A 51-year-old patient presented to our department complaining of generalized urticaria, itching, dyspnea and dizziness that was preceded 30 minutes earlier by a Chinese wheaten-based pancake followed by walking. He recovered 2 hours after the oral administration of 10 mg cetirizine. He had previously experienced 2 other outbreaks of anaphylactic reactions with similar clinical findings about 1 hour after the ingestion of wheaten food.
He had experienced 2 other outbreaks within a 4-month interval with severe anaphylactic reactions delayed to 10 and 24 hours after the ingestion of wheaten food. The first attack occurred 24 hours after wheat ingestion. The patient awoke at 7am and 15 minutes later (without having breakfast) he felt itchy, chest tightness, generalized urticaria and fell unconsciousness during showering. He had consumed noodles for breakfast the previous day and only rice porridge and pickled radish for dinner due to abdominal distension and nausea. On the second attack (before hospitalized for chronic gastroenteritis), he only ate some wheat biscuits at 10 am. At 8pm (about 10 hours after wheat ingestion) he experienced generalized urticaria and syncope during walking.
The patient had had a 20-year history of chronic gastroenteritis manifested by vomiting, abdominal pain and distension that was unresponsive to H2 antagonists, PPIs and prokinetic agents. He was instructed to take digestible food (such as noodles and porridge); however, the digestive symptoms still occurred with periodical abdominal distention and vomit. Interestingly, cetirizine dramatically alleviated his digestive symptoms; in addition, no anaphylactic reactions were experienced if he consumed wheaten food without exercise.
A skin prick test showed positive results to dust mite, shrimp and crab (wheal >=5 mm), but the patient could tolerate these foods. Prick to prick reactions to wheat allergens were strongly positive (salt soluble wheal 11 mmx9 mm, salt insoluble wheal 15 mmx12 mm). The levels of serum specific IgE to wheat, gluten and omega-5 gliadin were 0.87 KUA/L, 3.18 KUA/L and 7.16 KUA/L respectively. A gastroscopy indicated erosive gastritis and duodenal bulbar inflammation; addition, biopsy pathology indicated chronic nonspecific inflammation with no eosinophil infiltration. The patient had experienced anaphylaxis 5 times; subsequently, oral challenge tests were not performed. After 3 months of a strict wheat-free diet, he had no anaphylaxis attack and his digestive symptoms were alleviated significantly but did not disappear. An abdominal CT scan and a 3-D reconstruction indicated a compression and squash on the posterior horizontal duodenum, expansion on the anterior horizontal duodenum and a slightly narrowed mesenteric angle.