Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 17-year-old male is in the clinic for evaluation of suspected food allergy. He has had 4-5 episodes of facial angioedema when consuming pasta sauce with pasta. The symptoms start typically while he is eating the food, within a few minutes, and they are manifested by lip swelling, oral itching and the feeling of "throat closing". This happened when consuming whole grain pasta with JTM frozen pasta sauce from Gordon's food products. He reports having those reactions starting from approximately 1.5 years ago with different foods, but mostly pasta sauce. He also had a mild reaction when consuming bean tortilla. He had no respiratory symptoms, no wheezing and shortness of breath. He had no hives with those events, but he reported some abdominal discomfort. We evaluated each of the major food groups associated with allergic reactions. He has no reactions when consuming tree nuts, peanuts, eggs, milk, fish, shellfish, wheat or soy products. During the evaluation for oral allergy syndrome he reported nasal congestion throughout the year, worse in the fall. He was never formally tested or diagnosed with allergic rhinitis. He reports oral itching when consuming watermelon and some other foods in raw form. He has never been to the emergency room for those symptoms. He took Benadryl for the symptoms of food allergy described above and that helped his symptoms. They do not have an Epi-Pen and that has not been administered in the past.
Past medical history is positive the described symptoms of facial angioedema affecting mostly the lips after consuming pasta sauce based foods.
Past surgical history is negative.
On social history he lives at home with his family, a cat and a dog. There are no smokers in the home. There is carpet, but no visible mold.
There are no known medication allergies.
Current medications include a multi-vitamin, and the above-mentioned Benadryl during food allergic reactions and he has not taken it since them.
On physical examination, his nose has pale boggy turbinates on both sides with some mild mucoid discharge.
Procedures: He had spirometry and skin prick testing. The spirometry was normal. The skin prick test was strongly positive to mold mix, trees, grass, birch, ragweed, weeds, Aspergillus and Homodendrum.
What is the most likely diagnosis?
This is a patient with facial angioedema after consuming pasta-based meals with a specific food sauce. He has no reported reaction to wheat or any of the major food allergens, including tree nuts, peanuts, eggs, milk, shellfish, fish, soy and wheat.
He does report some symptoms of oral allergy syndrome, especially with watermelon which is known to have a cross-reactivity with ragweed. He does have evidence of allergic rhinitis with sensitization to ragweed and weed mix, which includes mugwort, and birch. Oral allergy syndrome is certainly a consideration for him. The symptoms are oral allergy, however, typically appear when consuming raw foods, not processed foods, such as pasta sauce.
Hereditary angioedema can be of consideration, however he does not have symptoms of abdominal pain and there is no family history, and this can be ruled out by blood work.
We do not have any information about the pasta sauce that he consumed. This pasta sauce is produced by JTM and Gordon food suppliers (food service companies) and they do not publish the ingredients of their products because they are not available in the stores. I asked them to bring the container/label with the ingredients so we can do a testing with the sauce and the specific ingredients as well.
What diagnostic test would you suggest?
We provided Epi-Pen and training to be used in case of a severe food allergic reactions. For his allergic rhinitis, I provided a sample of nasal steroid to be used and also he can use an oral antihistamine daily.
Regarding the further workup of his food allergic reactions, it is advisable to obtain the ingredients and a sample of the sauce from JTM and Gordon's food services. We can perform a skin prick-puncture test with the sauce, and also specific IgE testing for the ingredients of the sauce, as well as beans and paprika (in the chili).
If this is negative, then a food challenge can be considered.
Prevalence of wheat allergy in Japan is 0.2% - the assessment was based on questionnaire-based exam, skin prick test, and omega-5 gliadin sIgE (http://goo.gl/Mp4nW).