What is the management for a patient with hypersensitivity to protein-induced enterocolitis due to salmon?

Management of Hypersensitivity to Protein-Induced Enterocolitis Due to Salmon

The cornerstone of management for salmon-induced food protein-induced enterocolitis syndrome (FPIES) is complete elimination of salmon from the diet, along with appropriate treatment of acute reactions based on severity. 1

Diagnosis Confirmation

• FPIES is diagnosed primarily based on clinical history of characteristic symptoms occurring 1-4 hours after food ingestion, with improvement after withdrawal of the suspected trigger food 2, 1
• Key symptoms include:
  • Profuse, projectile vomiting 1-4 hours after salmon ingestion
  • Possible diarrhea within 24 hours
  • Lethargy, pallor, and in severe cases, hypotension
• Oral food challenges (OFCs) should only be performed in a medical setting to confirm diagnosis if history is unclear 2, 1
• Standard allergy testing (skin prick tests or specific IgE) is typically negative as FPIES is non-IgE mediated 3, 4

Acute Reaction Management

Treatment should be tailored to reaction severity:

Mild Reactions

• Attempt oral rehydration with clear fluids
• Consider ondansetron 0.15 mg/kg IM (max 16 mg) if patient is ≥6 months old
• Monitor for 4-6 hours from symptom onset 1

Moderate Reactions

• Administer ondansetron 0.15 mg/kg IM (max 16 mg)
• Establish IV access for normal saline bolus (20 mL/kg)
• Transfer to ED/ICU if persistent hypotension, shock, lethargy, or respiratory distress 1

Severe Reactions

• Establish IV access with rapid normal saline bolus (20 mL/kg), repeat as needed
• Administer IV ondansetron 0.15 mg/kg (max 16 mg)
• Consider IV methylprednisolone (1 mg/kg; max 60-80 mg)
• Monitor and correct acid-base and electrolyte abnormalities 2, 1

Long-term Management

1. Strict Avoidance of Salmon

   • Avoid all forms of salmon including processed foods containing salmon
   • Read food labels carefully and inquire about ingredients when dining out

2. Cross-reactivity Considerations

   • Fish-induced FPIES may show cross-reactivity with other fish species
   • Introduction of other fish should only be done under medical supervision 5, 4
   • Some patients may tolerate certain fish species while reacting to others 4

3. Nutritional Management

   • Consult with a nutritionist to ensure adequate nutrition despite dietary restrictions 1
   • Ensure appropriate alternative protein sources are included in the diet

4. Follow-up and Monitoring

   • Regular follow-up is necessary to assess for resolution
   • Consider oral food challenges under medical supervision after 12-18 months of avoidance to evaluate for tolerance development 1, 3

Special Considerations

• Fish-induced FPIES typically has lower rates of resolution compared to milk or soy-induced FPIES 6
• OFCs for fish should be performed with caution, as they can trigger severe reactions 7
• A modified OFC protocol giving a single dose per day on non-consecutive days may be safer than multiple doses on the same day 7
• Patients should be instructed to call 911 or go to the emergency department immediately if they have accidentally ingested salmon and experience >3 episodes of vomiting, moderate-to-severe lethargy, signs of dehydration, or respiratory distress 1

Prognosis

• Fish-induced FPIES typically has a more protracted course compared to other FPIES triggers 4, 6
• Some patients may develop tolerance to specific fish species while continuing to react to others 4
• Regular reassessment for tolerance development should be conducted every 12-18 months under medical supervision 3