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Clinical manifestations of food allergy: An overview

Clinical manifestations of food allergy: An overview
Literature review current through: May 2024.
This topic last updated: Jun 23, 2022.

INTRODUCTION — An adverse food reaction is a general term for any untoward response to the ingestion of a food. Adverse food reactions can be divided into food allergies, which are immunologically mediated, and all other reactions, which are nonimmunologic (table 1).

Adverse food reactions are common and often assumed by patients to be allergic in nature. However, nonimmunologic reactions to food are more common than true food allergies. (See "Food allergy in children: Prevalence, natural history, and monitoring for resolution", section on 'Prevalence of childhood food allergy' and "Food intolerance and food allergy in adults: An overview", section on 'Epidemiology'.)

Food allergy is due to an abnormal immunologic response following exposure (usually ingestion) to a food [1,2]. There are multiple types of food allergy, each with distinct clinical and pathophysiologic features. Food allergies are broadly categorized into either immunoglobulin E (IgE) mediated or non-IgE-mediated processes [3]. Some disorders, such as atopic dermatitis or the eosinophilic gastrointestinal disorders (EGIDs), have characteristics of both mechanisms. (See "Role of allergy in atopic dermatitis (eczema)" and "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)".)

This topic reviews the clinical manifestations of the different categories of food allergies. Other aspects of food allergy are discussed separately. (See "History and physical examination in the patient with possible food allergy" and "Diagnostic evaluation of IgE-mediated food allergy".)

IgE-MEDIATED REACTIONS — IgE-mediated food allergic reactions are rapid in onset, typically beginning within minutes to two hours from the time of ingestion. IgE-mediated reactions to carbohydrate allergens in meats, a type of reaction reported mainly in adults, represent an exception to this temporal pattern since these reactions begin four to six hours after ingestion (see "Allergy to meats"). Most patients react to one or two specific foods/food groups, although an increasing number of patients react to multiple foods.

Signs and symptoms can involve the skin, respiratory and gastrointestinal tracts, and cardiovascular system and are believed to be caused by mediator release from tissue mast cells and circulating basophils (table 2). Two unique and distinct presentations are the oral allergy syndrome and food-dependent, exercise-induced anaphylaxis (FDEIAn). (See "Clinical manifestations and diagnosis of oral allergy syndrome (pollen-food allergy syndrome)" and "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis" and "Anaphylaxis: Acute diagnosis", section on 'Diagnostic pitfalls'.)

Urticaria and angioedema — Acute urticaria and angioedema are probably the most common cutaneous manifestations of allergic reactions to food, generally appearing within minutes of ingestion of the food allergen. Food allergy may account for 20 percent of cases of acute urticaria [4,5]. (See "New-onset urticaria" and "An overview of angioedema: Clinical features, diagnosis, and management".)

By comparison, food allergies are an uncommon underlying cause of chronic urticaria and angioedema (defined as greater than six weeks of regular outbreaks). (See "Chronic spontaneous urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history", section on 'Foods and food additives'.)

Food can also cause acute contact urticaria. In this condition, urticaria develops only on skin that was in direct contact with the food. In addition to the common allergens, raw meats, seafood, raw vegetables and fruits, mustard, rice, and beer are among the foods that have been implicated in this form of reaction [6-8].

Oropharyngeal symptoms — Oropharyngeal symptoms can occur in isolation or as part of a systemic reaction to a food (table 2). Symptoms may occur in isolation because the allergy is mild, not much allergen was ingested, or the allergen is labile, as is seen in oral allergy syndrome.

Oral allergy syndrome, or pollen-food allergy syndrome, is considered a form of contact allergy that is common in patients with allergic rhinitis to pollen. It is caused by the presence of heat, acid, and digestive enzyme-sensitive proteins (eg, profilins) within these foods that are cross reactive with allergenic pollen proteins. Symptoms are confined almost exclusively to the oropharynx and include the immediate onset of pruritus, irritation, and mild swelling of the lips, tongue, palate, and throat upon ingestion of fresh, uncooked fruits and vegetables [9-11]. Cooked fruits and vegetables typically do not elicit the symptoms. Symptoms usually subside within minutes after ingestion ceases. However, progression to systemic symptoms can occur, and anaphylaxis has been reported [12]. Symptoms may be more noticeable during the associated pollen season. (See "Clinical manifestations and diagnosis of oral allergy syndrome (pollen-food allergy syndrome)" and "Management and prognosis of oral allergy syndrome (pollen-food allergy syndrome)", section on 'Risk of systemic reactions'.)

