Two of the most important features that distinguish allergic reactions associated with allergen-specific IgE are the rapid onset of symptoms, usually within 5-10 minutes of exposure to foods, and the gradual resolution in the course of one or two hours. Most mild to moderate reactions occur within this time frame. Mild to moderate reactions are generally defined as reactions confined to the skin or gastrointestinal tract, while severe reactions are those that threaten the airway or cause a fall of blood pressure. It can be very difficult in most subjects to predict when a reaction is becoming so severe that treatment must be initiated. Severe reactions can gradually evolve from relatively minor symptoms and can form a second phase of response once the initial symptoms have resolved, or they can gradually develop slowly and persist for considerable periods of time. This variation in the presentation of severe symptoms needs to be specifically sought in the history. Most reactions that are due to intolerance are slow in onset, and are often dose-related or related to the duration of exposure, such as from eating a food on several occasions over several days.11,12 In contrast, allergic reactions are usually due to small doses and start immediately upon exposure.9,10
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