TREE NUT ALLERGY MASQUERADING AS FOREIGN BODY ASPIRATION: PISTACHIO ALLERGY PRESENTING WITH ISOLATED SUPRAGLOTTIC EDEMA

Abstract

Introduction Foreign body aspiration and food allergy are common causes of respiratory distress in pediatric patients. We present a case of respiratory distress in a 19 month old male who reportedly choked on a pistachio. However, during evaluation for foreign body aspiration, he was found to have isolated supraglottic edema due to pistachio IgE mediated hypersensitivity. Case Description A previously healthy 19 month old male presented with coughing and difficulty breathing immediately after reportedly choking on a pistachio. His respiratory rate was 50, heart rate was 180 bpm, and pulse oximetry was 30% which improved to 100% with supplemental oxygen. Exam was notable for grunting, accessory respiratory muscle use, and the absence of rash, angioedema, or wheezing. He was given intramuscular epinephrine 0.15mg without improvement. Chest X-ray revealed no radio-opaque foreign body or pneumothorax. Otolaryngology performed immediate laryngoscopy/bronchoscopy that revealed significant supraglottic edema of epiglottis, aryepiglottic folds, and bilateral arytenoids (Figure 1). There was no evidence of foreign body, and he was intubated for airway protection. Intravenous epinephrine 9mcg, dexamethasone 7mg, and diphenhydramine 12.5mg were administered with improvement of edema. He was successfully extubated and discharged. Six weeks later, IgE to pistachio was 4.91 KU/L and cashew was 3.25 KU/L. IgE testing to other tree nuts was negative. He has subsequently had no further episodes with strict avoidance of tree nuts. Discussion Food allergy must be considered in the differential diagnosis of foreign body aspiration, despite the lack of cutaneous findings and particularly following the ingestion of commonly allergic foods.