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Abstract
To investigate clinical features of acute allergic reactions to peanuts and other nuts.
Analysis of data from consecutive patients seen by one doctor over one year in an allergy clinic at a regional referral centre.
62 patients aged 11 months to 53 years seen between October 1993 and September 1994.
Type and severity of allergic reactions, age at onset of symptoms, type of nut causing allergy, results of skin prick tests, and incidence of other allergic diseases and associated allergies.
Peanuts were the commonest cause of allergy (47) followed by Brazil nut (18), almond (14), and hazelnut (13). Onset of allergic symptoms occurred by the age of 2 years in 33/60 and by the age of 7 in 55/60. Peanuts accounted for all allergies in children sensitised in the first year of life and for 82% (27/33) of allergies in children sensitised by the third year of life. Multiple allergies appeared progressively with age. The commonest symptom was facial angioedema, and the major feature accounting for life threatening reactions was laryngeal oedema. Hypotension was uncommon. Of 55 patients, 53 were atopic--that is, had positive skin results of tests to common inhaled allergens--and all 53 had other allergic disorders (asthma, rhinitis, eczema) due to several inhaled allergens and other foods.
Sensitisation, mainly to peanuts, is occurring in very young children, and multiple peanut/nut allergies appear progressively. Peanut and nut allergy is becoming common and can cause life threatening reactions. The main danger is laryngeal oedema. Young atopic children should avoid peanuts and nuts to prevent the development of this allergy.
... The most frequently diagnosed LA was lentil (n = 57, 66%), followed by peanut (53, 61%), chickpea (n = 24, 28%), pea (n = 21, 24%), bean (n = 7, 8%), and soybean (n = 1, 1%). More than half of the patients (n = 52, 60%) had multiple (≥2) LA, and the age of onset of LA symptoms occurred significantly earlier than in the single LA subgroup (18 months (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) vs. 28 months (17-42), p = .042) ( Table 1). ...
... Twenty-one patients were allergic to peas, 16 28 (17-42) 18 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) .042 ...
... 24 In the literature, co-allergy to tree nuts was reported in 28%-50% of peanut-allergic patients. [25][26][27] This shows that peanut allergy is a heterogeneous disease and variability between countries may be due to the differences in exposures, genetic backgrounds, and culinary cultures. ...
Background
Legumes are nutritionally valuable as an inexpensive protein source, but may cause severe allergic reactions. This study aimed to identify the characteristics of legume allergies (LAs) in Turkish children.
Methods
A total of 87 children (4.9 (3.1–7.0) years) with LAs confirmed by either oral food challenge (OFC) or consistent history were reviewed.
Results
The median age of onset was 19 (12–38) months. The most frequent LA was lentil (n = 57, 66%), followed by peanut (n = 53, 61%), chickpea (n = 24, 28%), pea (n = 21, 24%), bean (n = 7, 8%), and soybean (n = 1, 1%). From these, it was observed that 60% had multilegume (≥2) allergies and the age of onset occurred earlier compared with the single LA subgroup (18 (11–30) vs. 28 (17–42) months, p = .042). Single LA was present in peanut (51%) and lentil (16%) allergies, but not chickpea, pea, and bean. Fifteen patients had tolerated lentils before their first allergic reaction. The majority of children with LA (91.9%) were allergic to multiple foods including tree nuts (71%), hen's egg (66%), and cow's milk (49%). Seventy‐eight patients (89.7%) also presented with atopic comorbidities concerning atopic dermatitis (70%), asthma (40%), and allergic rhinitis (30%). Patients with anaphylactic type of reaction (20%) had higher frequency of aeroallergen sensitization (p = .001). Lip dose challenge with legume paste predicted the result of OFC with a diagnostic accuracy of 81.82% and a positive likelihood ratio of 10.8.
Conclusion
In Turkey, LA is a reflection of multiple food allergies and the presence of allergy to a least frequently encountered legume is a sign of multiple LA.
... When it is well known that atopic dermatitis [37][38][39][40][41][42] and food allergy [43][44][45][46][47][48][49] have their onset within the first year of life in 70-100% of infants [37][38][39][40][41][42], and in the second in 69-96% of cases [43,44], it may not be clear that allergy to a panel of foods be gins before the first year of age in a wide proportion of ba bies [45][46][47][48][49]. For example allergy to cow milk evidently begins in at least 72%, and to egg in 71% of infants [45][46][47]. ...
... When it is well known that atopic dermatitis [37][38][39][40][41][42] and food allergy [43][44][45][46][47][48][49] have their onset within the first year of life in 70-100% of infants [37][38][39][40][41][42], and in the second in 69-96% of cases [43,44], it may not be clear that allergy to a panel of foods be gins before the first year of age in a wide proportion of ba bies [45][46][47][48][49]. For example allergy to cow milk evidently begins in at least 72%, and to egg in 71% of infants [45][46][47]. ...
... However the percentages of 52,3% for fish, and of 62% for cereals can be unexpected, and even more the rates of legumes, fruits, and nuts [45][46][47]. The case of peanuts depends on the country where the study was done [48,49], whereas chocolate has been absolved [45]. ...
p> Background : Allergic asthma and rhinitis, atopic dermatitis, urticaria and food allergy are genetic diseases of infants and children. Several investigators have provided evidence for a genetic localization for atopy. Babies of atopic parents are at high risk of developing atopic diseases, however the phenotypic expression of such diseases varies widely, being very mild in some infants and children, severe and frustrating in many, even life-threatening in others, being also common, disabilitating, and chronic.
Methods : A meta-analysis was done of all available studies on the age of onset of the atopic march, without attempting at being comprehensive in this meta-analysis, but instead selecting what appeared the most relevant articles in the literature.
Results : In the first year of life, there is the onset of atopic dermatitis in 79,8% [ 60,2% to 100%], of cow’s milk allergy in 72,7%, egg allergy in 71%, and fish allergy in 51,3% of babies. Asthma starts in the first year of life in 41,8%, in the 2nd in 49,3%, and within the 8th year in 92,5% of children. Allergic rhinitis begins in 35% of babies in the 1st year of life, and in 59% or 13-19% in those aged 2-5 years. It seems therefore that the role of pediatric allergy and immunology has been hitherto somewhat obscured, as shown by the atopic march.
Conclusion : It follows that this role is instead substantial, unmatched, focusing on the early and often very early onset of the atopic march, which needs strategic interventions in the very first months of life or even before birth. As the main goal of modern medicine is prevention of chronic and severe diseases, the possibility of preventing such disorders in predisposed children has stimulated the investigators’ imagination since the beginning of the century, when atopic diseases were not as common as now.</p
... Peanut and hazelnut allergies frequently occur at preschool age, in 55% of children by 2 years of age and in 92% by 7 years of age [21]. The later onset of clinical symptoms is usually explained by later first consumption. ...
... The development of primary allergy to peanut after previous problem-free consumption is a rarity. Approximately one third of patients are clinically allergic both to peanuts and to tree nuts [21]. In a recent prospective study of cross-allergy in peanut and nut allergic patients by Brough et al., approximately 30% of patients also reacted to cashew, 28% to walnut and pistachio, 22% to hazelnut, and 20% to pecan [22]. ...
Peanuts are Leguminosae, commonly known as the legume or pea family, and peanut allergy is among the most common food allergies and the most common cause of fatal food reactions and anaphylaxis.
The prevalence of peanut allergy increased 3.5-fold over the past two decades reaching 1.4–2% in Europe and the United States. The reasons for this increase in prevalence are likely multifaceted. Sensitization via the skin appears to be associated with the development of peanut allergy and atopic eczema in infancy is associated with a high risk of developing peanut allergy.
Until recently, the only possible management strategy for peanut allergy was strict allergen avoidance and emergency treatment including adrenaline auto-injector in cases of accidental exposure and reaction.
This paper discusses the various factors that impact the risks of peanut allergy and the burden of self-management on peanut-allergic children and their caregivers.
... Nut allergy is associated with clinical symptoms that can range in severity from mild to life-threatening, and in this sense when a patient is diagnosed with an allergy to a certain nut it is often advised to avoid the consumption of the entire group [51,52]. ...
... Biochemically, amandin, also known as almond major protein (AMP), is a member of the cupin superfamily, namely the 11S seed storage globulin family [51,52]. Globulins are very abundant proteins in legumes and tree nuts, and in almonds they correspond to roughly 65% of total almond protein content [9]. ...
Tree nuts are considered an important food in healthy diets. However, for part of the world’s population, they are one of the most common sources of food allergens causing acute allergic reactions that can become life-threatening. They are part of the Big Eight food groups which are responsible for more than 90% of food allergy cases in the United States, and within this group, almond allergies are persistent and normally severe and life-threatening. Almond is generally consumed raw, toasted or as an integral part of other foods. Its dietary consumption is generally associated with a reduced risk of cardiovascular diseases. Several almond proteins have been recognized as allergens. Six of them, namely Pru du 3, Pru du 4, Pru du 5, Pru du 6, Pru du 8 and Pru du 10, have been included in the WHO-IUIS list of allergens. Nevertheless, further studies are needed in relation to the accurate characterization of the already known almond allergens or putative ones and in relation to the IgE-binding properties of these allergens to avoid misidentifications. In this context, this work aims to critically review the almond allergy problematic and, specifically, to perform an extensive overview regarding known and novel putative almond allergens.
... If nut allergens transfer from hand to mouth, it may cause serious reaction even from minute quantity. In different individuals, the symptoms appearing on skin could be the most mutual and collective in respect to non-anaphylactic indications categorized, keeping in view all the observations and hypothesis by different researchers (Ewan, 1996;Sicherer, Burks, & Sampson, 1998). Many enduring individuals exhibits the indications related to anaphylaxis without exhibiting the indications on skin, this observation is also observed by others (Rance et al., 2003). ...
