Food protein-induced enterocolitis mimics surgical emergency in a neonate: A case report

Razan Bawazir; Osama A Bawazir; Abdullah Bawazir

doi:10.4103/jcn.jcn_145_20

CASE REPORT

Year : 2021 | Volume : 10 | Issue : 2 | Page : 130-132

Food protein-induced enterocolitis mimics surgical emergency in a neonate: A case report

Razan Bawazir¹, Osama A Bawazir², Abdullah Bawazir¹
¹ College of Medicine, King Saud Bin AbdulazizUniversity for Health Sciences, Riyadh, Saudi Arabia
² Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah; Department of Surgery, Faculty of Medicine, Umm Al Qura University, Makkah, Saudi Arabia

Date of Submission	10-Sep-2020
Date of Decision	23-Dec-2020
Date of Acceptance	06-Jan-2021
Date of Web Publication	15-May-2021

Correspondence Address:
Razan Bawazir
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Makkah
Saudi Arabia

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jcn.jcn_145_20

Abstract

Food protein-induced enterocolitis syndrome (FPIES) is described as a non-IgE-mediated food sensitivity of the gastrointestinal tract, especially in infants and children. This case demonstrates that FPIES can present with extreme symptoms that mimic surgical emergency like necrotizing enterocolitis and physician should be suspicious of this in neonate with rectal bleeding.

Keywords: Food protein-induced enterocolitis syndrome, necrotizing enterocolitis, rectal bleeding

How to cite this article:
Bawazir R, Bawazir OA, Bawazir A. Food protein-induced enterocolitis mimics surgical emergency in a neonate: A case report. J Clin Neonatol 2021;10:130-2

How to cite this URL:
Bawazir R, Bawazir OA, Bawazir A. Food protein-induced enterocolitis mimics surgical emergency in a neonate: A case report. J Clin Neonatol [serial online] 2021 [cited 2023 Mar 21];10:130-2. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/130/316173

Introduction

Food protein-induced enterocolitis syndrome (FPIES) is described as a nonimmunoglobulin E (IgE)- mediated food sensitivity of the gastrointestinal tract, especially in infants and children. FPIES is generally recognized through vomiting and lethargy due to the ingestion of offending food.^[1] Cases of FPIES present with diarrhea, vomiting, and weight loss; in extreme cases, it can present with internal bleeding and metabolic acidosis.^[2] It is promoted commonly through cow milk and soy. However, any proteinaceous food such as rice and poultry can trigger it.^[3] Herein, we present cases with a severe form of FPIES with symptoms that mimic surgical catastrophes such as bilious vomiting and rectal bleeding.

Case Report

A 4-day-old male presented to a pediatric clinic with complaints of failure to thrive with bloody stool and worsening of bilious vomiting after beginning synthetic formulation. The infant was admitted to neonatal intensive care unit for observation and referred to a pediatric medical professional to exclude the possibility of necrotizing enterocolitis (NEC) or other abdominal abnormalities. Laboratory data revealed a slight elevation in thrombocytes (481 × 1000/μL), high neutrophil count (49%), marked lymphocytosis (75%), and low levels of hemoglobin (11.5 g/dL). According to stool analysis, the stool was positive for occult blood. Stool had mucoid consistency with the presence of pus cells (20–30) and no presence of microbial growth or parasites in stool. Furthermore, the liver function test showed low levels of ammonia (61 μmol/L) and an elevation in bilirubin (197.29 μmol/L) with normal renal and coagulation profile. Clinical examination revealed a tender and lax abdomen with no abdominal distension or tenderness and no other abnormalities [Figure 1]. However, the child had a bleeding rectum [Figure 2] even though the abdominal X-ray [Figure 3] was normal and had no evidence of coagulopathy. This neonate was diagnosed with severe FPIES that is triggered by cow milk. The baby was then kept nil per os for 48 h without deterioration of abdominal symptoms. The offending food, i.e., cow's milk, was eliminated substantially from his feed. The course of the remedy required the advent of a new elemental food regimen formula (Neocate^® [Nutricia]). The neonate tolerated the feeding very well, was nourished, and the bloody stool was resolved within the 1^st week of introducing the new formula. The neonate gradually gained weight and was thriving at the follow-up clinic visit.

