Case Report

Oral Immunotherapy in an Adult with Cow´s Milk Allergy

Cosmin Boteanu¹, Calle Puerto de Maspalomas^2*, Maria del Mar Reaño Martos¹, Esther Lourdes Pérez González¹, Alexandra Maria Yago Meniz¹, Alfredo Iglesias Cadarso¹ and Matilde Rodriguez Mosquera^1
1Department of Allergy and Immunology, Hospital “Puerta de Hierro” Majadahonda, Spain
²Department of Allergy and Immunology, Hospital “Central de la Cruz Roja San Jose y Santa Adela”, Spain

^*Corresponding author: Calle Puerto de Maspalomas, Department of Allergy and Immunology, Hospital “Central de la Cruz Roja San Jose y Santa Adela”, 1, 6º 5, Madrid 28029 Madrid, Spain

Published: 20 Mar, 2017
Cite this article as: Boteanu C, de Maspalomas CP, del Mar Reaño Martos M, González ELP, Meniz AMY, Cadarso AI. Oral Immunotherapy in an Adult with Cow´s Milk Allergy. Ann Clin Case Rep. 2017; 2: 1308.

Abstract

Background: Cow’s milk allergy is the most common food allergy in infants and young children. Oral immunotherapy with food (OIT) is a therapeutic possibility to induce tolerance.
Case Presentation: We report a case of desensitization to cow's milk proteins in a 36-year- old patient diagnosed in childhood with allergy to cow's milk proteins.
Results: We performed an allergy study with skin-prick tests (DIATER Madrid-Spain) and specific IgE (Cap System, Phadia, Uppsala, Sweden) with: cow’s milk, alpha-lactalbumin, beta-lactoglobulin, Casein, sheep’s milk, goat’s milk with positive results. The patient gave his informed consent and we performed the OIT with cow's milk following our protocol. The patient finally tolerated 200 mL of cow’s milk daily.
Conclusions: Although the persistence of allergy to cow's milk protein in adults is rare, the OIT could be a good option in the treatment of these patients, improving the security and the quality of life of the patients and their families.

Keywords: Cow´s milk allergy; Oral immunotherapy; Adult; Food allergy; Treatment

Introduction

Food allergy affects 2-3% of adults and 6% of children [1]. Cow’s milk allergy is the most common food allergy in infants and young children affecting 2-3% of the general population [2]. The prevalence is less than 1% in 6 year-old children or older [3]. Most children outgrow their allergy by age 3 years [4]. However there are studies with worse percentages of tolerance. Saarinen et al found about 11% of children with previously IgE-mediated cow’s milk allergy to have persistent sensitivity at age 8.6 years [5].
The only treatment for food allergy is strict avoidance of the food and use of an epinephrine injector if needed. Oral immunotherapy with food (OIT) is a therapeutic possibility to induce tolerance [6]. The first case of successful oral immunotherapy was described in 1908 in a male with egg anaphylaxis [7].
A Cochrane meta-analysis revising controlled studies of OIT in cow's milk allergy concluded that oral immunotherapy is effective in desensitization of most pediatric patients with IgE-mediated allergy [8].
There are few studies on milk desensitization in adults those studies presents the results in a global manner (groups that includes adults and children) [9,10]. In the study of Levy and al. [9] there are adults that tolerated full dose as well as adults that did not achieve full tolerance.
We present a case of desensitization to cow's milk proteins in an adult patient. The OIT could improve the quality of life of the patients and their families.

Table 1

Table 2

Table 3

Table 4

Table 5

Case Presentation

We report the case of a 36-year- old patient with a history of allergic asthma due to pollen sensitization (Olea europea and Cupressus arizonica) diagnosed in childhood with allergy to cow's milk proteins. He was breast-fed until 1 month of age. When introducing a cow’s milk formula he developed vomiting food refusal and 5-6 stools a day some of them bloody. An upper gastrointestinal transit discarded hiatal hernia and hypertrophic pyloric stenosis.
At 4 months years old serum specific IgE for cow's milk proteins was negative. Then a cow’s milk provocation test (CPT) was performed with a positive result: 30 minutes from the beginning he presented vomiting. A cow’s milk and derivates free diet was recommended.
Skin prick-tests (SPT) to cow’s milk proteins (beta-lactoglobulin alpha-lactalbumin casein serum albumin) and CPT performed one year later were positive: 45 minutes from the onset the patient presented hives itching and sneezing. An annual follow-up with skin tests and specific IgE was conducted for 14 years remaining positive. The patient first came to our allergy department with 36 years of age. He was in a strict free cow’s milk protein diet despite which he had suffered several episodes of labial angioedema maculopapular lesions perioral itching and dyspnea all related with the intake of foods containing traces of cow's milk some of them in the last 6 months before attending our outpatient clinic. Once requiring treatment with intramuscular epinephrine. He underwent an allergy study in our department (Table 1 and 2).
The patient gave his informed consent and we began the OIT with cow's milk following our protocol as seen below (Table 3). Patient was premedicated with: ebastine 10 mg (1 hour before) and budesonide 160 mcg/formoterol 4.5 mcg turbuhaler (1/12 hours daily).
Before starting the OIT an endpoint titration prick-test with cow's milk was performed using dilution 1/10000, 1/1000, 1/100: 1/10000: 2x2 mm 1/1000: 5x5 mm 1/100: 6x6 mm Histamine 5x5 mm SSF NEG.
According to our protocol we did not perform a cow’s milk provocation test before starting the OIT because the patient has presented several allergic reactions some of them severe after accidental exposures in the last 6 months (Table 3).
The first six visits were twice a week and then weekly. The dose was increased only in the allergy department and then maintained daily at home. As seen in the table when the patients received several doses in one day the interval between doses was 60 minutes. In every visit after the last dose the patient stayed 120 m
inutes in the clinic. The patient referred some days with the doses of 50 mL, 75 mL and 100 mL isolated nonspecific abdominal discomfort that disappeared without medication or dose changes.
Build-up phase of OIT ends after administration of 200 ml of cow's milk / day without premedication. The patient was advised to avoid milk and dairy from other animals (goat, sheep) because of positive skin-testing and serum specific IgE. Three months after finishing the build-up phase of OIT, in the context of acute gastroenteritis and exercise, the patient presented 30 minutes after the daily dose of 200 ml facial erythema and edema, palpebral angioedema, cutaneous pruritus, and dyspnea. Evaluated in our department, symptoms resolved in about 30 minutes after treatment with ephinefrine metilprednisolone and dexchlorpheniramine.
The following day the patient tolerated 100 mL in our department and then we recommended him to continue with this dose daily at home and to come to our department 4 days later or before if an adverse reaction occurred. Five days after the reaction the patient came to our department and told us that he had decided on his own to increase the dose up to 200 mL without any symptoms. He is up to now tolerating 200 mL everyday.
According to our protocol we performed SPT after the end of build-up phase (Table 4). We also measured specific IgE 1 and 3 months after the end of build-up phase (Table 5).
We present a case of desensitization to cow's milk proteins in an adult patient. This procedure is used successfully in children but not many cases are reported in adults. Although the persistence of allergy to cow's milk protein in adults is rare the OIT could be a good option in the treatment of these patients could improve the quality of life of the patients and their families.
More studies are needed before including OIT in routine clinical practice both in children and adults.

References

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2. Wood R A, Sicherer S H, Vickery B P, Jones S M, Liu A H, Fleischer D M, et al. The natural history of milk allergy in an observational cohort. J Allergy Clin Immunol. 2013; 131: 805-812.
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