... These groups exhibited such symptoms, which T. Tufail, et al. Trends in Food Science & Technology 86 (2019) 209-216 were just like non-anaphylactic symptoms that is exactly match with the findings of previous authors (Ewan, 1996). Most of patients had anaphylaxis without the involvement of cutaneous (Hourihane et al., 2001). ...
... Chez les enfants, les allergies alimentaires sont souvent transitoires (Bock 1987 (Ewan PW 1996 ;Sampson 1999a ;Sampson 2000). Sachant qu'un américain consomme environ 3,5 kg d'arachides par an (Ewan 1996) alors qu'un italien n'en mange que 0,68 kg/an (Perelli M, et al. 1994) un parallèle peut donc être fait entre la forte consommation d'un aliment et une prévalence élevée de l'allergie à cet aliment. ...
... Chez les enfants, les allergies alimentaires sont souvent transitoires (Bock 1987 (Ewan PW 1996 ;Sampson 1999a ;Sampson 2000). Sachant qu'un américain consomme environ 3,5 kg d'arachides par an (Ewan 1996) alors qu'un italien n'en mange que 0,68 kg/an (Perelli M, et al. 1994) un parallèle peut donc être fait entre la forte consommation d'un aliment et une prévalence élevée de l'allergie à cet aliment. Moneret-Vautrin DA, et al. 1998 ;Young, et al. 1994). ...
Le nombre de cas d'allergie alimentaire est en augmentation dans les pays occidentaux. Le poisson est l'un des cinq aliments les plus incriminés. Les différentes études menées sur les allergènes de poisson ont permis d'identifier une parvalbumine comme étant l'allergène majeur. Plusieurs auteurs ont pourtant effectué des cartographies répertoriant de nombreuses autres protéines détectées par les IgE des patients sensibilisés au poisson. L'objectif de ce travail était d'identifier de nouveaux allergènes chez le cabillaud de l'Océan Atlantique, Gadus morhua. Deux allergènes ont été identifiés par transcription inverse et PCR, et comparaison avec les banques de données. L'un des allergènes, appelé Gad ml, est une parvalbumine comme tous les allergènes majeurs connus chez les poissons. Elle présente plus d'identité avec l'isoforme 2 de l'allergène majeur de saumon Sal sl qu'avec l'allergène majeur de Cabillaud de la Mer Baltique Gadus callarias, et semble se dimériser. Le second allergène, appelé Gad mll, est une glycéraldéhyde 3-phosphate déshydrogénase, protéine ubiquitaire qui n'avait encore jamais été détectée comme allergène. Gad mll, est un allergène très représenté puisqu'il est détecté par douze patients sur vingt-cinq patients allergiques au cabillaud testés. La détection, par les IgE des patients allergiques, de la protéine Gad mll exprimée de façon recombinante, dans les cellules COS-1, confirme son allergénicité. Ce travail permet d'envisager des développements en industries agro-alimentaires et diagnostiques, ainsi qu'une étude de vaccinothérapie par ADN.
... 1,5 Tree nut sensitization is quite common, influenced by cross-reactive proteins with tree pollen (which may vary depending on where one may reside). [5][6][7] But to what extent is this sensitization clinically relevant for our patients, truly necessitating avoidance? Few studies have been conducted that provide a robustly (and oral challenge) proven rationale for widespread avoidance of "all" tree nuts due to allergy to just one, or multiple sensitizations to others that have never been ingested. ...
... Elizur et al publish challenge-proven co-allergy rates significantly lower than prior reported estimates and rates that may be predicted based on co-sensitization alone. [5][6][7] Given recent data suggesting that peanut sensitized children without tree nut exposure have some likelihood of developing tree nut sensitization, adoption of early peanut introduction guidelines in multiple nations there is a distinct possibility children develop incidental tree nut sensitization as an unintended trade-off for preventing peanut allergy. 12 Thus, it becomes up to us as a field as to how we handle this situation--conservatively, fearing the potential that sensitization without a clinical context denotes a likely allergic reality; or more rationally, utilizing the NUTCRACKER data to optimally manage such children to help prevent unnecessary avoidance. ...
Tree nut allergy affects approximately 1.4-2.3%, depending on the study methodology, patient age, and region in which the study was conducted.1,2 Tree nut allergy can be severe, and tends to persist throughout life.1,3 Tree nut is not a singular allergen like the other allergens—we use the term “tree nut” to refer to these items, but in essence it can refer to one nut, eight nuts, or per the US Food and Drug Agency classification, on the order of 19 items.1,4 Older, more conservative practice is to treat one nut as “all nuts”, and instruct avoidance of all tree nuts where there is a clinical allergy proven to just one. This is often supported by high rates of co-sensitization, which is high among tree nuts because of structural similarity, and fueled concerns of cross-contamination, proper identification, or labeling confusion.1,5
... Peanut and tree nut allergy were uncommon until the early 1990s following which there was a substantial rise in prevalence [6][7][8][9][10]. In the UK, peanut allergy affects between 0.5% and 2.5% of children [6,9,11,12]. ...
... sIgE components and food challenges may be able to differentiate between the two better; 5) sIgE components for hazelnut should be considered. Evidence for other tree nuts is lacking; 6) A decision to perform a challenge will depend on the clinical context; 7) Consider component testing for hazelnut and consider food challenge cut-off are likely to represent walnut allergy. Unfortunately, the sensitivity is low (17%). ...
Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut pro- teins. Nut allergy is a global disease. Limited epidemiological data suggest varying preva- lence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symp- toms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usu- ally mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisa- tion, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food chal- lenges are usually not necessary but may be used to confirm or refute a conflicting his- tory and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehen- sive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medica- tion. Regular re-training is required.
... In general, tree nut allergy is associated with clinical symptoms that can range in frequency and severity (mild to life-threatening), highlighting their impact on the quality of life of nut-allergic patients. Accordingly, upon the diagnosis of allergy toward a specific nut, patients are most commonly advised to avoid/eliminate the consumption of other tree nuts (Ewan 1996;Sicherer, Muñoz-Furlong, and Sampson 2003). Despite being a species of the Rosaceae family, almond allergy is regarded as atypical. ...
This review provides a global overview on Rosaceae allergy and details the particularities of each fruit allergy induced by ten Rosaceae species: almond/peach/cherry/apricot/plum (Amygdaleae), apple/pear (Maleae), and raspberry/blackberry/strawberry (Rosoideae). Data on clinical symptoms, prevalence, diagnosis, and immunotherapies for the treatment of Rosaceae allergy are herein stated. Allergen molecular characterization, cross-reactivity/co-sensitization phenomena, the impact of food processing and digestibility, and the methods currently available for the Rosaceae detection/quantification in foods are also described. Rosaceae allergy has a major impact in context to pollen-food allergy syndrome (PFAS) and lipid transfer protein (LTP) allergies, being greatly influenced by geography, environment, and presence of cofactors. Peach, apple, and almond allergies are probably the ones most affecting the quality of life of the allergic-patients, although allergies to other Rosaceae fruits cannot be overlooked. From patients' perspective, self-allergy management and an efficient avoidance of multiple fruits are often difficult to achieve, which might raise the risk for cross-reactivity and co-sensitization phenomena and increase the severity of the induced allergic responses with time. At this point, the absence of effective allergy diagnosis (lack of specific molecular markers) and studies advancing potential immunotherapies are some gaps that certainly will prompt the progress on novel strategies to manage Rosaceae food allergies.
... 11 Over 70% of peanut reactions occur on the rst known exposure, indicating prior sensitization, perhaps transcutaneously, via inhalation, or via human milk. 12,13 Since human milk is often the primary source of nutrition in infancy, it has been postulated that it could be a source for allergen introduction. 14 Although IgEmediated reactions to human milk are rare, they do occur, demonstrating its immunogenic nature. ...
Rationale
There is little information regarding the allergen content of milk feeds in the preterm population. Previous studies have evaluated specific proteins/peptides via ELISA, but no studies have performed a broad analysis of the allergenic peptide content and protease activity of milk feeds in this population. Preterm infants spend a critical window of time for immune development in the Newborn Intensive Care Unit (NICU), and may receive fortified donor milk, maternal milk or formula feeds via nasogastric tube or bottle instead of fresh breastmilk via breastfeeding.
Methods
To evaluate feasibility, we initially performed mass spectrometry on four human milk samples (two term and two preterm) from the Mommy’s Milk Human Milk Biorepository (HMB) which included maternal surveys of diet and environmental exposures. We analyzed the results against the University of Nebraska FASTA database and UniProt for a total of 2211 protein sequences. We then further analyzed 5 samples from the Microbiome, Atopy and Prematurity (MAP) pilot study along with formula and human milk fortifier controls and performed not only mass spectrometry, but also peptidomic and protease activity analysis.
Results
Each HMB sample had between 806 and 1007 proteins, with 37 to 44 non-human proteins/sample encompassing 26 plant and animal species. Bovine proteins were the most numerous; seven unique Bos taurus proteins were found in all four samples, and three contained Bos d 5. Cat, dog, mosquito, salmon, and crab were detected in all four samples. All donors ingested fish, shellfish and tree nuts, and all had salmon and crab proteins in their milk samples; two almond proteins were detected in three samples. Aeroallergens, including dust mite (Der f 28, Der f 25) and mold (Cla h 4) were identified in all samples. Two samples contained allergens to latex (Hev b 9) and chicken (Gal d 10). One sample contained several unique proteins, including carrot, two molds (including Pen c 19) and Der f 33-like protein. In the preterm MAP samples, 784 digested non-human proteins were identified, 30 were non-bovine in origin. Proteins from 23 different species including aeroallergens, food, and contact allergens were identified. Protease activity was highest in human milk samples without human milk fortifier and lowest in preterm formula.
