Milk‐induced pulmonary disease in infants (Heiner syndrome)

Abstract

Heiner syndrome (HS) is a food hypersensitivity pulmonary disease that affects primarily infants, and is mostly caused by cow's milk (CM). Only a few reports have been published, which may be due to its misdiagnosis. We review here a series of eight cases. When first diagnosed they were 4-29 months of age. They were fed CM from birth and their chronic respiratory symptoms began at age 1-9 months. The symptoms were in the form of cough in seven, wheezing in three, hemoptysis in two, nasal congestion in three, dyspnea in one, recurrent otitis media (OM) in three, recurrent fever in four, anorexia, vomiting, colic or diarrhea in five, hematochezia in one, and failure to thrive (FTT) in two. All had radiologic evidence of pulmonary infiltrates. High titers of precipitating antibodies to CM proteins were demonstrated in six of six and milk-specific immunoglobulin E (IgE) was positive in one of two. Pulmonary hemosiderosis (PH) was confirmed in one patient who showed iron-laden macrophages (ILM) in the bronchoalveolar lavage (BAL), gastric washing, and open lung biopsy. Additional findings, in a descending frequency, were eosinophilia, anemia, and elevated level of total IgM, IgE or IgA. Milk elimination resulted in remarkable improvement in symptoms within days and clearing of the pulmonary infiltrate within weeks. Parents consented to milk challenge in only three cases, all of whom developed recurrence of symptoms. After 2 yr of milk avoidance in one patient, milk challenge was tolerated for 2 months, and then the patient developed symptoms, serum milk precipitins, pulmonary infiltrate, and ILM. The HS should be suspected in young children with chronic pulmonary disease of obscure cause. The diagnosis is supported with a positive milk precipitin test and improvement on a trial of milk elimination. Severe cases may be complicated with PH, which should be suspected in the presence of anemia or hemoptysis and be confirmed with the demonstration of ILM.

Scientific Opinion on the evaluation of allergenic foods and food ingredients for labelling purposes

“…Heiner syndrome is a rare pulmonary hypersensitivity syndrome, in which individuals are likely to be cow's milk sensitive, which affects primarily young children and is characterised by pulmonary haemosiderosis, diarrhoea, anaemia and poor growth (Moissidis et al, 2005).…”

Lane-Hamilton syndrome: case report and review of the literature

“…There is an impressive similitude in history, clinical symptoms and radiologic evidence of pulmonary infiltrates in milkinduced pulmonary disease in infants, the so-called Heiner syndrome [18]. Withdrawal of cow's milk results in remarkable improvement.…”

Diffuse Lung Disease

“…Other disorders capable of causing pulmonary hemorrhage, such as respiratory tract infections, airway neoplasms, bronchiectasis, coagulopathies, pulmonary venous hypertension, and pulmonary arteriovenous malformations, should be excluded before a diagnosis of IPH is made. IPH is associated with cow's milk allergy (Heiner syndrome) (Moissidis et al 2005), celiac disease (LaneHamilton syndrome) (Hendrickx et al 2011), and Down syndrome (Taytard et al 2013). Imaging findings can include airspace opacities, nodules, septal thickening, cysts, and honeycombing (Fig.…”