Case Report
Our patient is a three-month old full-term male with an unremarkable
past medical history. He presented with anaphylaxis after being fed
cow’s milk formula for the first time. He was exclusively breastfed
since birth but an initial trial of regular cow’s milk formula led to a
severe allergic reaction. Within 30 minutes after introducing cow’s milk
he had an episode of vomiting followed by wheezing, stridor and
bilateral eyelid and lip swelling. Treatment included injection of
intramuscular epinephrine and further emergency medical services. In the
emergency room, vital signs were stable (blood pressure (83/63), heart
rate (153), respiratory rate (48), and an oxygen saturation (100%). His
physical exam was remarkable for diffuse urticarial rash and bilateral
eyelid swelling. Subsequently, he was treated with oral prednisolone,
diphenhydramine, ranitidine, given a normal saline bolus and was
admitted to pediatric intensive care for anaphylaxis monitoring.
Laboratory evaluations were as follows: total immunoglobulin E (IgE)23 kU/L, IgE to cow’s milk: 1.64 kU/L, soybean igE
<0.1 kU/L, alpha-lactalbumin: 1.73 kU/L,
Beta-lactoglobulin: 3.73 kU/L, casein: 2.58 kU/L:. An oral
challenge with soymilk was attempted but the patient developed acute
right eyelid edema and urticarial rash. He was then trialed on
extensively hydrolyzed formula but unfortunately developed immediate
angioedema and diffuse urticaria. His condition was suggestive of an
type 1 hypersensitivity phenomena requiring further management in the
intensive care unit. Eventually, an amino acid-based formula was given
and was well tolerated without any further reactions. He was discharged
with an EpiPen and amino acid-based formula and was followed by the
allergy team as an outpatient.
Our patient presented with signs and symptoms consistent with
anaphylaxis and was appropriately treated with intramuscular epinephrine
which is the single most effective treatment for anaphylaxis.(6) Oral
steroids and antihistamines were given as adjuvant therapy in the
management of the anaphylactic symptoms[6].
The standard for the diagnosis of IgE mediated food allergies is a
blinded oral challenge test, but when the presentation is consistent
with a severe allergic reaction or anaphylaxis, the diagnosis can be
confirmed with a positive IgE test in the blood or a skin prick test
[8]. In our case the etiology was confirmed via an IgE test to milk
and its components. However, an oral trial with soy and an extensively
hydrolyzed formula proved unsuccessful.