Correspondence
Recurrent Peanut Allergy
N Engl J Med 2002; 347:1535-1536November 7, 2002
- Article
To the Editor:
Allergy to peanuts is potentially fatal, affects 1 in 150 persons in the United States, and until recently was considered to be permanent.1,2 However, recent reports document a 20 percent rate of resolution by school age.3,4 We offer an institutionally approved research protocol for double-blind, placebo-controlled oral food challenges for use in children older than 3.5 years of age who have been allergic to peanuts and who have a clinical profile consistent with potential resolution of peanut allergy, as defined by the absence of recent reactions and a serum peanut-specific IgE antibody concentration of less than 10 kU per liter.3
We describe three of our patients who tolerated peanuts during such a challenge involving 8 g of peanut flour followed by a 32-g serving of peanut butter but who went on to have recurrence of peanut allergy. The three boys initially had convincing clinical reactions and laboratory evidence of peanut sensitization that diminished over time before the oral challenges (Table 1Table 1
Immunologic Findings and Clinical Course in Three Boys with Recurrence of Peanut Allergy.). In the year after having no allergic reaction on oral challenge, the boys ate peanuts infrequently and in small quantities. The recurrence of peanut allergy was documented in Patient 1 by a repeated challenge that elicited a generalized reaction, in Patient 2 by repeated mild reactions and a concentration of peanut-specific IgE antibody (15 kU per liter) that was highly (>95 percent) predictive of clinical reactions,5 and in Patient 3 by a severe reaction and recurrence of sensitization.We can only speculate as to why these children became resensitized. Although they were not reactive, they were ingesting only small amounts of peanut intermittently — a regimen that is typically considered to be sensitizing. This regimen contrasts with typical regimens designed to build tolerance (which entail the continuous administration of small doses or the intermittent administration of large doses). These 3 patients were evaluated after 44 children entered our ongoing study of the resolution of peanut allergy. At that time, 26 children had no allergic reaction on oral challenge, and follow-up (mean duration, 15 months) in 21 children revealed that only 10 routinely ate peanuts. This observation is worrisome if the aforementioned hypothesis is correct.
The clinical ramifications of our observations are profound and may apply to other foods as well as to peanuts. Recurrence of peanut allergy is possible even when it has been shown to have resolved. It seems prudent to maintain access to emergency medications, such as self-injectable epinephrine, for patients with resolved peanut allergy until peanuts are routinely tolerated in relevant quantities for at least one to two years.
5 ReferencesPaula J. Busse, M.D.
Anna H. Nowak-Wegrzyn, M.D.
Sally A. Noone, R.N., M.S.N.
Hugh A. Sampson, M.D.
Scott H. Sicherer, M.D.
Mount Sinai School of Medicine, New York, NY 10029-6574
scott.sicherer@mssm. edu 1
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- Citing Articles (24)
Citing Articles
1
Michelle Nguyen, Brynn Kevin Wainstein, Wendy Hu, John B. Ziegler. (2010) Parental satisfaction with oral peanut food challenges; perception of outcomes and impact on management of peanut allergy. Pediatric Allergy and Immunology 21:8, 1119-1126
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Scott H. Sicherer, Robert A. Wood, Donald Stablein, Robert Lindblad, A. Wesley Burks, Andrew H. Liu, Stacie M. Jones, David M. Fleischer, Donald Y.M. Leung, Hugh A. Sampson. (2010) Maternal consumption of peanut during pregnancy is associated with peanut sensitization in atopic infants. Journal of Allergy and Clinical Immunology 126:6, 1191-1197
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Andrea Borchers, Suzanne S. Teuber, Carl L. Keen, M. Eric Gershwin. (2010) Food Safety. Clinical Reviews in Allergy & Immunology 39:2, 95-141
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A. M. Byrne, J. Malka-Rais, A. W. Burks, D. M. Fleischer. (2010) How do we know when peanut and tree nut allergy have resolved, and how do we keep it resolved?. Clinical & Experimental Allergy 40:9, 1303-1311