As examples, a birch-allergic patient may develop itching of the lips or mouth upon eating apple, pear, cherry, carrot, celery, and potato, while a ragweed-allergic patient may react to melons and banana, and a mugwort-allergic patient may react to celery or mustard (figure 1). Tree nuts and peanuts can also cause isolated oral symptoms but as such would not be classified as the typical pollen-food allergy syndrome.

Respiratory tract symptoms — Asthma and environmental allergies (allergic rhinitis and conjunctivitis) are more common in children with food allergy. In addition, conjunctival, nasal, and lower respiratory tract symptoms are common components of systemic food allergic reactions (ie, anaphylaxis) (table 3). However, isolated allergic rhinoconjunctivitis or asthma in response to foods is rare. An exception is occupational asthma (sometimes with accompanying rhinitis) in food industry workers. "Baker's asthma," caused by IgE-mediated allergy to inhaled wheat proteins, is an example [13]. Patients with these conditions may not react to the food upon ingestion. (See 'Anaphylaxis' below and "Respiratory manifestations of food allergy" and "Asthma in children younger than 12 years: Initial evaluation and diagnosis", section on 'Allergic history'.)

Gastrointestinal symptoms — IgE-mediated gastrointestinal symptoms, including nausea, abdominal pain, abdominal cramping, vomiting, and/or diarrhea, are more prominent features in anaphylaxis due to ingestion of a food allergen. The term "gastrointestinal anaphylaxis" is used when gastrointestinal symptoms occur in isolation. However, gastrointestinal symptoms are rarely the sole manifestations of a food-allergic reaction. More commonly, gastrointestinal symptoms occur in conjunction with involvement of other target organs (table 2) [14-16]. The onset of upper gastrointestinal symptoms (nausea, vomiting, abdominal pain) is generally minutes to two hours after ingestion of the offending food, but lower gastrointestinal symptoms, such as diarrhea, can begin two to six hours after ingestion. (See "Food-induced anaphylaxis", section on 'Signs and symptoms'.)

Anaphylaxis — Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death [17]. Patients may develop a combination of symptoms and signs related to the cutaneous, respiratory, gastrointestinal, and/or cardiovascular systems that constitute anaphylaxis (table 4 and table 3). Anaphylactic reactions may culminate in hypotension, vascular collapse, cardiac dysrhythmias, or death. Anaphylaxis occasionally follows a biphasic course, with a recurrence of symptoms hours after the initial onset. Skin symptoms may be absent. (See "Anaphylaxis: Emergency treatment" and "Food-induced anaphylaxis", section on 'Clinical features'.)

FDEIAn describes an anaphylactic response that occurs only if the patient exercises or exerts himself or herself within two to four hours of ingestion of food. These reactions seem to be most prevalent in adolescents and young adults, although they can occur in patients of any age. Common causative foods include wheat, celery, and seafood. The food can be ingested in the absence of exercise without development of symptoms. Some patients react after eating any food prior to exercise. These patients also have no reactions in the absence of exertion. (See "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis", section on 'Diagnosis of FDEIA'.)

In addition to exercise, other cofactors may increase the risk that a food allergen will elicit anaphylaxis rather than a mild reaction, including menstruation, nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, elevated body temperature, acute infections, and antacids [18].

NON-IgE-MEDIATED REACTIONS — Non-IgE-mediated food allergies present as more subacute and/or chronic symptoms that are typically isolated to the gastrointestinal tract and/or skin. Affected patients commonly present with a characteristic constellation of clinical and demographic features that are consistent with well-described disorders.

The exclusive non-IgE-mediated food allergy disorders principally include:

Food protein-induced enterocolitis syndrome (FPIES; entire gastrointestinal tract)

Food protein-induced enteropathy (small bowel)

Food protein-induced proctitis and proctocolitis (rectum and colon)

Food-induced pulmonary hemosiderosis (Heiner syndrome)

The manifestations of these disorders are discussed briefly here and reviewed in detail elsewhere. (See "Food protein-induced allergic proctocolitis of infancy" and "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children" and "Role of allergy in atopic dermatitis (eczema)".)