Figure 1: (a) The neonate abdomen showing no abdominal distension, (b) Bilious aspirate from the nasogastric tube

Click here to view

Figure 2: Fresh blood in the diaper

Click here to view

Figure 3: (a) X-ray of the abdomen showing nonspecific gas distribution and no free air, (b-d) Extensive bowel wall thickening extending from the duodenum to the colon

Click here to view

Discussion

Cow's milk protein is the most common food allergen in infants. An allergic reaction starts in the 1^st month of an infant's life and includes irritability, constant diarrhea, and reduced feeding. FPIES is an adverse immune response due to the ingestion of specific food. The intestines are aided using enormous mediators such as cytokines that alter mucosal inflammation and oral tolerance. However, a few humans' systems react to proteins as pathogens and cause inflammations. These unknown reactions probably due to food are considered as food allergies. Food reactions are categorized into two types: immune-mediated reactions and nonimmune-mediated reactions. Immune-mediated reaction consists of IgE-mediated food allergy (IgE-FA), mixed IgE, and non-IgE-FA. Nonimmune-mediated reactions are not considered as a food allergic reaction. FPIES is classified under IgE-FA.

Rubin was the first to describe this anomaly while diagnosing a patient affected with intense bloody diarrhea and who was treated by removing cow's milk from his food regimen. Pathophysiology of FPIES still needs further elucidation. It is caused by the increased permeability of the intestines from the activated gut's T-cells and the discharge of pro-inflammatory cytokines.^[4] The physical presentation of signs and symptoms is extensively variable. Infants may additionally show apnea, lethargy, abdominal distension, and bloody stool. Laboratory results can be abnormal, displaying multiplied stages of metabolic acidosis or thrombocytopenia.^[5]

The varied signs and symptoms of FPIES can be similar to that of other different sicknesses. Bloody mucoid stool, a symptom of FPIES, is also common in intussusception and gastroenteritis. To avoid disastrous consequences, it is vital to provide an appropriate diet plan and efficaciously diagnose FPIES. FPIES diagnosis depends on eliminating the causative food and the reappearance of signs and symptoms when the offending food is reintroduced.^[6] It can be diagnosed via a meticulous clinical examination and by maintaining a record of the affected person. Moreover, it is also essential to prevent unnecessary food elimination, which may result in nutritional deficiency. Those who eliminate a more significant amount of food may be at a higher risk. The correct time for the reintroduction of complementary food is when the patient has overcome the allergy.^[7] The current guidelines concerning the introduction of complementary food favor adding low-risk food (vegetables and fruits), followed by the introduction of moderate-to-high-risk food in the later months gradually. Since FPIES triggers hemoglobin nadir, it is highly recommended to introduce iron-rich food to the diet. A remedy can be carried out by supplying elemental or hydrolyzed formulas to infants. The infant was provided with an amino acid-based formula (Neocate) to promote weight gain. Patients with severe instances of FPIES are guided to switch to acid-based formula as an ideal choice as infants might be susceptible to deficiency of calcium and other minerals.^[8]

Conclusion

FPIES is a non-IgE-GI-FA with diverse presentations and is usual in neonates and infants. It can be present with extreme symptoms that mimic other severe pathologies. Its detection is based totally on clinical medical history and conventional symptoms including vomiting, drowsiness, lethargy, and diarrhea that disappear after eliminating the trigger food. It can be diagnosed as early as in the 1^st week of ailment.

Severe cases of FPIES may be confused for surgical conditions, which include NEC. Meticulous evaluation is mandatory to rule out surgical catastrophes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ribeiro A, Moreira D, Costa C, Pinto Pais I. Food protein-induced enterocolitis syndrome: A challenging diagnosis. BMJ Case Rep 2018;2018:bcr2017222822.
2.	Michelet M, Schluckebier D, Petit LM, Caubet JC. Food protein-induced enterocolitis syndrome – A review of the literature with focus on clinical management. J Asthma Allergy 2017;10:197-207.
3.	Leonard SA, Pecora V, Fiocchi AG, Nowak-Wegrzyn A. Food protein-induced enterocolitis syndrome: A review of the new guidelines. World Allergy Organ J 2018;11:4.
4.	Geljic A, Hojsak I. Methaemoglobinaemia in two exclusively breastfed infants with food protein-induced enterocolitis syndrome. J Paediatr Child Health 2020. doi: 10.1111/jpc.15086. [Online ahead of print].
5.	Liu H, Turner TW. Allergic colitis with pneumatosis intestinalis in an infant. Pediatr Emerg Care 2018;34:e14-5.
6.	Kabuki T, Joh K. Extensively hydrolyzed formula (MA-mi) induced exacerbation of food protein-induced enterocolitis syndrome (FPIES) in a male infant. Allergol Int 2007;56:473-6.
7.	Afaa TJ, Afrane AK, Etwire V. Gastrointestinal food allergy in Ghanaian children: A case series. Ghana Med J 2017;51:138-42.
8.	Hill DJ, Murch SH, Rafferty K, Wallis P, Green CJ. The efficacy of amino acid-based formulas in relieving the symptoms of cow's milk allergy: A systematic review. Clin Exp Allergy 2007;37:808-22.