Conclusions
These findings represent the first preterm milk feed mass spectrometry and protease analysis with identification of known allergenic proteins to food, contact and aeroallergens. The varying degree of protein detection may reflect variable individual secretion and augmentation of feeds. This raises questions of whether the composition of milk feeds in the NICU impact the development of atopic disease in the preterm population and whether the complex interaction between allergens, proteases, and other human milk components can serve to induce sensitization or tolerance to allergens in infants.
... Peanut and tree nut allergies often coexist in the same patients, ranging between 30% and 50% in some study populations, although with different patterns of specific tree nut reactivity. [64][65][66][67][68][69][70][71] Most publications have reported on tree nut sensitization, rather than challenge-proven allergy. The Australian HealthNuts Study, a prospective study of the development of peanut allergy, found a 61% sensitization rate for tree nuts (cashew, almond, or hazelnut) among 4-year-olds with peanut allergy. ...
... Peanut and tree nut allergies often coexist in the same patients, ranging between 30% and 50% in some study populations, although with different patterns of specific tree nut reactivity. [64][65][66][67][68][69][70][71] Most publications have reported on tree nut sensitization, rather than challenge-proven allergy. The Australian HealthNuts Study, a prospective study of the development of peanut allergy, found a 61% sensitization rate for tree nuts (cashew, almond, or hazelnut) among 4-year-olds with peanut allergy. ...
The diagnosis and management of food allergy is complicated by an abundance of homologous, cross-reactive proteins in edible foods and aeroallergens. This results in patients having allergic sensitization (positive tests) to many biologically related foods. However, many are sensitized to foods without exhibiting clinical reactivity. Although molecular diagnostics have improved our ability to identify clinically relevant cross-reactivity, the optimal approach to patients requires an understanding of the epidemiology of clinically relevant cross-reactivity, as well as the food-specific (degree of homology, protein stability, abundance) and patient-specific factors (immune response, augmentation factors) that determine clinical relevance. Examples of food families with high rates of cross-reactivity include mammalian milks, eggs, fish, and shellfish. Low rates are noted for grains (wheat, barley, rye), and rates of cross-reactivity are variable for most other foods. This review discusses clinically relevant cross-reactivity related to the aforementioned food groups as well as seeds, legumes (including peanut, soy, chickpea, lentil, and others), tree nuts, meats, fruits and vegetables (including the lipid transfer protein syndrome), and latex. The complicating factor of addressing co-allergy, for example, the risks of allergy to both peanut and tree nuts among atopic patients, is also discussed. Considerations for an approach to individual patient care are highlighted.
... Peanut allergy was uncommon before the 1990s, where reports were limited to case series or small cohorts (1,2). The prevalence of peanut allergy has risen significantly over the last 3 decades (3)(4)(5), although this is likely to be, at least in part, due to increased knowledge and recognition of the condition. ...
p>In this review we provide an overview on the latest knowledge in the prevention and active management of peanut allergy. The rise in incidence of food allergy has generated new challenges in the management of affected individuals. Strategies to counter- act the increase in prevalence of peanut allergy can be considered as a pyramid, beginning with primary prevention of those at risk through earlier introduction of peanut into the infant diet, to secondary prevention of peanut-sensitised children through improvements in the correct diagnosis of peanut allergy and finally to the treatment of children with proven peanut allergy.
Conclusion . With the paradigm shift towards an active management, peanut allergy should no longer be seen as a life sentence.</p
... Peanut and tree nut allergies often coexist in the same patients, ranging between 30% and 50% in some study populations, although with different patterns of specific tree nut reactivity. [64][65][66][67][68][69][70][71] Most publications have reported on tree nut sensitization, rather than challenge-proven allergy. The Australian HealthNuts Study, a prospective study of the development of peanut allergy, found a 61% sensitization rate for tree nuts (cashew, almond, or hazelnut) among 4-year-olds with peanut allergy. ...
Foods can induce adverse reactions by a variety of mechanisms. An understanding of the characteristic signs and symptoms and the related mechanisms of adverse food reactions allows the clinician to efficiently diagnose and treat patients. Adverse reactions to foods can be classified based on whether there is a nonimmunologic or immunologic basis for symptoms. Food intolerance, or a nonimmunologic reaction, includes a range of responses to foods that result primarily from an individual’s intrinsic inability to metabolize a component of the food, e.g. , lactose sugar in dairy products. Other nonimmunologic adverse reactions may be attributed to food toxins or pharmacologic properties pharmacologic properties of foods themselves. Immunologic adverse reactions, in contrast, involve immune responses to food and are termed food allergy. Food allergy may further be categorized based on the underlying immunopathophysiology as immunoglobulin E (IgE) mediated, non‐IgE mediated, or cell mediated. Some chronic allergic responses involve a combination of immune mechanisms. This review provides a general classification system for adverse food reactions and describes specific conditions.
... Cashew belongs to the family of Anacardiaceae, categorised under the taxonomic class of Magnoliopsida to which most common tree nuts belong, as depicted in Figure 1. Several studies have shown that a tree nut-allergic patient has considerable chance of being sensitised (86%) [6] or allergic to multiple tree nuts (35-37% based on clinical history [7,8] and 14-47% based on food challenges [6,9]). The underlying reason is thought to be the major sequential and structural homology between the highly abundant seed storage proteins (glycinins, vicilins, and 2S albumins) and to a lesser extent the defence-related proteins (nsLTP, chitinases, and PR-10 proteins, e.g. ...
Background
Tree nut-allergic individuals are often sensitised towards multiple nuts and seeds. The underlying cause behind a multi-sensitisation for cashew nut, hazelnut, peanut and birch pollen is not always clear. We investigated whether immunoglobulin E antibody (IgE) cross-reactivity between cashew nut, hazelnut and peanut proteins exists in children who are multi-allergic to these foods using a novel IMMULITE ® -based inhibition methodology, and investigated which allergens might be responsible. In addition, we explored if an allergy to birch pollen might play a role in this co-sensitisation for cashew nut, hazelnut and peanut.
Methods
Serum of five children with a confirmed cashew nut allergy and suffering from allergic symptoms after eating peanut and hazelnut were subjected to inhibition immunoassays using the IMMULITE ® 2000 XPi. Serum-specific IgE (sIgE) to seed storage allergens and pathogenesis-related protein 10 (PR10) allergens were determined and used for molecular multicomponent allergen correlation analyses with observed clinical symptoms and obtained inhibition data.
Results
IgE cross-reactivity was observed in all patients. Hazelnut extract was a strong inhibitor of cashew nut sIgE (46.8%), while cashew nut extract was less able to inhibit hazelnut extract (22.8%). Peanut extract showed the least inhibition potency. Moreover, there are strong indications that a birch pollen sensitisation to Bet v 1 might play a role in the observed symptoms provoked upon ingestion of cashew nut and hazelnut.
Conclusions
By applying an adjusted working protocol, the IMMULITE ® technology can be used to perform inhibition assays to determine the risk of sIgE cross-reactivity between very different food components.
... 24 Coexistent peanut and tree nut allergy was reported to be between 20% and 50% based on self-reported questionnaires, IgE test results (by specific IgE measurements or skin prick testing), or both. [25][26][27][28] However, questionnaire-based data and IgE test results might overestimate the rate of clinical allergy by overreporting allergic symptoms and cross-reactivity between peanut and tree nuts. The rate of coexistent peanut and tree nut allergy based on oral food challenges (OFCs) has been cited as less than 30% 29,30 ; however, these studies were mainly conducted retrospectively 29,30 and included only a limited number of tree nuts. ...
Background:
Peanut, tree nut, and sesame allergies are responsible for most life-threatening food-induced allergic reactions. Rates of coexistent allergy between these foods have been from mostly retrospective studies that include only a limited number of tree nuts or were not based on oral food challenges.
Objective:
The Pronuts study is a multicenter European study (London, Geneva, and Valencia) assessing the challenge-proven rate of coexistent peanut, tree nut, and/or sesame seed allergy.
Methods:
Children aged 0 to 16 years with at least 1 confirmed nut or sesame seed allergy underwent sequential diagnostic food challenges to all other nuts and sesame seed.
Results:
Overall, the rate of coexistent peanut, tree nut, and sesame seed allergy was 60.7% (n = 74/122; 95% CI, 51.4% to 69.4%). Peanut allergy was more common in London, cashew and pistachio nut allergies were more common in Geneva, and walnut and pecan allergies were more common in Valencia. Strong correlations were found between cashew-pistachio, walnut-pecan, and walnut-pecan-hazelnut-macadamia clusters. Age (>36 months) and center (Valencia > Geneva > London) were associated with an increased odds of multiple nut allergies. By pursuing the diagnostic protocol to demonstrate tolerance to other nuts, participants were able to introduce a median of 9 nuts.
Conclusion:
We found a higher rate of coexistent nut and sesame seed allergies than previously reported. Performing sequential food challenges was labor intensive and could result in severe allergic reactions; however, it reduced dietary restrictions. Age was a significant predictor of multiple nut allergies, and thus the secondary spread of nut allergies occurred in older children.
