.6 - 11,2 х109 /l), basophils - 2%; Eosinophils - 4%; stab - 1%; segmented - 20%; cells - 64%; monocytes - 9%. The absolute number of lymphocytes - 4000 (norm 2400 - 6800), CD3 - 36% (norm 47 - 76%), the absolute number of CD3- 1400 (norm 1100 - 5200), SD22 - 31% (norm 33 - 46%) the absolute number of SD22 - 1200 (norm 400 - 2100), CD4 - 31% (norm 33 - 46%), CD8 - 43% (norm 17 - 30%), CD4 / CD8 - 0,72 (norm 1.5 - 2.2).

Hormone Panel: free thyroxine - 1,29 ng/dl (norm 0,96 - 1,77); thyroid-stimulating hormone - 4,87 uIU /ml (norm  0,70 - 5,97).

Levels of specific IgE: very high - an egg; high - cow's milk; moderate - potatoes banana,  egg yolk, raspberries, corn, barley rice, wheat flour; low - buckwheat, chicken, apples.

Common urine analysis: oxalates in a large number.

Coprogram: yeast fungi, extracellular starch in large quantities; neutral fat, fiber not digested, muscle fiber - a little.

The bacteriological stool cultures for pathogenic flora: negative.

Fecal analysis on dysbacteriosis: revealed the presence of hemolytic E. coli - 1,2х108 (70%); increasing the number of fungi of the genus Candida - 1х104, reducing lactic acid bacteria  < 106 and bifidobacteria < 107.

EKG: metabolic alterations in the myocardium.

Echocardiography: normal. Additional chord in cavity of the left ventricle .

Ultrasonography of the abdomen: a moderate liver enlargement (size of the right lobe is 83 mm), the increase of the pancreas (13 7 x 10 x mm).

X-ray of hands: bone without destructive changes; osteogenesis corresponds to the 2.5 years.

Fibroezofagogastroduodenoscopy: antrum - the mucous membrane is moderately hyperemia of the oedematous, with fine-grained hyperplasia with point erosions without fibrin at its apex. Duodenal mucosa is moderately hyperemia of the oedematous, in the bulb - fine grain hyperplasia. Conclusion: Erosive-grained antral gastritis. Granular bulbit. Catarrhal duodenitis.

Mucosal biopsy gastrointestinal tract: 1) esophagus: full-blooded vessels, and small papillomatous structure. 2) Antrum - hyperplasia with small erosions, fragments of the glandular stomach polyp. 3) the duodenal bulb: moderate villous atrophy, shortening and extension of the crypts, a small number of goblet cells, moderate infiltration of plasmacytes and lymphocytes. Conclusion: chronic immuno-allergic inflammation with malabsorption syndrome.

Consultations: Ophthalmologist and neurologist,  the center of metabolic diseases, genetics - no abnormalities, endocrinologist - somatogenic growth inhibition.

The diagnosis: polyvalent food  allergy: a mixed form (atopic dermatitis, chronic erosive hyperplastic gastroenteropathy) with secondary malabsorption syndrome and intestinal dysbiosis, delay of physical development.

Treatment: Individual diet. Oral ingestion: almagel (04.06 - 13.06), alerzin (28.05 - 13.06), singulair - 4 mg per day (07.06), espumizan (28.05 - 13.06), atoxil (28.05 - 06.05), aevit. Local: triderm, elidel, topikrem. In the nose: Vibrocil, nasal lavage with saline.

As a result of therapy, there was a positive dynamics of child's condition: a good appetite,very rare crampy abdominal pains, reducing of itching skin and reduction of rashes, normalization of stool.

Recommendations at discharge: keeping a food diary, exclusion of products that are marked intolerance and high sensitization; singulair 4 mg once a day for a long time; fenkarol for 3 weeks, and then - Edem (erius) - long-term; Creon 10000 ? capsule for 2-3 weeks; laktobakterin - 2 weeks, mineral water "Luzhanska» ? of the cup without gas for 40 minutes before meals - 2 months; "Skin-cap", as a means for skin care; hardening; vaccination III Infanrix HEXA; the next vaccination - measles, rubella, parotitis, months after this test.

The control hospitalization was after 6 months: rashes and itching of the skin has considerably decreased, stool has normalized, weight has increased.

Histological examination of the gastrointestinal mucosa greatly facilitates the timely diagnosis of gastrointestinal form of food allergy. If there are manifestations of AD and complaints from the gastrointestinal tract is necessary to define specific Ig E to specific foods to determine the diet, correct implementation of which will reduce the severity of the disease, which will improve the quality of life of these patients.


Bibliography

1.   Kaznacheeva L. F. Hastroyntestynal'naya forma pyshchevoy allerhyy u detey [Tekst] / L. F.   Kaznacheeva // Praktycheskaya medytsyna.- 2010.- # 45.- S.88-92.

2.   Macharadze D. Sh. Atopycheskyy dermatyt y pyshchevaya allerhyya. Chto obshcheho? [Tekst] / D. Sh. Macharadze // Lechashchyy vrach. – 2013. - # 5. – S. 24-30.

3.   Okhotnykova E. N. Hastroyntestynal'naya pyshchevaya allerhyya u detey [Tekst] / E. N. Okhotnykova // Klinichna imunolohiya. Alerholohiya. Infektolohiya. - 2013. - # 2. - S. 5-13.

4.   Pyshchevaya allerhyya u detey // Pod red. Y. Y. Balabolkyna, V. A. Revyakynoy. M., 2010, 190 s.

5.   Robison R.G. Food Allergy [Text] / R. G. Robison, J. A. Pongratsits // Allergy Asthma Prots. – 2012. - Vol. 33, #3. – P. 77-79.

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