cow s milk allergy is the most common food allergy in children . symptoms usually involve the skin and the gastrointestinal and respiratory tracts .
gastrointestinal tract manifestations of cow s milk allergy are nonspecific , and are the only type that can be diagnosed in all age groups . here
, we report a rare case of cow 's milk allergy in an infant with hypoalbuminemia and malnutrition .
sami ulus maternity and children s health and diseases training and research hospital , ankara , turkey , in september 2013 , for weakness and swelling of the legs that had endured for two days .
laboratory data revealed albumin at 1.7 g / dl ; serum na , k , urea , creatinin , and alanine - aspartate aminotransferase levels were normal .
anti - gliadin , anti - endomysium , and anti - tissue transglutaminase antibodies were negative .
cow s milk allergy was diagnosed due to cow s milk - specific ige and skin prick test results .
on rare occasions , cow s milk allergy presents with hypoalbuminemia . when diagnosis is delayed , this allergy may impair the growth and quality of life and may even be life - threatening .
cow s milk allergy ( cma ) is the most common food allergy in infants and young children , with a prevalence of 2% - 3% in the general population .
allergic reactions to cow s milk may be categorized as ige - mediated , non - ige - mediated , and mixed types ( 1 , 2 ) . in infancy
, there is no definitive means of differentiating ige- and non - ige - mediated cma , owing to significantly overlapping presentations ; however , quick onset symptoms are almost always ige - mediated ( 1 ) .
symptoms and signs of cma usually involve the skin and the gastrointestinal and respiratory tracts .
gastrointestinal tract manifestations of cma are nonspecific and the only type that can be diagnosed in all age groups ( 1 ) .
when diagnosis is delayed , the allergy may impair the growth and quality of life and even be life - threatening ( 3 ) .
rarely , cma may also present with hypoalbuminemia ( 4 , 5 ) . here , we report a rare case of cma in an infant with hypoalbuminemia and malnutrition .
sami ulus maternity and children s health and diseases training and research hospital , ankara , turkey , in september 2013 , after having suffered weakness and swelling of the legs for two days .
she had diarrhea four times , and was vomiting three times daily , for two months .
her stool was non - bloody and watery ; however , these complaints were resolved one week before hospital admission .
milk formula and complementary feeding was started at six months of age , but the patient usually avoided this combination and ultimately vomited .
the interval between intake of cow s milk and onset of symptoms could not be determined by her mother , whose prenatal , natal , and postnatal history was not significant ; neither was her family history .
the patient was agitated and pale , with bilateral pretibial pitting ( + 2 ) edema .
her weight was 7 kg ( 3% - 10% percentile ) and her height was 66 cm ( 3% percentile ) .
laboratory data revealed a white blood cell count of 10.000/mm , hemoglobin at 7.5 g / dl , mcv at 102 fl , platelets at 405  10/mm , and albumin at 1.7 g / dl .
serum na , k , urea , creatinin , and alanine - aspartate aminotransferase levels were normal .
her serum vitamin b12 level was < 45 pg / ml ( 200 - 1510 pg / ml ) , indicating severe vitamin b12 deficiency .
the maternal hemoglobin level was 11 g / dl , mcv was 100 fl , and the maternal serum vitamin b12 level was 167 pg / ml .
the patient s serum folic acid and ferritin levels were normal ; anti - gliadin , anti - endomysium , and anti - tissue transglutaminase antibodies were negative .
serum iga , igm , and igg were normal , but ige concentration was 250 iu / ml ( normal level is 0 - 15 iu / ml ) . there was no peripheral eosinophilia .
ku / l ( normal level : < 0.35 ku / l ) and caseine - specific ige level was 0.35
the skin prick test for cow s milk protein was 4  5 mm ( negative control 0 mm , positive control 6  7 mm ) and positive ( table 1 ) .
albumin was administered as an infusion twice and stopped when her serum albumin level reached 2.4 g / dl .
treatment with intramuscular vitamin b12 was commenced , and normalization of her vitamin b12 ( 1320 pg / ml ) was seen .
she had difficulty in oral feeding , so a nasogastric tube was inserted for feeding and an amino - acid - based infant formula was started .
the latter showed significant clinical improvement as her appetite and activity improved ; she gained 1500 grams of body weight over the following 20 days .
after one month , the serum albumin reached a normal level ( 3.6 g / dl ) spontaneously .
an oral cow s milk challenge test was planned , but the patient did not attend the follow - up .
gastrointestinal symptoms and signs of cma may be caused by inflammation , dysmotility , or a combination of both .