... 9,10 Peanut allergy significantly affects quality of life 11 because it is typically lifelong, the leading cause of food-induced anaphylaxis in children, and the leading cause of food allergyrelated deaths. 12,13 Historically, peanut-allergic individuals were advised to avoid tree nuts for multiple reasons, including concerns about cross-contact, [14][15][16] concomitant tree nut allergy, 17 and risk of developing tree nut allergy in the future. 18 Unnecessary avoidance of tree nuts in peanut-allergic individuals may have multiple deleterious effects on overall health and quality of life. ...
Background:
Individuals with peanut allergy often avoid tree nuts, yet true rates of tree nut allergy in peanut-allergic individuals are as low as 7%.
Objective:
To examine tree nut sensitization patterns in peanut-allergic individuals, patient and family choice regarding tree nut consumption, and factors that influence consumption of tree nuts.
Methods:
All patients presenting for peanut allergy evaluation to an outpatient allergy office were included during a 4-month period. In addition to demographic information, sensitization to tree nuts and tree nut consumption were collected. Logistic regression was performed to generate odds ratios with 95% CIs in univariate and multivariate analyses for variables that predict tree nut consumption.
Results:
A total of 258 individuals with peanut allergy were enrolled. Ninety-five (36.8%) consumed all tree nuts ad libitum, 63 (24.4%) consumed some but not all tree nuts, and 100 (38.8%) consumed no tree nuts. Of the 100 electively avoiding all tree nuts, the most commonly reported reason was fear of cross-contact (50%). Although there was no difference between rates of sensitization between individual tree nuts (P = .056), cashew and pistachio had higher serum specific IgE levels compared with other tree nuts (P < .001). The tree nut most commonly consumed by peanut-allergic individuals was almond (P < .001). Consumption of foods with precautionary labeling was the strongest predictor of tree nut consumption in peanut allergic individuals (P < .001) CONCLUSION: Our data highlight the potential for safe introduction of tree nuts in peanut-allergic individuals and indicate that peanut-allergic individuals who consume foods with precautionary labeling are most likely to consume tree nuts.
... Cashew belongs to the family of Anacardiaceae, categorised under the taxonomic class of Magnoliopsida to which most common tree nuts belong, as depicted in Figure 1. Several studies have shown that a tree nut-allergic patient has considerable chance of being sensitised (86%) [6] or allergic to multiple tree nuts (35-37% based on clinical history [7,8] and 14-47% based on food challenges [6,9]). The underlying reason is thought to be the major sequential and structural homology between the highly abundant seed storage proteins (glycinins, vicilins, and 2S albumins) and to a lesser extent the defence-related proteins (nsLTP, chitinases, and PR-10 proteins, e.g. ...
Background:
Allergic sensitisation towards cashew nut often happens without a clear history of eating cashew nut. IgE cross-reactivity between cashew and pistachio nut is well described; however, the ability of cashew nut-specific IgE to cross-react to common tree nut species and other Anacardiaceae, like mango, pink peppercorn, or sumac is largely unknown.
Objectives:
Cashew nut allergic individuals may cross-react to foods that are phylogenetically related to cashew. We aimed to determine IgE cross-sensitisation and cross-reactivity profiles in cashew nut-sensitised subjects, towards botanically related proteins of other Anacardiaceae family members and related tree nut species.
Method:
Sera from children with a suspected cashew nut allergy (n = 56) were assessed for IgE sensitisation to common tree nuts, mango, pink peppercorn, and sumac using dot blot technique. Allergen cross-reactivity patterns between Anacardiaceae species were subsequently examined by SDS-PAGE and immunoblot inhibition, and IgE-reactive allergens were identified by LC-MS/MS.
Results:
From the 56 subjects analysed, 36 were positive on dot blot for cashew nut (63%). Of these, 50% were mono-sensitised to cashew nuts, 19% were co-sensitised to Anacardiaceae species, and 31% were co-sensitised to tree nuts. Subjects co-sensitised to Anacardiaceae species displayed a different allergen recognition pattern than subjects sensitised to common tree nuts. In pink peppercorn, putative albumin- and legumin-type seed storage proteins were found to cross-react with serum of cashew nut-sensitised subjects in vitro. In addition, a putative luminal binding protein was identified, which, among others, may be involved in cross-reactivity between several Anacardiaceae species.
Conclusions:
Results demonstrate the in vitro presence of IgE cross-sensitisation in children towards multiple Anacardiaceae species. In this study, putative novel allergens were identified in cashew, pistachio, and pink peppercorn, which may pose factors that underlie the observed cross-sensitivity to these species. The clinical relevance of this widespread cross-sensitisation is unknown.
... Very small amounts of tree nuts can cause an allergic reaction, in some cases triggering anaphylaxis, a life-threatening condition [4][5][6]. Allergies to tree nuts generally develop in the childhood, but unlike other food allergies, these persist for lifelong [7][8][9]. To prevent allergic reactions caused by tree nuts, the only effective approach is avoiding the ingestion of tree nuts and products containing them; hence, in many regions (such as the United States and the European Union), manufacturers are required to state on the label of their products whether they contain tree nuts even if only in trace amounts. ...
Tree nuts comprise a category of food allergens that must be included in the food labels in several countries. We developed a polymerase chain reaction (PCR) method using eight specific primer pairs to detect eight representative tree nuts (almond, Brazil nut, cashew, hazelnut, macadamia nut, pecan, pistachio, and walnut) under the same experimental conditions. The specificity of the eight primer pairs was confirmed by PCR testing against a variety of plant and animal samples. The detection limit of the method ranged from 1 fg to 1 pg DNA of individual tree nuts. The method detected tree nut DNA in processed and unprocessed food. In addition, the primer pairs could be combined into two sets of tetraplex PCR system. The developed method is specific, sensitive, and efficient, making it useful for detecting trace amounts of eight species of tree nut in foods.
... Previously, co-existent peanut and tree nut allergy was reported to be between 20%-59% based on self-reported questionnaires and/or IgE testing (by specific IgE or skin prick testing). [6][7][8][9] However, these modalities are limited by over-reporting of allergic symptoms, false diagnosis, and positive tests related to cross-reactivity to pollen or cross-reactive carbohydrate determinants; all these factors might result a spuriously higher rate of reported allergy. ...
... Brazil nut is the seed of a giant tree (Bertholletia excelsa) native to South America. Allergy to Brazil nut is common in the US and UK (Roberts et al., 2005;Sicherer et al., 2010) and may be associated with severe reactions (Borja et al., 1999;Ewan, 1996;Pastorello et al., 1998). To date, Ber e 1 (2S albumin) and Ber e 2 (legumin) are characterized allergens from this source. ...
Tree nuts are considered as part of a healthy diet due to their high nutritional quality. However, they are also a potent source of allergenic proteins inducing IgE mediated hypersensitivity often causing serious, life-threatening reactions. The reported prevalence of tree nut allergy is up to 4.9% worldwide. The general term "tree nuts" comprises a number of nuts, seeds, and drupes, derived from trees from different botanical families. For hazelnut and walnut several allergens have been identified which are already partly applied in component resolved diagnosis, while for other tree nuts such as macadamia, coconut, and Brazil nut only individual allergens were identified and data on additional allergenic proteins are missing. This review summarizes the current knowledge on tree nut allergens and describes their physicochemical and immunological characterization and clinical relevance.
... It is probable that CN-specific IgE was performed as part of the workup in this group with suspected peanut allergy and likely accounts for why 43 of those tested had never consumed CN; CN specific IgE was performed to investigate for possible tree nut allergy. Ewan estimated that 30% of patients who are allergic to at least one food in the nut family are allergic to several tree nuts [16]. ...
Background:
Cashew nut (CN) allergy appears to be increasing. Reactions are variable and may include anaphylaxis.
Aim:
To describe the clinical features of CN allergy in a group of children attending an allergy clinic with suspected peanut allergy and confirmed sensitisation to CN.
Methods:
Patients were identified retrospectively by reviewing the Immunology Database at University Hospital Galway over a 5-year period, Oct. 2010 to Sept. 2015. Patients confirmed sensitised to CN (specific IgE > 0.35 kUa/L, ImmunoCAP Assay) were selected and contacted.
Results:
Over the 5-year period, 115 children were identified; 102/115 were individually contacted. Of the 102 children, 55 had a history of prior CN exposure with confirmed clinical reaction, 43 had no prior CN exposure, and 4 were sensitised and tolerating CN. For those with clinical CN allergy (N = 55), 30 (55%) were male and median age of onset was 2 years (lower quartile 1.5, upper quartile 4.8). Severity of reaction was graded as mild for 13 children, moderate in 13 additional children, and severe in 29 children. Median CN serum IgE level was 3.2 kUa/L (range 0.36 to > 100) in the clinical reaction group, 2.91 kUa/L (range 0.36 to > 100) in the sensitised group, and 3.4 kUa/L (range 0.94 to 5.21) in those tolerating CN. IgE values were not significantly different between those with mild, moderate, or severe reaction to CN (p = 0.346).
Conclusion:
Children are ingesting CN at a young age with more than half of allergic reactions reportedly severe in nature. The specific CN IgE value was not helpful in predicting severity of reactions.
... In terms of peanut allergy, recent data from the German Registry of Anaphylaxis revealed that peanut allergy is no longer a life-threatening problem of the USA only, but is of growing significance in German-speaking countries as well [6] . Very small children are primarily affected by severe peanut allergy and at risk of developing symptoms immediately at first consumption [7,8] . Therefore, it is of increasing importance to focus on potential marker allergens to understand the mechanistic processes. ...
Background:
Little is known about breast milk as a vehicle for tolerance development or sensitization to peanuts very early in life. Thus, well-characterized and highly sensitive detection systems for the reliable determination of peanut allergens in breast milk are mandatory.
