Severe upper gastrointestinal hemorrhage due to milk protein allergy: A case report

Abstract

Background: Upper gastrointestinal hemorrhage is a life-threatening manifestation of cow's milk protein allergy (CMPA). We analyze the clinical characteristics of a case of milk protein allergy manifested as severe upper gastrointestinal hemorrhage.

Case summary: The hospital admitted a 2-month-old male infant due to "melena for 6 days, hematemesis twice". The main symptom was melena, initially occurring once or twice per day, then gradually increasing to five or six times per day at their peak. During the course of the illness, the infant vomited blood, but there were no reports of vomiting, fever, pale complexion, dyspnea, wheezing, or difficulty breathing. Laboratory tests showed hemoglobin level of 87 g/L, platelet count of 349 × 10⁹/L, and eosinophil percentage of 0.031. Coagulation studies were normal. After avoiding certain foods and feeding with an amino acid formula for 2 weeks, a repeat gastroscopy revealed less bleeding. After six weeks, a positive oral food challenge test confirmed a severe CMPA. At the 4-month follow-up, there was no gastrointestinal bleeding, and the infant was growing and developing well.

Conclusion: The manifestations of milk protein allergy are diverse and nonspecific, with gastrointestinal bleeding being less common, especially in infants. When infants present with unexplained massive hematemesis, it's critical to investigate the possibility of CMPA.

Keywords: Case report; Cow’s milk protein allergy; Gastrointestinal bleeding; Hematemesis; Infants; Melena.

Figure 1

Endoscopic changes seen before and after therapy. A: Gastroscopy showed that there were ulcers in the esophagus (at the initial stage of the disease); B: Extensive erosive hemorrhagic gastritis (at the initial stage of the disease); C: Scattered hemorrhagic spots in the gastric antrum (at the initial stage of the disease); D: The subsequent gastroscopic reexamination after a milk protein-free diet and administration of an amino acid-based formula showed healed esophageal results; E: The subsequent gastroscopic reexamination after a milk protein-free diet and administration of an amino acid-based formula showed healed gastric body results; F: The subsequent gastroscopic reexamination after a milk protein-free diet and administration of an amino acid-based formula showed healed gastric antrum results.

Figure 2

The timeline of care: A 2-month-old male child reported in this case was not treated at the initial stage of the disease, but his symptoms worsened later. After a 3-day hospitalization at the local medical facility, the diagnosis of “massive gastrointestinal bleeding” was established. The treatment consisted of administration of a hemostatic drug and supplementation with vitamin K1, as well as transfusion of 0.5 units of leuko-reduced red blood cells. However, his symptoms continued to repeat. He was transferred to our hospital for further medical intervention. Physical examination showed atopic dermatitis of the face. The laboratory examination showed eosinophilia increase. Gastroscopy suggests extensive erosive hemorrhagic gastritis. Results of histopathologic examinations demonstrated chronic non-atrophic active gastritis of the gastric mucosa with 2 eosinophils/High power field and chronic active duodenitis with 11 eosinophils/High power field. The symptoms and signs improved after diet avoidance and an amino acid-based formula. Six weeks later, the positive oral food challenge test was performed to diagnose milk protein allergy. After 4 months of follow-up, the growth and development of the children were normal.