Celiac disease is not classically considered a food allergy, but it is caused by a non-IgE-mediated immune reaction to a food protein (gluten). As such, it is also discussed here, and the skin manifestations (dermatitis herpetiformis) are discussed below. (See 'Skin manifestations' below.)

Gastrointestinal manifestations — The type of gastrointestinal signs and symptoms may vary in some disorders, depending upon whether the food is consumed regularly or infrequently. In addition, certain disorders are associated with systemic manifestations. Chronic vomiting and diarrhea, particularly if accompanied by failure to thrive, suggests disorders such as food protein-induced enteropathy, celiac disease, FPIES, or an eosinophilic gastrointestinal disorder (EGID). EGIDs are mixed IgE and non-IgE-mediated reactions and are discussed further below. (See 'Mixed IgE- and non-IgE-mediated reactions' below.)

Food protein-induced proctitis/proctocolitis – Passage of blood-tinged stools and mucus in an otherwise healthy infant without an anal fissure is suggestive of food protein-induced proctitis/proctocolitis. The most common trigger is cow's milk in the mother's diet, although it can also occur in formula-fed infants. This disorder typically presents between two and eight weeks of age and resolves in a few days with complete elimination of the offending protein. (See "Food protein-induced allergic proctocolitis of infancy".)

Food protein-induced enterocolitis syndrome (FPIES) – Infants with FPIES are generally sicker in appearance than those with other non-IgE-mediated allergic gastrointestinal disorders, with lethargy and pallor (table 5). The stools are typically watery, with occasional mucus, although grossly bloody diarrhea (melena) is possible. The vomiting is intermittent in the chronic setting but can be severe and can lead to dehydration. Patients may also have malabsorption. Poor weight gain/failure to thrive is common. Laboratory abnormalities include hypoalbuminemia, anemia, and leukocytosis. Symptoms of FPIES resolve upon elimination of the causative food, although it may take several weeks to a month to start to see an improvement. (See "Food protein-induced enterocolitis syndrome (FPIES)".)

If the causative food is later reintroduced, there is a characteristic delayed onset (approximately two to four hours) of profuse vomiting, followed by return of the other signs and symptoms (table 5). Children can require emergency treatment for hypotension, lethargy, or shock in this setting, and laboratory studies may show acidosis, methemoglobinemia, and an increase in neutrophils. The acute manifestations of FPIES can be clinically identical to IgE-mediated gastrointestinal anaphylaxis; therefore, testing is usually necessary to determine if food-specific IgE is present. (See 'Gastrointestinal symptoms' above.)

FPIES in older children and adults is rare and typically presents a milder syndrome of nausea, protracted vomiting, and cramping several hours after ingestion.

FPIES is uncommon in exclusively breastfed infants. Cow's milk and soy are the most common triggers in infants and children, although many other food protein triggers have been reported. There are several reports of shellfish as a causative food in adults.

Protein-induced enteropathy – Infants with food protein-induced enteropathy can present with findings similar to patients with FPIES who are regularly ingesting a causative food (eg, chronic vomiting and diarrhea, failure to thrive). (See "Food protein-induced enterocolitis syndrome (FPIES)", section on 'Allergic food protein-induced proctocolitis and enteropathy' and "Food protein-induced allergic proctocolitis of infancy".)

Celiac disease – Celiac disease, also known as gluten-sensitive enteropathy, is an immune-mediated inflammatory disease. It classically presents in infants and young children with chronic diarrhea, anorexia, abdominal distension and pain, failure to thrive or weight loss, and sometimes also vomiting. The gastrointestinal manifestations are similar in older children and adults but usually milder and include steatorrhea, weight loss, and other signs of nutrient or vitamin deficiency due to malabsorption. Flatulence and steatorrhea are suggestive of celiac disease rather than other forms of food-protein-induced enteropathy or FPIES. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children", section on '"Classical" gastrointestinal symptoms' and "Diagnosis of celiac disease in adults" and "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults", section on 'Gastrointestinal manifestations'.)

Skin manifestations — The primary skin manifestation of exclusive non-IgE-mediated food allergy is the vesicular eruption seen with dermatitis herpetiformis in up to one-quarter of adult patients with celiac disease. Dermatitis herpetiformis is characterized by an itchy papular vesicular eruption usually located symmetrically on the extensor surfaces of the elbows, knees, buttocks, sacrum, face, neck, trunk, and occasionally within the mouth (picture 1A-B). The predominant symptoms are itching and burning that are rapidly relieved with rupture of the blisters. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children", section on 'Non-gastrointestinal manifestations'.)