Methods:
For the quantification of the marker allergens Ara h 2 and Ara h 6 in the low nanogram per milliliter range in breast milk samples of a German cohort, sensitive and highly specific sandwich ELISAs were optimized and validated.
Results:
The Ara h 2 ELISA revealed a limit of detection (LOD) of 1.3 ng Ara h 2/mL and a quantification range of 2.3-250 ng/mL, the Ara h 6 ELISA showed an LOD of 0.7 ng/mL and a working range of 1.1-14.4 ng/mL. The assays showed no relevant cross-reactivity against other potentially cross-reactive legume, seed, and tree nut extracts (<0.01%, except for Ara h 1 in the Ara h 2 ELISA <0.1%). Ara h 2 was detectable in breast milk samples from 14/40 (35%) of the participants in concentrations from 2.3 to 184 ng/mL, Ara h 6 appeared in 9/40 (22.5%) of the lactating mothers between 1.1 and 9.7 ng/mL, and 1 highly positive sample with 79 ng/mL. Both allergens appeared at the same time points, but Ara h 6 in lower concentrations than Ara h 2.
Conclusions:
Sensitive and specific diagnostic tools for the determination of Ara h 2 and Ara h 6 in human breast milk were established. The kinetics of secreted Ara h 2 and Ara h 6 seem to be similar but with a difference in concentration. Follow-up investigations on their tolerogenic or sensitizing properties in breast milk become now accessible.
... Consequently, severe and potentially fatal reactions to mahleb might be possible for almondsensitized individuals even if they had never consumed mahleb previously (Bock and others 2001). Adding to the concern is the fact that allergic reaction mediated by seed storage proteins tend to be considerably more severe than those mediated by allergens found in the fruit (Ewan 1996;Flinterman and others 2008). ...
en There are a number of examples of immunologic cross‐reactivity elicited by pollens, fruits, seeds, and nuts of closely related plant species. Such cross‐reactivity is of particular concern for patients with food allergies. In this report, we investigated a spice (mahleb) that is prepared from the kernel of the St. Lucie cherry, Prunus mahaleb, for cross‐reactivity with almond (Prunus dulcis), using enzyme‐linked immunosorbent assay (ELISA) and Western blot. Almond and mahleb are members of the same genus. Cross‐reactivity between the mahleb and almond was demonstrated by reaction of cherry and almond kernel protein extracts with antibodies raised against almond proteins. Almond‐specific murine monoclonal IgG, rabbit polyclonal IgG, and almond‐allergic serum IgE each exhibited cross‐reactivity with cherry kernel protein. Because of the demonstrated cross‐reactivity between almond and mahleb, these findings should be of special concern to almond‐allergic patients and attending medical personnel.
Practical Application
pt Mahleb is cross‐reactive with almond‐allergic patient IgE and is likely to elicit an allergic response in sensitive individuals. This information is important for the protection of almond‐allergic patients.
... One possible explanation is that small amounts of allergen could have been present in breast milk or hidden in foods, 25,26 especially eggcontaining foods. Infants may have developed cutaneous sensitization through non-oral routes such as the skin and respiratory tract. ...
Background:
The effect of infant feeding practices on the development of food allergy remains controversial. We examined the relationship between timing and patterns of food introduction and sensitization to foods at age 1 year in the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort study.
Methods:
Nutrition questionnaire data prospectively collected at age 3, 6, 12, 18 and 24 months were used to determine timing of introduction of cow's milk products, egg and peanut. At age 1 year, infants underwent skin prick testing to cow's milk, egg white and peanut. Logistic regression models were fitted to assess the impact of timing of food exposures on sensitization outcomes, and latent class analysis was used to study patterns of food introduction within the cohort.
Results:
Among 2124 children with sufficient data, delaying introduction of cow's milk products, egg and peanut beyond the first year of life significantly increased the odds of sensitization to that food (cow's milk adjOR 3.69, 95% CI 1.37-9.08; egg adjOR 1.89, 95% CI 1.25-2.80; peanut adjOR 1.76, 95% CI 1.07-3.01). Latent class analysis produced a three-class model: early, usual and delayed introduction. A pattern of delayed introduction, characterized by avoidance of egg and peanut during the first year of life, increased the odds of sensitization to any of the three tested foods (adjOR 1.78, 95% CI 1.26-2.49).
Conclusions:
Avoidance of potentially allergenic foods during the first year of life significantly increased the odds of sensitization to the corresponding foods. This article is protected by copyright. All rights reserved.
... Patients allergic to one particular TN often demonstrate cosensitization to other tree nuts as well. 8,9 In PA patients, TN co-sensitization may occur in up to 86% of patients, though only 34% may display clinical reactivity TN (e.g. symptom development after ingestion). ...
Background:
Characteristics and outcomes of tree nut (TN) oral food challenges (OFCs) in patients with TN allergy or sensitization alone are poorly studied.
Objective:
To determine the relation between TN sensitization levels and OFC outcomes.
Methods:
Open TN OFCs performed from 2007 through 2015 at a referral center were analyzed to compare outcome based on skin prick test (SPT) wheal size, food-specific immunoglobulin E (sIgE), peanut co-allergy, and TN sensitization only vs TN allergy with sensitization to other TNs. Delayed OFC was defined as longer than 12 months from the time of an sIgE level lower than 2 kUA/L.
Results:
Overall passage rate was 86% for 156 TN OFCs in 109 patients (54 almond, 28 cashew, 27 walnut, 18 hazelnut, 14 pecan, 13 pistachio, and 2 Brazil nut). Passage rates were 76% (n?= 67) in patients with a history of TN allergy who were challenged to another TN to which they were sensitized and 91% (n?= 65) in those with TN sensitization only (mean sIgE 1.53 kUA/L; range 0.35-9.14). Passage rates were 89% (n?= 110 of 124) for a TN sIgE level lower than 2 kUA/L and 69% (11 of 16) for a TN sIgE level of at least 2 kUA/L. In?44?challenges in patients with peanut allergy and TN co-sensitization, the TN OFC passage rate was 96%. In 41 TN OFCs with a TN SPT wheal size of at least 3 mm, 61% passed, with a mean wheal size of 4.8 mm (range 3-11) in those passing vs 9 mm (range 3-20) in those failing.
Conclusion:
TN challenges are frequently passed in patients with TN sensitization with or without a history of TN reactivity despite a TN SPT wheal of at least 3 mm or a TN sIgE level of at least 2 kUA/L. Nearly all patients with peanut allergy and TN co-sensitization passed the TN challenge, questioning the clinical relevance of "co-allergy."
... A minority of food, including peanut, tree nuts, soy, was thought to cause the majority of allergic reactions 43 . Sensitization, mainly to peanuts, is occurring in very young children, and multiple peanut/nut allergies appear progressively 44 . Leguminous crops are also reported to be source of IgE mediated reactions in Mediterranean and Asian countries 45 . ...
This study was to investigate the association between dietary patterns and rhinitis in primary school children. 1,599 students without rhinitis at baseline survey were selected from a primary school children cohort. Information on food consumption, respiratory symptoms, and confounders was collected using questionnaires. Dietary patterns were defined using principal component analysis. Logistic regression was performed to calculate odds ratio (OR) with 95% confidence intervals (95% CI). The incidence of rhinitis during 12 months follow-up was 21.2%. Three patterns were extracted and labeled as pattern I, II and III. Dietary pattern II which had higher factor loadings of legumes, butter, nuts and potatoes was associated with an increased risk of rhinitis (OR: 1.34, 95% CI: 1.01–1.87) when the highest tertile of pattern score was compared to the lowest tertile, after adjusted for confounders. Besides, every 1-unit increase of score of pattern II was also associated with an increased risk of rhinitis (OR: 1.19, 95% CI: 1.05–1.35). Neither pattern I nor Pattern III was observed to be associated with risk of rhinitis. A diet with higher levels of consumption of legumes, butter, nuts and potatoes may increase the risk of allergic rhinitis in primary school children.
... Considering the relatively high prevalence of PA, the assessment of cross-allergy to every single allergenic TN and legume requiring a full allergy workup may therefore take even a few years to be completed. Even though rates of cross-allergy to TN have been reported to range from 28% to 50% in PA (11)(12)(13)(14), very few studies have characterized these cross-allergic patients. Therefore, targeting patients with severe or crossallergic phenotypes would be highly useful for allergists when determining appropriate management and follow-up practices for PA patients. ...
Background:
Peanut allergy in children is often associated with allergies to tree nuts and/or legumes. The aim of the present study was to analyze in cluster a cohort of children allergic to peanuts and assessed for cross-reactivity to nuts and legumes and to identify different phenotypes.
Methods:
We included retrospectively 317 children with peanut allergy evaluated at the Allergy Unit of the Saint Vincent Hospital of Lille in the last 12 years. A complete work-up for peanut allergy and nuts and legumes was carried out for each patient. A hierarchical agglomerative clustering method was used to search for clusters of individuals in the evaluated cohort.
Results:
Cross-allergy to TN and/or other legumes was identified in 137 patients (43.2%), atopic dermatitis being a major risk factor (adjusted OR = 16 [95%CI: 7.4-37]; p<0.001). Three phenotypes emerged from cluster analysis. Cluster 1 (72 patients) is characterized by high level of rAra h 2, low threshold reactive doses for peanut and high proportion of asthma; Cluster 2 (93 patients) is characterized by high threshold reactive doses for peanut and the lowest proportion of cross-allergy to TN and/or legumes; Cluster 3 (152 patients) has a high risk of cross-allergy to TN and/or legumes and most patients suffer from eczema.
