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Fish Sensitization in a Group of Allergic Egyptian Children

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Fish Sensitization in a Group of Allergic Egyptian Children Egypt J Pediatr Allergy Immunol 2013;11(1):23-28. Original article Fish sensitization in a group of allergic Egyptian children Background: There are no published data on fish allergy in Egypt. Elham Hossny, Objective: We sought to screen for the frequency of fish sensitization in a Zeinab Ebraheem, group of atopic Egyptian infants and children in relation to their Ayman Rezk. demographic and phenotypic data. Methods: We consecutively enrolled 87 allergic children; 1-15 years old (median 5.0 yr). The study measurements included clinical evaluation for the site and duration of allergy, possible precipitating factors, and family Pediatric Allergy and history of allergy as well as skin prick testing with a commercial fish Immunology Unit, extract, and serum fish specific and total IgE estimation. Children’s Hospital, Results: Twelve subjects (13.8%) were sensitized to fish as evidenced by Ain Shams University, positive skin prick test (SPT) results; five (41.7%) of them gave a history Cairo, Egypt. suggestive of fish allergy compared to two (2.7%) of the non-sensitized children (p=0.00). The SPT results did not vary significantly with age, gender, family history of atopy, or serum total or fish specific IgE (SpIgE). Correspondence: Conclusion: Fish sensitization does not seem to be rare in atopic Zeinab Ebraheem, children in Egypt. It can be associated with any clinical form of allergy Pediatric Allergy and and the causal relationship needs meticulous evaluation. Wider scale Immunology Unit, population-based studies are needed to assess the prevalence of fish Children’s Hospital, allergy and its clinical correlates in our country. Ain Shams University, Abassia, Cairo, Egypt. E-mail: Key Words: fish allergy; sensitization; skin prick test; specific IgE; children; Egypt zeinabeh2002@yahoo. com 50% of individuals allergic to some type of fish are INTRODUCTION at risk for reacting to a second species. However, up Fish is a major source of dietary protein, especially to 40 % of patients sensitized to one or more fish do in coastal areas. A large share of fish is now not present symptoms on consuming other species, consumed not longer as entity but as ingredient in the best tolerated of which belong to the highly processed food products. This development Scombroidea family which includes tuna.10 Cod involves that the risk for food cross-contamination parvalbumin shares IgE binding epitopes with frog due to elaborate manufacturing processes and parvalbumin. This in vitro cross-reactivity seems to 11 differently handled hygiene practices has likewise be also clinically relevant. 1, 2 increased. The age of the initial consumption may Fish and shellfish are two of the most common influence the age of the initial reaction.12 In recent causes of IgE-mediated food-allergic reactions in years, the number of new fish allergy cases during both children and adults. The prevalence estimates the first year of life appears to have diminished. 3-5 of fish allergy range between 0% and 2%. The This may reflect a parental tendency to delay the edible fish include more than 20000 species; introduction of fish into the infant diet, although however, the most commonly consumed belong to there is no public health advice to support this.13 only a few orders of the ray-finned fish Until recently, the American Academy of Pediatrics (Actinopterygii). The major fish allergen, Gad c 1, had recommended that fish be avoided until the age has been extensively studied and is a 12-kDa of 3 years.14 Paradoxically, early large exposure calcium binding sarcoplasmic protein belonging to rather than conventional strict avoidance has 6 the protein family of parvalbumins. Although induced immune tolerance.15 After adjustment for species-specific epitopes have been reported, potential confounders, late introduction of fish was parvalbumin, in general, constitutes the major significantly associated with increased risk of 7-9 cross-reactive fish allergen. It is estimated that sensitization to fish and inhalant allergens.16 23 Hossny et al. Sensitization to fish was not associated with the Study Measurements timing of fish introduction in a recent report from All patients included in the study were subjected to Sweden. However, the early introduction of fish the following: into the child's diet was associated with less eczema Clinical evaluation: development.17 The early introduction of food Detailed history was taken for the duration and allergens during infancy might thereby induce severity of symptoms, possible precipitating factors tolerance.18 including seafood, response to treatment, and Adverse reactions in infants or children at the family history of allergy. Patients were subjected to first introduction of fish may result from the a general clinical examination, as well as chest, passage of fish allergens through breast milk or the skin, and ENT examination to verify the diagnosis. presence of these allergens in the indoor air and Skin prick