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Jennifer S Kim, Scott Sicherer. (2010) Should avoidance of foods be strict in prevention and treatment of food allergy?. Current Opinion in Allergy and Clinical Immunology 10:3, 252-257
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Carla M. Davis. (2009) Food Allergies: Clinical Manifestations, Diagnosis, and Management. Current Problems in Pediatric and Adolescent Health Care 39:10, 236-254
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Justin M. Skripak, Robert A. Wood. (2008) Peanut and tree nut allergy in childhood. Pediatric Allergy and Immunology 19:4, 368-373
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A Wesley Burks. (2008) Peanut allergy. The Lancet 371:9623, 1538-1546
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Robert J. Boyle, Mimi L.-K. Tang. (2008) Recurrent Peanut Allergy May Not Be Prevented by Continued Peanut Ingestion. International Archives of Allergy and Immunology 147:3, 260-262
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U. Staden, C. Rolinck-Werninghaus, F. Brewe, U. Wahn, B. Niggemann, K. Beyer. (2007) Specific oral tolerance induction in food allergy in children: efficacy and clinical patterns of reaction. Allergy 62:11, 1261-1269
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Scott H. Sicherer, Hugh A. Sampson. (2007) Peanut allergy: Emerging concepts and approaches for an apparent epidemic. Journal of Allergy and Clinical Immunology 120:3, 491-503
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David M. Fleischer. (2007) The natural history of peanut and tree nut allergy. Current Allergy and Asthma Reports 7:3, 175-181
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Philippe A. Eigenmann, Jean-Christoph Caubet, Samuel A. Zamora. (2006) Continuing food-avoidance diets after negative food challenges. Pediatric Allergy and Immunology 17:8, 601-605
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Janet L. Beausoleil, Jonathan M. Spergel. (2006) Late diagnosis of tree nut and sesame allergy in patients previously sensitized but tolerant to peanut. Annals of Allergy, Asthma & Immunology 97:4, 443-445
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Alessandro Fiocchi, Amal Assa'ad, Sami Bahna. (2006) Food allergy and the introduction of solid foods to infants: a consensus document. Annals of Allergy, Asthma & Immunology 97:1, 10-21
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Jean A. Chapman, I.L. Bernstein, Rufus E. Lee, John Oppenheimer, Richard A. Nicklas, Jay M. Portnoy, Scott H. Sicherer, Diane E. Schuller, Sheldon L. Spector, David Khan, David Lang, Ronald A. Simon, Stephen A. Tilles, Joann Blessing-Moore, Dana Wallace, Suzanne S. Teuber. (2006) Food allergy: a practice parameter. Annals of Allergy, Asthma & Immunology 96:3, S1-S68
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Anna Nowak-Wegrzyn, Hugh A. Sampson. (2006) Adverse Reactions to Foods. Medical Clinics of North America 90:1, 97-127
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Amy M. Scurlock, A.W. Burks. (2004) Peanut allergenicity. Annals of Allergy, Asthma & Immunology 93:5, S12-S18
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Kelly D Stone. (2004) Advances in pediatric allergy. Current Opinion in Pediatrics 16:5, 571-578
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Satyapal Rangaraj, Veena Ramanathan, David P. Tuthill, Elizabeth Spear, Jonathan O'B Hourihane, Mazin Alfaham. (2004) General paediatricians and the case of resolving peanut allergy. Pediatric Allergy and Immunology 15:5, 449-453
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Sami L Bahna. (2004) You can have fish allergy and eat it too!. Journal of Allergy and Clinical Immunology 114:1, 125-126
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BY-H Thong, JO'B Hourihane. (2004) Monitoring of IgE-mediated food allergy in childhood. Acta Paediatrica 93:6, 759-764
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Roland Solensky. (2003) Resolution of fish allergy: a case report. Annals of Allergy, Asthma & Immunology 91:4, 411-412
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Matthew I. Fogg, Nicholas A. Pawlowski. (2003) Anaphylaxis. Pediatric Case Reviews 3:2, 75-82
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