Conclusions:
The three phenotypes highlighted by the present study could be useful to identify children with high risk of cross-allergic reaction to TNs and legumes early after PA diagnosis. This article is protected by copyright. All rights reserved.
Introduction:
The basophil activation test (BAT) has shown evidence of high sensitivity and high specificity to support the diagnosis of IgE-mediated allergy. It is a functional test that uses live cells analyzed by flow cytometry and thus needs to be performed within 24h of blood collection. BAT has shown to be reproducible and reliable when tested in a clinical diagnostic laboratory with standardized protocols and flow cytometry settings.
Areas covered:
In this review, we summarize the evidence to support clinical use of BAT and the next steps required for clinical implementation for an improve clinical care for patients with suspected IgE-mediated food allergy.
Expert opinion:
BAT has recently been included in Clinical Guidelines of Food Allergy Diagnosis and its implementation in clinical practice depends largely on availability. Proposed clinical applications of the BAT include: distinction between food allergy and asymptomatic IgE sensitization; determination of food allergic status to peanut, tree nuts and seeds in polysensitized children; evaluation of tolerance to baked egg and baked milk in egg and milk allergic children; identification of patients at high-risk of severe allergic reactions; monitoring for spontaneous resolution of food allergy; confirmation of eligibility for specific treatments of food allergy; prediction and monitoring of response to immunomodulatory treatments.
Rationale: There is little information regarding the allergen content of milk feeds in the preterm population. Previous studies have not performed a broad analysis of the allergenic peptide content and protease activity of milk feeds in this population. Methods: To evaluate feasibility, we initially performed mass spectrometry on 4 human milk (HM) samples (2 term and 2 preterm) from the Mommy's Milk Human Milk Biorepository (HMB) and analyzed the results against the University of Nebraska FASTA database and UniProt for a total of 2,211 protein sequences. We then further analyzed five samples from the Microbiome, Atopy, and Prematurity (MAP) study including peptidomic and protease activity analysis. Results: Each HMB sample had between 806 and 1,007 proteins, with 37-44 nonhuman proteins/sample encompassing 26 plant and animal species. In the preterm MAP samples, 784 digested nonhuman proteins were identified, 30 were nonbovine in origin. Proteins from 23 different species including aeroallergens, food, and contact allergens were identified. Protease activity was highest in HM samples without human milk fortifier and lowest in preterm formula. Conclusions: These findings represent the first preterm milk feed mass spectrometry and protease analysis with identification of known allergenic proteins to food, contact, and aeroallergens. These results raise questions of whether the composition of milk feeds in the neonatal intensive care unit impact the development of atopic disease in the preterm population and whether the complex interaction between allergens, proteases, and other HM components can serve to induce sensitization or tolerance to allergens in infants. Clinical Trial Registration Number: NCT04835935.
p> Introduction: It is unclear at present which type of food challenge (open vs. double blind) is best suited for the diagnosis of food hypersensitivity (FHS) in children.
This research aimed to assess 1) what is the best approach for the diagnosis of FHS; 2) how maternal dietary and infant feeding and weaning practices influence the development of FHS; 3) the role of a personal or family history of atopy in dietary practices.
Methods: A birth cohort of children born during 2001 - 2002 was recruited at the ante-natal clinic and followed prospectively for two years. In addition, three sets of school cohorts were approached to participate in the study. To address the first aim, all cohorts were utilised and the use of open food challenges (OFC) and double blind placebo controlled food challenges (DBPCFC) were assessed in the diagnosis of FHS. To address the second aim the birth cohort was used. A food frequency questionnaire (FFQ) was developed and validated to obtain the information on the maternal diet. Standardised questionnaires were developed and used prospectively to assess feeding and weaning practices and their influence on the infant’s FHS. To address the third aim the family history of atopy was obtained during recruitment of the birth cohort.
Results: We found that the positive predictive value of the one-day OFC challenges was higher than the one-week OFC. The data therefore suggest that OFC may be suitable for diagnosing immediate (objective) symptoms, whereas a DBPCFC may be needed for the diagnosis of delayed (subjective) symptoms.
Fruit and vegetable intake during pregnancy, food avoidance during lactation and weaning age of the infant affected the development of FHS.
A family history of atopy positively affected exclusive breast feeding at three months and delayed introduction of peanuts into the infant’s diet by six months. </p
Background
The severity of allergic reactions to foods can vary markedly. Little is known of variations in reaction severity within or between individuals or the effects of co-factors.
Objective
We examined the effects of sleep deprivation and exercise and repeat challenges on the severity and patterns of allergic reactions to peanut.
Methods
In a randomised crossover study, adults with peanut allergy underwent 3 open peanut challenges in random order: with exercise after each dose, with sleep deprivation preceding challenge, and with no intervention. Primary outcome was eliciting dose, reported elsewhere. Reaction severity was a secondary outcome, evaluated using a weighted log-transformed numerical severity score. Analyses estimated the difference in severity between non-intervention challenge and challenges with exercise or sleep deprivation, adjusting for challenge order and using the highest dose tolerated by each individual across all their challenges. Symptom pattern reproducibility was assessed by comparing symptom sequences using pairwise sequence alignment to obtain percentage match in symptom pattern.
Results
Eighty-one participants (mean age 25y) completed at least one post-baseline challenge. Sleep deprivation, but not exercise, significantly increased severity score by 48% (95%CI 12%,84%;p=0.009) compared to no intervention. A 38% increase in severity was observed between the first and last post baseline challenge (95%CI 1%,75%;p=0.044). The average pairwise match of symptoms within individuals was 82.4% and across individuals was 78.3%.
Conclusion
A novel severity score demonstrates that sleep deprivation and repeated challenges increase reaction severity. Understanding factors affecting severity is essential for effective risk management. We also show that symptom patterns in repeat peanut challenges are similar within and between individuals.
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The phenomenon of food allergy cross:reactivity presents significant interest for investigators and health care specialists. This review provides an analysis of studies results of clinical features and manifestations mechanisms of cross:reactivity. There are information about the food allergens main classes, estimation of sensitivity of cross:reactivity different diagnostic methods, and principles of elimination diet in the article.
The oral food challenge (OFC) is the criterion standard for diagnosing food allergy, but prior studies indicate many allergists may not be using OFCs for various reasons. To better understand current OFC trends, practices, and barriers, the American Academy of Allergy Asthma and Immunology (AAAAI) Adverse Reactions to Foods Committee subcommittee updated a 19-item survey (previously administered in 2009) and sent it to AAAAI and American College of Allergy, Asthma, and Immunology (ACAAI) membership. There were a total of 546 respondents who represented approximately a 10% response rate. Among the 546 respondents, compared with 2009, significantly more providers offer OFCs (95% vs 84.5%), offer >10 OFCs per month (17% vs 5.6%), obtain informed consent (82.2% vs 53.6%), and performed OFCs in fellowship (71% vs 45%) (all P < .001). Fellowship OFC training was limited, with 56% performing <10 OFCs in fellowship and 29% performing none. Although 94% see patients <12 months of age, 35.5% do not offer OFCs for early peanut introduction. Although 79% dedicate a supervising medical provider (MD, NP, PA) and 86% have a written OFC protocol, only 60% had a standardized reaction treatment protocol and 56% prepared emergency medications before OFC. Compared with 2009, there was significant worsening of perceived barriers to performing OFCs, including time (65.6% vs 55%), space (55.3% vs 27.1%), staffing (59.6% vs 44.3%), experience (16.9% vs 11.5%), and hospital proximity (10.9% vs 7.9%), though reimbursement as a barrier improved (45.9% vs 53.7%) (all P < .01). Compared with 2009, although more providers offer OFCs, multiple perceived barriers to performing OFCs have worsened. Hesitancy to challenge infants and emergency preparedness issues are emerging potential concerns.
Taken into account data from which is considered a product not safe, estimate the safe level of a contaminant on food, for example, always have many unavoidable uncertainties. It cannot be overemphasized enough, that this also happens as in any other human activity. In most cases, we hope, to define as clearly as possible the eventual risk associated with particular conditions of exposure to a given substance in food. There are numerous toxic compounds that reside naturally in certain foods that unable these to be consumed above certain limits or even are fully prohibited in some other countries. Chapter starts with a clear explanation of differences and relationships between food allergy and food poisoning, continued with main allergens in food and main toxics. Finally, authors summarize different origins of toxins and allergens (natural from foods, from additives, pollutants and food processing).
The treatment of hemorrhoids focuses on the individual symptoms and consists of invasive procedures, including operative and semi-operative interventions (injection sclerotherapy and rubber band ligation) in addition to basic measures (including stool regulation and defecation behavior). Sclerotherapy is carried out as an outpatient procedure by injecting chemical into the sucmucosa of the hemorroids agents and leads to an alteration of the hemorroidal tissue but in contrast to rubber band ligation and surgical treatment measures not in a reduction of the hemorroidal tissue. This leads to a histological reorganization of the hemorroidal tissue and can be repeated until the symptoms are controlled. Several different sclerosing agents can be submucosally injected. In German-speaking regions polidocanol is mostly used and predominantly applied intrahemorrhoidally (method according to Blond). The indications for sclerotherapy are based on the leading symptoms of the hemorrhoids and according to the German S3 guidelines, injection sclerotherapy is recommended for first-degree and second-degree hemorrhoids. In addition, injection sclerotherapy can be performed as a supplement to rubber band ligation and also to treat residual symptomatic hemorrhoids after surgical interventions. Furthermore, in this clinic injection sclerotherapy according to Blond is the first-line invasive treatment for patients taking anticoagulants or platelet aggregation inhibitors.
