Recurrent acute pancreatitis by food allergy?

To the Editor,

I have read the article titled “Recurrent Acute Pancreatitis in a Patient With Peanut Allergy” by Sasaki et al. [1] with great interest. This article describes a patient who had a recurrent episode of peanut-induced acute pancreatitis during an oral food challenge such as in earlier literature [2–6]. I have a couple of major and minor comments/concerns on their case as a pediatric allergist.

First, in this study [1], total amylase levels released from the pancreas and salivary gland were found to be transiently elevated due to severe/multiple food allergies, and it is not known whether there is a change in salivary amylase or pancreatic amylase levels when the allergic food is consumed. Could this be a simple reaction and not pancreatitis? Also, would the normalization of these values and clinical findings on the second day of hospitalization be consistent with a true pancreatitis clinic?

What is the normal value of serum and pancreatic amylase in this report? A serum value between 19 and 86 U/L is often given in our hospital. As in other literature, the normal range of amylase varies between 60 and 190 U/L [2]. If this is the case, the patient has had this enzyme above this value for years and is suggestive of chronic pancreatitis, but not acute pancreatitis. As can be seen in Figure 1, the serum amylase value was always above the normal value for 8 years [1].

Second, did exocrine and endocrine pancreatic function remain normal in this reported case? [1] Although not present in this case, some reports mention “transient enlargement of the pancreas on sonography and computed tomography (CT) scan.” It is also reported in the literature that there may be problems in other gastrointestinal system organs other than pancreatitis [2, 3, 7]. Is there such a disorder before or after pancreatitis in this case? It is not mentioned here at all.

Third, it is controversial whether this patient had acute or chronic pancreatitis, and it is also controversial whether the picture in this case was due to peanut alone. In the table in Figure 1, besides peanuts, this patient also has hazelnut, almond, coconut, buckwheat, apple, and peach food allergies and has the appearance of multiple/severe food allergies. It is also possible that chronic pancreatitis or chronic amylase elevation is related to the persistence of these multiple/severe food allergies? [2, 3].

Fourth, are food allergen-induced IgE-mediated or non-IgE-mediated mechanisms involved pathophysiologically in the development of this kind of pancreatitis? Or can cross-allergic food antigens be the cause of recurrent pancreatitis in children with food allergies? [3, 8]. The authors do not explain this, but it is important to understand this to understand the case. It is difficult to explain the picture in this case by direct infiltration of the pancreas by immune cells such as eosinophils. In the pathogenesis of allergic diseases, the arrival of eosinophils in the inflammatory environment and their contribution to inflammation is a delayed reaction and does not lead to rapid amylase elevation and decrease [9]. However, their second suggested pathophysiologic mechanism in the article is more plausible [1].

There may be a transient amylase enzyme elevation and suspicious abdominal pain, but imaging, either ultrasonography, CT, or endoscopic examination of the pancreas, would be good to confirm if this is true pancreatitis [2]. Otherwise, it could be a transient enzyme elevation due to many causes. It seems to be a transient condition that does not require intensive treatment, with restriction of fluid administration and oral intake. Whether a drug such as cromoglycate or similar is used for treatment and care has never been discussed. Since the cases in the literature, the symptoms were reproduced in the 2 hours after the consumption of some particular food and cured for years by the suppression of this food and the use of cromoglycate [2].

Minor concerns: in Figure 1, peanut-specific IgE value is incorrectly shown as <100 IU/mL. In the text, it is given as >100 IU/mL [1]. When the skin prick test is mentioned, histamine is included as a positive control, while the negative control test is not mentioned in the skin prick test [1]. Also, was a skin prick test performed after an oral food challenge in this patient? Although it is understood in this way from the narrative, there is something wrong with this sequence of testing procedures.

Conflicts of interest

The authors have no financial conflicts of interest.

Author contributions

ÖÖ has contributed in writing of this article.