Pediatric egg-induced anaphylaxis may present differing symptoms than other food allergies
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Key takeaways:
- Patients with egg-induced anaphylaxis were significantly younger than other patients with food-induced anaphylaxis.
- These patients exhibited more vomiting and less throat tightness and angioedema.
Children experiencing egg-induced anaphylaxis may be seeing certain symptoms that differentiate them from other food-induced anaphylaxis, according to a study published in Annals of Allergy, Asthma and Immunology.
The use of pre-hospital epinephrine autoinjectors (EAIs) was about the same as for other food allergies, but vomiting and a lack of throat tightness and angioedema may be used to distinguish egg-induced anaphylaxis in pediatric populations, Connor Prosty, MDCM, BSc, a medical student at McGill University at the time of the study, and colleagues wrote.
Methods
In this cross-sectional study, 302 children (mean age, 2.6 years; 55.3% boys) with egg-induced anaphylaxis were recruited from February 2011 to September 2013 from 13 Eds using survey data from the Cross-Canada Anaphylaxis Registry database.
Anaphylaxis severity was graded according to a scale, with mild reactions involving flushing, urticaria, pruritis, angioedema, rhino-conjunctivitis, mild abdominal pain or an isolated episode of emesis.
Moderate reactions involved stridor, crampy abdominal pain, throat tightness, diarrhea, wheezing, dyspnea or more than one episode of emesis. Severe reactions included at least one instance of hypoxia, incontinence, hypotension/shock and/or receipt of a bolus of intravenous fluids, cyanosis and confusion or loss of consciousness.
Patients were administered questionnaires to determine demographics, comorbidities and information about episodes of anaphylaxis. This included anaphylaxis symptoms, location, trigger, management and outcome.
Results
Among the total cohort, a history of egg allergy was present in 39.4% of patients, with 49.7% having any known food allergy. A diagnosis of concomitant asthma was observed in 9.3% of patients and atopic dermatitis in 21.5%.
For patients with a known trigger of egg-induced anaphylaxis (60%), these triggers comprised lightly cooked eggs (47.5%); baked goods (27.6%); other (8.3%); sauce, mayonnaise and dressing (6.1%); pasta (5%); candy (3.3%); and ice cream (2.2%). The remaining 40% of cases did not specify a type of egg trigger.
Exposure by ingestion was the most common type of exposure (95.4%). Reactions occurred at home (71.2%), school or daycare (11.9%), restaurants (5%) or other locations (4%). Elapsed times between exposure and symptom onset included less than 5 minutes for 37.1% of the cohort, between 5 minutes and 2 hours for 53.6% and an unknown amount of time for 7.6%.
The most common symptoms were mucocutaneous, including urticaria (70.9%), angioedema (44%), pruritus (36.8%), flushing (29.1%) and rhino-conjunctivitis (15.2%).
Patients experienced respiratory symptoms of dyspnea (26.5%), wheezing (14.6%), throat tightness (7.6%), stridor (4.6%) and hypoxia (1.3%), where gastrointestinal symptoms included multiple episodes of emesis (33.8%), single episodes of emesis (30.5%), mild abdominal pain (7.9%), crampy abdominal pain (4.6%), and diarrhea (4.6%). The least common symptoms were circulatory and neurologic symptoms, with cyanosis at 3%, shock/hypotension at 2% and confusion/loss of consciousness at 4.3%.
Classification of anaphylaxis severity was mild in 30.5% of patients, moderate in 60.3% and severe in 9.3%.
EAIs were used by 32.1% of patients in pre-hospital settings. At least two doses of EAIs were used by 2.6%, but this was not significantly lower than other food-induced anaphylaxis (FIA) triggers. H1-antihistamines were used by 37.7% of patients. Patients with a previously known food or egg allergy had an EAI use of 52.3% and 55.5%, respectively.
Within a hospital setting, 43.7% of patients had epinephrine administered intramuscularly, 0.7% intravenously and 4.3% required at least two doses. H1-antihistamines were used by 43% of patients, and 17.9% used corticosteroids. Only 1.4% of patients required hospitalization.
A significant association between moderate to severe anaphylaxis and a history of known egg allergy was found in the cohort after adjustment for age and sex (adjusted OR = 1.22; 95% CI = 1.09-1.37).
Pre-hospital EAI use was associated with previously known egg allergy (aOR = 1.3; 95% CI, 1.16-1.46) and with reactions that occurred at school or daycare (aOR= 1.27; 95% CI = 1.05-1.54).
Compared with other triggers of FIA, egg-induced anaphylaxis patients were significantly younger (aOR = 0.99; 95% CI = 0.99-0.99) and less likely to be male (aOR = 0.97; 95% CI, 0.96-0.99).
These patients also exhibited more vomiting (aOR = 1.03; 95% CI = 1.00-1.05), less throat tightness (aOR = 0.97; 95% CI = 0.95-0.99) and angioedema (aOR = 0.97; 95% CI = 0.95-0.98).
Authors concluded that this may be the largest cohort of pediatric egg-induced anaphylaxis analysis and that due to the variance of symptoms, a degree of suspicion should be exercised in order to better identify egg-induced anaphylaxis due to the young age of patients and lack of FIA history.
Perspective
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This is an interesting article that allows further understanding of egg allergy. As noted, this is the third most common food allergy in children. Through data mining of the Cross-Canada Anaphylaxis Registry, Prosty et al provide several useful kernels of information regarding egg allergy.
Specifically, they found that almost two thirds of the group had not previously been diagnosed. These patients also were significantly younger than those requiring ED visits from other food allergens and had more frequent symptoms of vomiting with less frequent angioedema and throat tightness.
These findings are significant, as they indicate the need to consider food allergy in a vomiting child with exposure to egg. While these findings do not resonate with my own experience, I will say that I now need to consider them.
In future updates to the anaphylaxis parameters, we need to at least consider this somewhat different presentation. We also need to consider this in young children presenting with vomiting, especially with first or larger egg ingestion.
Finally, while this is a robust data set, still further research and validation are needed.
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