The genus of Pistacia plant systematically fits into the family of Anacardiaceae. Pistachios contain protein, carbohydrate, dietary fibers, fat, folic acid, vitamin K, magnesium and potassium, gama-tocopherols, phytochemicals, and polyphenols. Collectively, these constituents have been shown to possess antioxidant and anti-inflammatory functions to improve overall health when consumed as a healthy diet. We searched the following keywords within the literature databases: pistachio, heart disorders, lipids, weight, antioxidants, and allergy. Further searching theses keywords, we have found 50 articles in PubMed, 40 articles in ISI web of knowledge and 30 articles in Google Scholar. We have selected 100 articles, among them 80 articles were used as the references of this review. In the current article, we have discussed the most recent data published regarding the regulatory effects of pistachios on several clinical states such as heart related disorders, hyperlipidemia, hypertension, vascular stiffness and endothelial and gut functions, weight management, glucose metabolism, kidney function and finally allergies.
Seed storage proteins are extremely stable allergens in nuts, seeds, and legumes and are responsible for the most severe allergic reactions to these foods. The cross-reactivity between seed storage proteins from different sources has not been studied at a molecular level so far. This study aimed to ascertain the cross-reactivity between walnut and hazelnut seed storage proteins using recombinant allergens. Sera from 13 consecutive patients with severe primary walnut and/or hazelnut allergy and hypersensitive to both nuts were studied. IgE specific for rCor a 9, rCor a 14, and rJug r 1 was measured, and inhibition experiments were carried out by measuring IgE reactivity after absorption of patients' sera with freshly prepared walnut extract. All 13 sera showed strong IgE reactivity against walnut 2S albumin, Jug r 1, 12 reacted to hazelnut 2S albumin, Cor a 14, and 8 to the hazelnut legumin, Cor a 9. In inhibition experiments, absorption of sera with whole walnut extract led to the complete disappearance of IgE reactivity to Jug r 1 in 12/13 cases, as expected, but also to the complete disappearance of specific IgE to Cor a 14 in 9/12 sera, and of IgE reactivity to Cor a 9 in 7/8. In the remaining cases a dramatic drop in IgE reactivity was observed. The study shows that patients primarily allergic to either walnut or hazelnut showing a skin or serological reactivity to the other nut also are potentially at risk of severe allergic reactions caused by cross-reactivity between 2S albumins and legumins.
Cette thèse actualise les connaissances de l'évaluation de l'allergénicité des aliments et son application au diagnostic de l'allergie alimentaire. Après la définition, les caractéristiques et la classification des allergènes alimentaires, les phénomènes physico-chimiques modifiant l'allergénicité des aliments ainsi que les réactivités croisées sont décrites. Ainsi sont introduits les outils cliniques et biologiques utiles au diagnostic de l'allergie alimentaire et à la détection des traces d'allergènes alimentaires. Une collaboration étroite entre cliniciens et chercheurs biologistes, permet d'optimiser la prise en charge diagnostique et thérapeutique de l'allergie alimentaire. Cette démarche se concrétise par la mise à disposition et l'utilisation de divers outils (développement d'allergènes recombinants, dosage de contaminants alimentaires dans des médicaments ou aliments, ...) et est illustrée par diverses mises en situation clinique réelles.
Food allergy (FA) was born as cow’s milk (CM) allergy (CMA). Only humans began and continue to use milk of other animals to nurse offspring, although Hippocrates recorded gastric upset and hives due to CM and proposed dietetic measures. The use of animal milk to feed children began spreading around the mid-eighteenth century, with a preference for ass or goat’s milk rather than for CM [249]. In parallel, the consequent decline in breast feeding became evident from the fifteenth to nineteenth centuries: perhaps “nine months of blood, nine months of milk” [95] were too heavy. Subsequent discoveries in the fields of microbiology and medicine provided a more thorough basis for development of substitutes for breast milk (BM). Comparisons against the advisers of bottle feeding were requested, with unhappy results [95] and also differences in mortality among the BM-fed infants compared to non-BM-fed infants were worthlessly pointed out [249]. Even if at the start of the 20th century the first cases of anaphylaxis [436], one of which was fatal [161], and of CMA [196] were documented in the German literature, artificial feeding increased like an avalanche in the 20th century [249].
In this chapter we analyze the unending worldwide increase of pediatric allergic diseases and their natural history. Of concern is the early age at which atopy starts its march in these defenseless children.
The first description of an event similar to anaphylaxis was made at least 4,600 years ago [179]; however, only in 1765 was a fatal case reported in Europe (Chap. 17). In 1905, the first cases (one lethal) of food anaphylaxis were reported [72, 174], the subject of a book appeared in 1919 [111], and since 1926 [214] such cases have continued with an impressive frequency. The term “anaphylaxis” (from the Greek “αναϕυλαξις”, away from protection) was coined by Portier and Richet in 1902 during a Mediterranean voyage [156] to define the paradoxical effect of an experimental protocol. While attempting to immunize dogs to the venom of the sea anemone, after the first nonlethal tolerated dose, they unwillingly sensitized the animals with the second dose injected after 2 weeks, either equal to or less than the previous dose, and noted that the dogs exhibited severe manifestations, even lethal. Therefore the first injection sensitizes the animal, provoking synthesis of IgE antibodies; after a latent period for sensitization, re-exposure to the inciting allergen triggers within a few minutes the very severe clinical manifestations called anaphylactic shock, the reverse result of the prophylaxis envisaged by the scientists [156].
DefinitionMechanismsEpidemiologyAetiologyAssociations with Asthma, Rhinitis and AtopyClinical FeaturesDifferential DiagnosisInvestigationsAcute TreatmentLong-Term ManagementReferences
This chapter discusses the case of a 46-year-old painter and decorator, Michael. He has had an egg allergy since infancy but has also started to experience symptoms of an itchy mouth when eating certain plant foods. The skin prick and blood tests suggest that Michael is no longer allergic to eggs despite the recent reactions that he attributed to egg. His skin prick tests were positive to grass and trees, which fits with his hay fever pattern. Many people with springtime hay fever get an itchy mouth to raw fruits, known as pollen-food syndrome (PFS), also known as oral allergy syndrome (OAS). The questions raised in this chapter include queries regarding the food allergy prevalence in adults, typical symptoms of a food allergy, food allergens in the rice pudding and whether nutritional factors might be an issue for Michael if he is avoiding eggs, nuts and certain fruits.
To determine the systemic absorption of epinephrine when it is given by inhalation, six normal volunteers were given 15 puffs, followed by 30 puffs, of epinephrine from a pressurized aerosol (160 micrograms epinephrine/puff). The peak mean (+/- SE) plasma epinephrine levels were 1.50 (+/- 0.61) and 4.22 (+/- 1.93) nmol/L 1 minute after each dose, respectively. The effect on physiologic finger tremor correlated with the plasma epinephrine level and returned to baseline 20 minutes after taking the higher dose. There was a small fall in mean plasma potassium levels of 0.45 mmol/L and a small rise in plasma glucose levels of 0.81 mmol/L. On a separate occasion an injection of 0.3 ml of 1/1000 (300 micrograms) epinephrine was given subcutaneously to the same individuals. This caused a peak plasma epinephrine level of 2.43 (+/- 0.47) nmol/L at 10 minutes, and this was still raised at 2.05 (+/- 0.41) nmol/L after 40 minutes. The maximum fall in the mean plasma potassium level was 0.43 mmol/L after the injection.
Twelve cases of allergy to Brazil nut have been recorded in the last 8 years. The reaction is usually IgE mediated and most patients have other atopic diseases. There appear to be several proteins with potent antigenic components in Brazil nut.
For 16 years the double-blind, placebo-controlled food challenge (DBPCFC) has been used at the National Jewish Center for Immunology and Respiratory Medicine to determine whether adverse reactions to foods do occur in children. The objective of these studies was to explore these reproducible adverse reactions and to characterize them. Although skin testing was performed on all subjects, a history of an adverse reaction to food and to subsequent DBPCFC were the only criteria for entry into this study. Of 480 children studied, 185 (39%) have had positive DBPCFC results. In these 480 children, 245 (24%) of 1014 DBPCFCs showed positive results. Egg, peanut, and cow milk accounted for 73% of the positive DBPCFC reactions, but many foods produced reactions. Skin test results were positive in most children with a positive DBPCFC reaction, but the large number of patients with asymptomatic hypersensitivity limited the accuracy of a positive skin test result alone as a predictor of clinical symptoms during food ingestion. Evaluation of results in this large number of children for a prolonged period revealed reproducible patterns of symptoms, timing, and incriminated foods. Placebo reactions were rare. The procedure was safe. Twelve youngsters with a negative DBPCFC result subsequently had positive reactions to open challenges when large amounts of the challenge food were used. In each of these cases the reactions were limited to areas of direct contact with the food or could be explained by the larger amount of food ingested during the open challenge. Multiple food hypersensitivity has been a rare finding. The DBPCFC should be the "gold standard" for both research and clinical diagnostic evaluations until it is superseded by methods that have yet to be developed.
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Selected References
These references are in PubMed. This may not be the complete list of references from this article.
