Orale Rush-Toleranzinduktion bei einem Jungen mit schwerer IgE-vermittelter Kuhmilchallergie

Abstract

In literature the incidence of IgE-mediated cow's milk allergy in young children is reported to be 2.5 up to 7%. The majority outgrows the allergy at the age of 3 years. After the age of 6, however, patients have a very low probability of spontaneous recovery. First-choice treatment is the complete avoidance of cow's milk. However, even consequent adherence to an elimination diet only leads to a spontaneous remission in about 1/3 of the cases. We report on a 5-year-old boy, who developed Quinckes edema, generalized urticaria, hypotension and somnolence (anaphylaxis grade III) after the introduction of cow's milk in a baby formular in his diet at the age of 12 months. A milk-free diet was introduced, but several times, anaphylactic reactions occurred due to accidental intake of low amounts of hidden cow's milk in different finished products. IgE-mediated cow's milk allergy was diagnosed by skin prick test and specific IgE. For oral tolerance induction to cow's milk, a rush protocol within 6 days was used. End-point prick test titration with cow's milk (native cow's milk, dilutions 1 : 10, 1 : 100, 1 : 1 .000 milk/water, etc.) was performed. Starting with 1 ml of the prick test-negative dilution (1/1.000.000 (milk/water), cow's milk was given in increasing dosages. Doses were doubled ever 20 - 60 minutes. During up-dosing, no severe anaphylactic reactions were seen. At Day 3, the patient developed minor allergic symptoms (periorally localized urticarial lesion, mild rhinitis), which could be managed with oral antihistamines. On Day 6, the child tolerated 250 ml cow's milk without any side effects. Oral tolerance to cow's milk was induced successfully and was accompanied by immunological changes during the maintenance therapy. At the follow-up examination after 2 years, levels of specific IgE for whole milk protein (2.68 - 1.12 kU/1), casein (2.99 to 0.56 kU/1) and whey (1.78 to 0.63 kU/1) had decreased substantially. Simultaneously, Westemblot analysis showed a pronounced signal for IgG4, which was negative before tolerance induction. Tolerance induction in IgE-mediated cow's milk allergy is practicable within a few days. Due to the potential anaphylactic side effects, we recommend to perform the therapy only in an in-patient setting.