THREE CASES OF DELAYED-ONSET REPETITIVE EMESIS AFTER AVOCADO INGESTION

Introduction Food Protein-Induced Enterocolitis (FPIES) is a non-IgE mediated gastrointestinal food hypersensitivity typically presenting in infancy with vomiting and diarrhea, but can progress to shock. Rarely reported as an FPIES trigger, avocado is listed as among low-risk complementary foods to introduce for infants in the first international consensus guidelines for FPIES. Here we report 3 cases of FPIES to avocado. Case Description Three infants out of 15 total FPIES cases presenting to a single provider within 12-month period were reported to have FPIES reactions with avocado. All cases presented at 6-8 months of age with repetitive emesis developing 1-4 hours after avocado ingestion, with absence of respiratory or cutaneous symptoms. In two, diarrhea was prominent; and in one, lethargy was profound. Resolution of episodes occurred over hours without intravenous fluids. Avocado triggered the initial FPIES episode in two cases. Due to diagnostic delay, two cases had repeat exposures to avocado with symptom recurrence. Two had clear FPIES reactions to other foods, including cow milk, oats, and banana. Two had negative skin test to avocado. All had a personal history of atopic dermatitis and family history of atopy. Discussion Previously identified as a low risk food in multiple studies, avocado appears to be a common FPIES trigger at a single center in New York City. Knowledge of avocado as an emerging trigger for FPIES will aid diagnosis and guide counseling and complementary food introduction for infants.