Fries JH. Peanuts: allergic and other untoward reactions. Ann Allergy. 1982 Apr;48(4):220–226. [PubMed]
Between 1973 and 1985, 114 children, aged 2 to 14 years, underwent double-blind, placebo-controlled, food challenge (DBPCFC) to peanut. Thirty-two of 46 children with symptoms produced by DBPCFC to peanut were included in this longitudinal evaluation. Contact was made with the 32 subjects 2 to 14 years after their positive DBPCFC to peanut. All 32 subjects had exhibited a positive puncture skin test to peanut at the time of the original evaluation. Sixteen subjects had experienced symptoms caused by accidental peanut ingestion in the year before contact. Eight subjects had reacted to accidental ingestion in more than 1 year but less than 5 years before contact. Eight subjects had completely avoided peanut since the original evaluation and positive DBPCFC. No subjects could be demonstrated to have "outgrown" their peanut reactivity. All subjects tested continued to have skin reactivity to a puncture skin test with peanut extract. It appears uncommon for peanut-sensitive patients to lose their clinical reactivity, even after many years have elapsed. In addition, data were collected concerning reactions to other legumes and other (nonlegume) nuts. Only two patients with DBPCFC to peanut reacted on DBPCFC to soy or pea (one each). None of the subjects with a positive DBPCFC to peanut reacted to nonlegume nuts.
Patients with atopic dermatitis and food hypersensitivity who were adhering to an elimination diet underwent repeat double-blind, placebo-controlled oral food challenges annually for follow-up of their food allergy. After 1 year, 19 of 75 patients lost all signs of clinical food hypersensitivity (15 of 45 patients allergic to one food, and 4 of 21 allergic to two foods). Of the individual foods, 38 of 121 no longer elicited symptomatic responses. After 2 years, patients underwent a second rechallenge; 4 of 44 patients tested lost their clinical food hypersensitivity. In 20 patients undergoing a third rechallenge, no food hypersensitivity was lost. Loss rate of food hypersensitivity varied among foods; after 1 year, there was a 26% loss of symptomatic food allergy to five major allergens (egg, milk, soy, wheat, and peanut) compared with a 66% loss rate to other food allergens. Loss of symptomatic allergy was not affected by the patient's age at diagnosis, except with milk allergy, for which older patients were more likely to lose clinical food hypersensitivity (p less than 0.05). Total serum IgE and prick skin tests were not useful for predicting loss of symptomatic food hypersensitivity. There was no significant decrease in skin test wheal size corresponding to loss of clinical food hypersensitivity. Patients developing only skin symptoms during the initial challenge were most likely to lose symptomatic food hypersensitivity.
Peanuts, along with milk and eggs, have been documented to account for approximately 80% of adverse reactions to foods in patients with atopic dermatitis. Over the past 3 years, we have evaluated 71 patients with atopic dermatitis, ranging from mild to severe in nature. These patients were initially evaluated by allergy prick skin testing and when appropriate had double-blind placebo-controlled food challenges done. Thirty-nine (55%) patients had a positive prick skin test to one of the foods tested. There were 80 food challenges performed with peanut, accounting for 12 (32%) of the 38 positive challenges in 23 (31%) patients. As in earlier studies, patients developed skin (97%), respiratory (55%), and gastrointestinal (32%) symptoms during the challenge. Of the five patients with histories of prior anaphylactic reactions four (80%) were to peanut. These studies indicate that children with all degrees of atopic dermatitis may benefit from evaluation for food hypersensitivity. They also show that peanut is a major food protein responsible for these reactions.
Fatal food-induced anaphylaxis is rarely reported. In 16 months, we identified seven such cases involving five males and two females, aged 11 to 43 years. All victims were atopic with multiple prior anaphylactic episodes after ingestion of the incriminated food (peanut, four; pecan, one; crab, one; fish, one). In six cases the allergenic food was ingested away from home. Factors contributing to the severity of individual reactions included denial of symptoms, concomitant intake of alcohol, reliance on oral antihistamines alone to treat symptoms, and adrenal suppression by chronic glucocorticoid therapy for coexisting asthma. In no case was epinephrine administered immediately after onset of symptoms. Premortem or postmortem serum samples were available from six victims; in each case elevated levels of IgE antibodies to the incriminated food were demonstrated. Food-sensitive individuals must self-administer epinephrine promptly at the first sign of systemic reaction. Emergency care providers should be aware of cricothyrotomy as a life-saving procedure.
Eighty-three oral food challenges were performed on 25 patients with a history of immediate adverse reaction to foods. Seventy-one food challenges were performed in 24 patients, whereas 12 placebos were administered to nine patients. Of the 71 food challenges observed, 12 were positive in 10 patients. All challenges with placebo were negative. Doses of challenge foods provoking observable reactions ranged from 5 to 100 gm. The clinical signs and symptoms noted on food challenge reproduced those reported by history. Reactions were mild, generally self-limited, and were not accompanied by elevations in urinary histamine. A plasma histamine elevation was observed in one patient. A 10- to 12-mo follow-up survey of nine patients with negative food challenges revealed that six patients had resumed eating the challenge food on a regular basis without experiencing adverse reactions, whereas three patients continued to avoid the challenge food. All 10 patients with positive food challenges continued to avoid the challenge food.
Serious sequalae to the ingestion of several foods such as egg, fish and milk--and the lack of profound reactions to chocolate--have been well documented. However, no comparable study exists in regard to peanut, which has long been known to be a patent antigen. This article explores the role of peanut with respect to its hazards as an antigen and as a foreign body in the upper respiratory tract, and documents a number of fatal and near-fatal reactions.
Ten peanut-sensitive patients were enrolled in a double-blind crossover trial to determine whether ingestion of peanut oil can induce adverse reactions in such individuals. All patients had experienced prior allergic reactions to peanut ingestion, including any of the following: generalized urticaria, angioedema, abdominal cramps, vomiting, diarrhea, bronchospasm, or shock. All patients had elevated levels of serum IgE antibodies to both crude peanut extract and the purified peanut allergen, Peanut-I, by RAST assay; binding values ranged from 2 to 26 times that of negative control serum. All patients demonstrated negative puncture skin tests to both peanut oil and olive oil (control). At 30-min intervals, patients ingested 1, 2, and 5 ml of either oil contained in 1 ml capsules while under constant observation. These quantities exceed the maximum estimated dose of peanut oil that would occur in single meals. Patients returned 2 wk later for ingestion challenge with the remaining oil. No untoward reactions were observed with either peanut oil or olive oil. Peanut oil ingestion does not pose a risk to peanut-sensitive individuals.
Systemic reactions during anesthesia are commonly attributed to muscle relaxants, hypnotics, macromolecular solutions, latex, or parenteral antibiotics. After exclusion of these different components as causes, we were interested in the potential implication of rifamycin in the systemic reaction, which occurred during anesthesia, and in the immunologic mechanism by which it can trigger this reaction.
We report four cases of systemic reactions occurring after local administration of rifamycin. Three patients needed orthopedic surgery, and the fourth needed a urethrotomy. Severe systemic reactions occurred in all four patients when the surgeon washed the incision area with a rifamycin solution. All patients correctly responded to appropriate treatment and recovered. Skin tests were performed 2 months after the incident with the drugs used during anesthesia, latex, and rifamycin. To assess the relationship with a possible IgE-mediated mechanism, two in vitro tests were concomitantly performed to evaluate the cell reactivity to rifamycin: (1) determination of histamine release from peripheral basophils and (2) platelet cytotoxicity test, which explored the presence on platelets of specific IgE antibodies bound to the low-affinity receptor for IgE.
Skin tests were performed with different drugs used during surgery, and results were only positive for rifamycin in the four cases, accompanied in two cases by a systemic reaction. Histamine release from basophils was positive in three of four patients. The platelet cytotoxicity test results were positive in all four cases.
It appears that rifamycin, used locally during surgery, is apt to trigger severe systemic anaphylactic reactions, which are linked to an IgE-related process. This situation is worth pointing out, especially in patients who undergo repeated orthopedic operations during which, at least in Europe, rifamycin is commonly used for the prevention of local sepsis.
A quality-control retrospective review of medical records was conducted for cases of anaphylaxis encountered at Mayo Clinic Rochester during a 3 1/2-year period.
For inclusion in the study, all patients had to manifest general symptoms of mediator release such as generalized pruritus, urticaria, angioedema, and flushing. Of the 179 patients with anaphylaxis (mean age, 36 years), 66% were female, 49% had atopy, and 37% had a previous history of immediate reactions to allergens. Of these study patients, 11 were receiving medications capable of exacerbating anaphylaxis (beta-blockers in 7 of them).
Consultation with an allergist was obtained in 142 cases, and a probable diagnosis was made after review of the medical records. Causes of anaphylaxis included foods in 59 patients, idiopathic in 34, Hymenoptera in 25, medications in 23, and exercise in 12; false-positive diagnoses were recorded in 18. Allergy prick tests were done in 104 patients, 71 of whom had positive results; allergen-specific IgE tests were done in 44 patients, 23 of whom had positive results. In 19 patients, only allergen-specific IgE testing was done, and results were positive in 12. Normal test results included C1 esterase inhibitor in 33 patients, metabisulfite challenge in 15, and dye or preservative challenge in 10. Food skin tests were graded on a relative value scale and revealed 15 highly allergic, 24 moderately allergic, and 39 weakly allergic food groups.
A standard protocol should be used for assessment of patients with anaphylaxis, and fresh food extracts should be used for prick skin testing. A national incidence study of anaphylaxis is needed. The public and school personnel should be educated about food anaphylaxis, and emergency treatment for anaphylaxis should be readily available for patients.
Type 1 or immediate hypersensitivity: hayfever and asthma Clinical aspects of immunology
- Tae Platts-Mills
15 Platts-Mills TAE. Type 1 or immediate hypersensitivity: hayfever and
asthma. In: Lachmann PJ, Peters DK, eds. Clinical aspects of immunology.
4th ed. Oxford: Blackwell, 1982:570-686.