LAUSR

Food protein–induced enterocolitis syndrome (FPIES) is a rare manifestation of food allergy that presents as persistent vomiting, diarrhea, lethargy, dehydration, hypotension, and hypothermia within 1-4 hours of exposure to an allergen, with no skin or respiratory symptoms. An 11-week-old boy with chromosome 21 trisomy (23-year-old primipara, spontaneous vaginal delivery at 38 weeks’ gestation, birthweight 3600 g, 9/9 Apgar score), and fed with cow’s milk formula (CMF) was admitted to the emergency department due to persistent vomiting, watery diarrhea, nonresponsiveness, and drowsiness. On admission the child presented with lethargy, severe dehydration, hypotension (75/50 mmHg), anemia, high acute-phase reactant levels, metabolic acidosis, and electrolyte imbalance (Table). Fluids, electrolytes, treatment for acid-base disorders, and antibiotics were administered, and the clinical response was rapid. While taking the history, we learned that the child had been in a residential child care community (RCCC) since birth; in the past he had been hospitalized 5 times in various centers, each time presenting symptoms similar to those described above. During the first hospitalization, he was diagnosed with sepsis and treated with antibiotic therapy and intravenous hydration. Microbiological and serological tests did not confirm bacterial or viral gastrointestinal infection. Similarly, no infectious factor was established during subsequent incidents, and metabolic acidosis, endocrine disorders, immunodeficiency, and IgE-dependent food allergy were excluded. Based on the clinical picture, we suspected FPIES due to cow’s milk protein (CMP). CMF was replaced by caseinbased extensively hydrolyzed formula (EHF), which led to a fast improvement in the child’s condition. Over the next 3 months the child was readmitted to our department 3 times. Owing to social circumstances, each hospitalization lasted 3 to 4 weeks; the patient returned to the hospital within 1-2 days after discharge with similar symptoms. In hospital, the child tolerated EHF well. Therefore, during the stable period, we performed an oral food challenge (OFC) with incremental amounts of CMF (up to 15 mL [0.3 g protein]). Vomiting and Manuscript received October 9, 2019; accepted for publication December 10, 2019.