the signs include dysphagia , vomiting , regurgitation , dyspepsia , early satiety , anorexia , diarrhea ( with or without malabsorption or protein loss due to enteropathy ) , rectal bleeding , failure to thrive , abdominal pain , severe colic , and persistent constipation that is often accompanied by perianal abnormalities ( 1 , 3 ) . the state of inflammation may result in reduced bioavailability or an excessive loss of nutrients due to the increased intestinal permeability that causes poor growth in children with food allergies .
serum hypoalbuminemia on admission and a rapid decrease in serum albumin levels during follow - up are important clinical presentations of cma .
hwang et al . ( 4 ) described a number of children with enterocolitis caused by cow s milk , and reported that a failure to gain weight ( < 10 g / day ) and serum hypoalbuminemia ( < 3.5 g / dl ) upon admission are the highest indices of suspicion for cma .
in addition , rapid reduction in the serum albumin level to < 3 g / dl , during follow - up or after admission , may be regarded as an important diagnostic clue ( 4 ) .
reported that 4 of their 29 cma patients had serum albumin of less than 2.5 g / dl .
the nutritional status was normal in 38% , while first and second degrees of protein energy malnutrition were observed in 27.6% and 34.4% of patients , respectively ( 5 ) . upon admission ,
our patient presented a mild degree of protein energy malnutrition and severe hypoalbuminemia caused by the clinical manifestation of edema .
the most common causes of edema and hypoalbuminemia were ruled out as she had no loss of protein in urine and stool .
any diagnosis of cma must be either confirmed or excluded through an allergen elimination and challenge procedure .
specific ige and skin prick testing alone , although helpful in identifying patients who are more likely to have an immediate reaction to cow s milk protein , and those with a delayed reaction who are more likely to remain intolerant for a longer period , can not diagnose all cases of cma .
the cutoff values for positivity of skin prick test results and sige determinations , as reported in most studies in the literature , are a wheal diameter greater than 3 mm and a ku / l sige level greater than 0.35 , respectively ( 1 ) .
our patient was diagnosed with ige - mediated cma from her sige and skin prick test results .
an oral cow s milk challenge test was planned , but the patient did not attend the follow - up .
as soon as the diagnosis was made , she started being fed with amino - acid - based infant formula and breast milk was not stopped , as the mother s diet was reconfigured as a cow s milk proteins - free diet .
there was a significant clinical improvement in the patient after a period of one month , and an encouraging decrease in hypoalbuminemia was seen . as mentioned above ,
an oral cow s milk challenge test was planned , but the patient did not attend . in our country , b12 deficiency has been found in nearly 50% - 70% of pregnant women and 40% of newborn babies ( 7 ) .
the long - term prognosis for the majority of affected infants is generally good , with 80% - 90% naturally acquiring tolerance to cow milk proteins by the age of five .
however , recent studies suggest that the natural history of cma is changing , with an increasing persistence until later in life and increasing severity of illness ( 2 ) .
a multidisciplinary follow - up was recommended to our patient at pediatric allergy and pediatric nutrition units for three - month periods .
cma should be kept in mind as a cause , although it is unclear whether in this case hypoalbuminemia is the result of persistent vomiting or a diet with low protein content .
 introductioncow s milk allergy is the most common food allergy in children . symptoms usually involve the skin and the gastrointestinal and respiratory tracts . 
 gastrointestinal tract manifestations of cow s milk allergy are nonspecific , and are the only type that can be diagnosed in all age groups . here 
 , we report a rare case of cow 's milk allergy in an infant with hypoalbuminemia and malnutrition.case presentationa nine - month - old girl was admitted to dr . 
 sami ulus maternity and children s health and diseases training and research hospital , ankara , turkey , in september 2013 , for weakness and swelling of the legs that had endured for two days . 
 she had bilateral pretibial pitting ( + 2 ) edema . 
 laboratory data revealed albumin at 1.7 g / dl ; serum na , k , urea , creatinin , and alanine - aspartate aminotransferase levels were normal . 
 her urinary analysis did not reveal proteinuria . 
 stool samples were normal , and stool steatocrite was negative . 
 anti - gliadin , anti - endomysium , and anti - tissue transglutaminase antibodies were negative . 
 cow s milk allergy was diagnosed due to cow s milk - specific ige and skin prick test results.conclusionson rare occasions , cow s milk allergy presents with hypoalbuminemia . when diagnosis is delayed , this allergy may impair the growth and quality of life and may even be life - threatening . 
Introduction
Case Presentation
Conclusions
1. Introduction
2. Case Presentation
3. Discussion