test with fish extract: dust of houses where fish is frequently cooked This was performed using a commercial fish mix and/or processed. The sensitivity often appears at allergen extract, positive histamine control, and an early age, and in many patients, persists for negative control (Omega Laboratories, Montréal, life.19 In a surveyed sample, only 3.5% of the Canada). First generation short-acting subjects with fish allergy and 4% of the subjects antihistamines were avoided for at least 72 hours with shellfish allergy reported loss of that allergy.4 and second generation antihistamines were avoided The duration of seafood avoidance until the for at least 5 days before testing. The test sites were attainment of tolerance is unknown but is longer marked and labeled at least 3 cm apart to avoid the than that for other foods such as cow’s milk and overlapping of positive skin reactions. The marked egg.20 It probably depends on several factors, such site was dropped by the allergen and gently pricked as age of onset, degree of sensitization, type of by sterile skin test lancet. Positive and negative symptoms, severity of reaction, multiplicity of control solutions were similarly applied. The patient causative foods, and degree of avoidance. It is waited for at least 20 minutes before interpretation worth noting, however, that recurrence of of the results. Largest and orthogonal diameters of intolerance might occur.21 any resultant wheal and flare were measured. A The prevalence of fish sensitivity and allergy wheal of 3 mm or more above the negative control in Egypt is not sufficiently studied. Therefore, we was taken as a positive result.5,12,22 were stimulated to study the frequency of Laboratory investigations: sensitization to fish in a group of Egyptian allergic Specific IgE (SpIgE) assay for fish mix was children suffering from various allergic disorders. performed by Enzyme immunoassay (RIDASCREEN® Spezifisches IgE by Enzyme METHODS immunoassay for the determination of specific IgE Study Population in serum, R-Biopharm AG, Darmstadt, Germany). This cross sectional study comprised 87 children Levels of fish specific IgE ≥ 0.7 KIU/L were diagnosed clinically to have allergic diseases. They considered increased according to the manufacturer. were enrolled consecutively from the Pediatric Serum total IgE using the ELISA technique (Medix Allergy and Immunology Clinic, Children's Biotech, Inc., Agenzyme Company, Industrial Hospital, Ain Shams University, Cairo from July 1 Road, San Carios, CA, USA). The value of IgE to December 31, 2010. An informed consent was used for data analysis was the percentage calculated 23 obtained from the parents or care-givers prior to from the highest normal for age as follows: enrollment. The study protocol was approved by the Patient's normal value/highest normal for age local ethics committee. multiplied by 100. Inclusion criteria: Statistical analysis: - Age at enrollment between one and 18 years. Data were analyzed by a standard computer - A physician made diagnosis of allergic diseases program using the statistical software package including asthma, allergic rhinitis, urticaria, and SPSS for windows v.13 Chicago IL, USA. The eczema. mean, standard deviation (SD), median, and interquartile (IQ) range presented the descriptive Exclusion criteria: data. Groups were compared using the Kruskal- - Patients who cannot stop antihistamine therapy. Wallis and Mann-Whitney Z tests for non- parametric data. Fisher’s Exact and Chi square (X²) - Extensive skin lesions, positive dermatographism, tests were used for comparison of categorical data. and very dark skin. Pearson and Spearman coefficient tests were used - to correlate the numeric data. For all tests, p values 24 Fish Sensitivity in Egypt less than 0.05 were considered statistically (p=0.41/p=0.48) of the fish sensitized children. The significant. wheal and flare diameters were directly correlated (p=0.02). RESULTS Seven subjects in the studied sample (8%) The studied sample comprised 52 boys and 35 girls. gave a history suggestive of fish allergy. Of those, 5 Their ages ranged between one and 15 years (71.4%) had positive fish SPT results and the [median (IQR) = 5.0 (6.0); mean (SD) = 6.0 (3.5) difference from cases with negative SPT was years]. The diagnoses included respiratory allergy significant as two subjects only (2/75) gave such a (bronchial asthma and/or allergic rhinitis) in 44 history. Although 83.3% of patients with positive children, skin allergy (atopic dermatitis and/or SPT in our series had positive family history of urticaria) in 14 children, and both respiratory and allergic diseases compared to 65.3% in children skin allergy in 29 children of the studied sample. with negative SPT results, the difference did not The total IgE level was elevated for age in 33 reach statistical significance. The fish SPT results subjects (37.9%). The fish SpIgE was elevated were not significantly influenced by age or gender (above 0.7 kUA/L) in 87.4% (76/87) of the studied and did not vary with the serum total IgE status sample and the levels ranged between 0.4-18 whether elevated or not.
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