Differentiating acute food protein-induced enterocolitis syndrome from its mimics: a comparison of clinical features and routine laboratory biomarkers

Publication date: Available online 25 October 2018

Source: The Journal of Allergy and Clinical Immunology: In Practice

Author(s): Eric Lee, Elizabeth H. Barnes, Sam Mehr, Dianne E. Campbell

Abstract

Background

Food protein-induced enterocolitis syndrome (FPIES) is frequently misdiagnosed and subject to diagnostic delay. Profuse vomiting, the cardinal feature of acute FPIES, may occur in more common paediatric disorders such as gastroenteritis and sepsis.

Objectives

We sought to determine differentiating features at acute presentation between FPIES, gastroenteritis and sepsis in young children presenting to an emergency department (ED) with profuse vomiting.

Methods

We conducted a retrospective case-control study of children aged 6 months to 4 years with a diagnosis of acute FPIES who had presented to ED and compared the clinical features, vital signs and routine laboratory studies of this cohort to similarly aged children presenting to ED with vomiting diagnosed with bacterial/viral gastroenteritis or bacterial sepsis.

Results

181 acute FPIES ED presentations were compared to 55 gastroenteritis and 36 bacterial sepsis ED presentations. Children with FPIES were more likely to present with lethargy, floppiness and pallor. Compared to FPIES, children with sepsis were likely to present with fever, tachycardia, tachypnea and diarrhoea, whilst those with gastroenteritis were likely to present with fever, diarrhoea and blood in stools. Normal CRP, leucocytosis, lymphocytosis, thrombocytosis, low MPV and an elevated albumin/globulin ratio were more commonly seen in FPIES than sepsis or gastroenteritis. No other clinical or laboratory markers examined reliably distinguished between the three disease groups.

Conclusions

In the young vomiting child, lethargy, floppiness, pallor without fever and normal CRP should alert clinicians to a possible diagnosis of FPIES. In contrast a highly elevated CRP is not a feature of FPIES, and in such cases an alternative diagnosis must be considered.