Pulmonary manifestations — Food-induced pulmonary hemosiderosis (Heiner syndrome) is a rare syndrome in infants that consists of recurrent pneumonia with pulmonary infiltrates, hemosiderosis, iron deficiency anemia, and failure to thrive. Cow's milk is the most common causative food, with pork and hen's egg also being reported [19]. Elimination of the offending food results in resolution. Only seven cases have been described in the literature since 2013 [20]. (See "Milk allergy: Clinical features and diagnosis", section on 'Heiner syndrome'.)

The pathogenesis of Heiner syndrome is unclear. Serum precipitins to cow's milk and peripheral eosinophilia are often seen, and deposits of immunoglobulins and C3 may be found on lung biopsy. Lymphocytes from patients show abnormal proliferative responses to milk proteins [19].

Coexistence of celiac disease and idiopathic pulmonary hemosiderosis, also known as Lane-Hamilton syndrome, has been reported in a number of cases [21]. Idiopathic pulmonary hemosiderosis is a rare disease found primarily in children that causes recurrent episodes of diffuse alveolar hemorrhage that may eventually produce pulmonary hemosiderosis and fibrosis. Diffuse alveolar hemorrhage is characterized by hemoptysis, dyspnea, alveolar opacities on chest radiographs, and anemia. Introduction of a gluten-free diet has been associated with remission of pulmonary symptoms in several patients. (See "Idiopathic pulmonary hemosiderosis" and "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in adults", section on 'Idiopathic pulmonary hemosiderosis'.)

MIXED IgE- AND NON-IgE-MEDIATED REACTIONS — Some food allergy disorders can have both IgE- and non-IgE-mediated components. Similar to the exclusively non-IgE-mediated food allergies, the mixed disorders are typically isolated to the gastrointestinal tract and/or skin.

The mixed disorders primarily include:

Atopic dermatitis (see "Role of allergy in atopic dermatitis (eczema)")

Eosinophilic esophagitis (EoE) (see "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)")

Eosinophilic gastroenteritis (see "Eosinophilic gastrointestinal diseases")

Atopic dermatitis (eczema) — Food allergies may exacerbate atopic dermatitis, especially in young children with more severe eczema. Ingestion of the offending food acutely is thought to cause a flare of the patient's atopic dermatitis (increased erythema and pruritus of eczematous lesions). The flare occurs within minutes to a few hours if the reaction is IgE mediated but may take hours to days if the reaction is non-IgE mediated. The patient has persistent lesions if the food is eaten chronically. (See "Role of allergy in atopic dermatitis (eczema)" and "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis", section on 'Clinical manifestations'.)

The following features characterize the relationship between atopic dermatitis and food [22,23]:

The elimination of suspected food allergens frequently improves symptoms of atopic dermatitis within a few weeks.

Repeated exposure to suspect foods commonly exacerbates skin symptoms.

Eliminating foods to which an infant has demonstrable allergy can partially improve skin symptoms.

Eosinophilic gastrointestinal disorders — The eosinophilic gastrointestinal disorders (EGIDs) are characterized by symptoms of postprandial gastrointestinal dysfunction accompanied by eosinophilic infiltration of various segments of the intestinal tract on biopsy. Chronic symptoms are typical if the food trigger is consumed regularly. Symptoms are intermittent but can be delayed by hours to days if the food trigger is eaten infrequently. The pathophysiology of the EGIDs is poorly understood. Many patients have evidence of allergic sensitivities to food and/or environmental allergens, but the causal role of these sensitivities is unclear.

Eosinophilic esophagitis – EoE should be suspected in patients of any age presenting with esophageal symptoms. Infants and young children may present with feeding disorders and failure to thrive, whereas older children and adults typically present with dysphagia, vomiting, and abdominal pain [24]. A history of food impaction is common, particularly in adolescents and adults. Failure to respond to antacids and antireflux therapies is an important aspect of the history. Many patients with EoE have other atopic diseases. The most commonly implicated foods in children are cow's milk, egg, soy, corn, wheat, and beef, and most patients with evidence of food sensitivity tested positive for multiple foods. Elimination or elemental diets result in clinical and histologic improvement in most. (See "Clinical manifestations and diagnosis of eosinophilic esophagitis (EoE)".)

Eosinophilic gastroenteritis – Eosinophilic gastroenteritis can present at any age with abdominal pain, nausea, diarrhea, malabsorption, and weight loss. In infants, it may present as outlet obstruction with postprandial projectile vomiting that can mimic pyloric stenosis [25]. In adolescents and adults, it can mimic irritable bowel syndrome. Symptoms vary depending on the layer and portion of the gastrointestinal tract that is involved. Approximately one-half of patients have allergic disease, such as defined food sensitivities, asthma, eczema, or rhinitis. However, food allergy testing has not been shown to effectively identify specific culprit foods. An empiric elimination diet or elemental diet may improve symptoms and histologic findings in up to half of patients. (See "Eosinophilic gastrointestinal diseases".)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of food allergy includes a variety of disorders resulting from nonimmunologic reactions to food. As a group, these types of adverse food reactions are far more common than food allergy. Examples include lactose intolerance, gastroesophageal reflux, and disorders resulting from anatomic and neurologic abnormalities, enzymatic deficiencies, metabolic diseases, toxins, gastrointestinal infections, and a host of other processes (table 1) [12,26-29]. (See related topic reviews.)

Allergic reactions to food additives are rare. (See "Allergic and asthmatic reactions to food additives".)

Migraine headache is another disorder that has been ascribed to food "allergy," but the relationship is not a true allergy. Although not very common, there are certain foods that may trigger migraines through nonallergic mechanisms due to their inherent chemical properties (eg, aromatic amine content) (table 6). (See "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Pathophysiology, clinical features, and diagnosis of migraine in children".)

The full differential diagnosis of each of the specific disorders reviewed in this topic is discussed in the specific topics on each of those disorders. (See related topic reviews.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Food allergy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Food allergy (The Basics)")

Beyond the Basics topic (see "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)")

SUMMARY

Categorization of food allergies – Food allergies arise from abnormal immunologic reactions, usually to food proteins. Food allergies are broadly categorized into either immunoglobulin E (IgE) mediated or non-IgE-mediated processes. Some disorders have characteristics of both mechanisms. (See 'Introduction' above.)

IgE-mediated food allergy – IgE-mediated food allergy typically develops rapidly after food ingestion (ie, usually within minutes). Symptoms can affect one or more organ systems (table 2). Isolated allergic rhinoconjunctivitis or asthma in response to foods is rare. Specific disorders include cutaneous reactions (urticaria, angioedema), anaphylaxis (including food-dependent exercise-induced anaphylaxis [FDEIAn]), and oral allergy syndrome. (See 'IgE-mediated reactions' above.)

Non-IgE-mediated food allergy – Non-IgE-mediated food allergies present as more subacute and/or chronic symptoms, which are typically isolated to the gastrointestinal tract. The type of gastrointestinal signs and symptoms may vary in some disorders, depending upon whether the food is consumed regularly or infrequently. In addition, certain disorders are associated with systemic manifestations. Specific syndromes include food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctitis/proctocolitis, celiac disease, and food-induced pulmonary hemosiderosis (Heiner syndrome). (See 'Non-IgE-mediated reactions' above.)

Mixed (IgE- and non-IgE-mediated) food allergy – Both IgE and non-IgE-mediated mechanisms can be involved in atopic dermatitis and eosinophilic gastrointestinal disorders (EGIDs). Food allergies may exacerbate atopic dermatitis, especially in young children with more severe eczema. Infants and young children with eosinophilic esophagitis (EoE) may present with feeding disorders, whereas older children and adults typically present with dysphagia, vomiting, and abdominal pain. A history of food impaction is common, particularly in adolescents and adults. Eosinophilic gastroenteritis can present at any age with abdominal pain, nausea, diarrhea, malabsorption, and weight loss. In infants, it may present as outlet obstruction with postprandial projectile vomiting. In adolescents and adults, it can mimic irritable bowel syndrome. Symptoms vary depending on the layer and portion of the gastrointestinal tract that is involved. (See 'Mixed IgE- and non-IgE-mediated reactions' above.)

Differential diagnosis – The differential diagnosis of food allergy consists of a number of nonimmunologic food reactions and disorders (table 1). In addition, each specific type of food allergy has an extensive differential diagnosis that includes disorders that are not related to food. (See 'Differential diagnosis' above.)

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