Fruit-Induced Anaphylaxis: Clinical Presentation and Management

Evaluation of the incidence of systemic symptoms in PR-10-related pollen-food allergy syndrome in Western Japan

BACKGROUND

Pollen food allergy syndrome (PFAS) primarily presents as oral allergy syndrome (OAS) with occasional systemic symptoms. Few studies have examined the systemic symptoms of PR-10-related PFAS, which are common among pediatric patients in Japan.

METHODS

Two surveys were conducted to investigate the possibility of more severe patients in medical institutions and misdiagnoses among school children: one for patients diagnosed with PR-10-related PFAS at medical institutions and another for elementary and junior high school children whose parents completed an online questionnaire. We examined allergenic foods/symptoms, incidence of OAS, and systemic symptoms in PR-10-related PFAS patients allergic to Rosaceae fruits/soybeans.

RESULTS

Among 221 patients with PR-10-related PFAS at medical institutions, 205 and 86 developed allergic symptoms to Rosaceae fruits and soybeans, respectively. The incidence of systemic symptoms was significantly higher in the soybean group (43/86, 50.0%) than in the Rosaceae fruits group (43/205, 21.0%) (p < .001). Among the 29,906 school children, 3309 (11.1%) responded; 202 were children with PR-10-related PFAS, 194 and 29 developed allergic symptoms to Rosaceae fruits and soybeans, respectively. The incidence of systemic symptoms was higher in the soybean group (12/29, 41.4%) than in the Rosaceae fruits group (46/194, 23.7%), although not significantly (p = .067).

CONCLUSION

Two surveys were conducted targeting patients with confirmed diagnoses and general students. The incidence of systemic symptoms associated with PR-10-related PFAS was similar at 20% for Rosaceae fruits and 40%-50% for soybeans in both surveys. Attention should be given to the potential for systemic symptoms in patients with PR-10-related PFAS.

Benefits of Epinephrine for Anaphylaxis Outweigh Potential Harm-A Safety Review

Anaphylaxis is a potentially life-threatening allergic reaction that can progress quickly, and although fatal anaphylaxis is very rare, treatment should be given as soon as possible. The recommended first-line treatment for anaphylaxis is intramuscular (IM) epinephrine. Yet epinephrine for anaphylaxis is underused, which can have deleterious, or even tragic, consequences. Although fear of self-injection substantially affects adherence, hesitancy to use epinephrine for anaphylaxis may be linked to the common unsubstantiated perception that epinephrine is dangerous. Therefore, the objective of this narrative review is to describe the safety of epinephrine when administered for the treatment of anaphylaxis. Cardiovascular adverse events (AEs) are the greatest safety concern with epinephrine because of its known effects on cardiac output and vasoconstriction. Cardiovascular events and overdose are significantly more likely to occur with accidental intravenous bolus administration than IM administration. Although serious AEs have been reported with IM epinephrine, and there are potential risk factors for cardiovascular AEs for some patients, there are no absolute contraindications for its use in a life-threatening situation. Appropriately dosed and administered epinephrine should engender no fear of use for anaphylaxis. The potential harm of delaying or withholding epinephrine treatment for anaphylaxis far outweighs the potential risk of AEs.

Fruit allergy and anaphylaxis in children: Culprit fruits and clinical findings

Background: Fruit allergy usually presents with mild-to-moderate symptoms but serious systemic reactions, e.g., anaphylaxis, may also occur. Objective: This study aimed to examine the clinical and laboratory characteristics of patients with fruit allergy and fruit-induced anaphylaxis. Methods: Patients diagnosed with fruit allergy at Dışkapı Hematology and Oncology Hospital and Bilkent City Hospital between January 2017 and January 2023 were included in the study. The diagnosis of anaphylaxis was made according to the European Allergy and Clinical Immunology Anaphylaxis Guideline. Results: During the study period, skin-prick tests with food allergens were performed on 9432 patients in our clinic, and fruit allergy was detected in 78 patients (0.82%). Five patients with inaccessible medical records were excluded from the study. 40 (54.8%) were boys. The median (interquartile range) age at the onset of symptoms was 72 months (12.5-144 months). Sixty-eight of the patients (93.2%) had a concomitant allergic disease, the most common of which was allergic rhinitis (n = 48 [65.8%]). The 73 patients had a history of reaction to 126 fruits. Twenty-five patients (19.8%) were allergic to multiple fruits. The most common fruit allergen was banana (22/126 [17.4%]), followed by peach (18/126 [14.2%]) and kiwi (17/126 [13.5%]). Mucocutaneous findings were observed most frequently after fruit consumption (120/126 [95.2%]). Anaphylaxis occurred in 17 patients (23.2%) with 21 fruits.The fruits most commonly associated with anaphylaxis were banana (6/21 [28.6%]) and kiwi (6/21 [28.6%]). Conclusion: Fruit allergy generally presents with mild symptoms, e.g., oral allergy syndrome, but severe systemic symptoms, e.g., anaphylaxis, can also be observed. Kiwi and banana are the fruits that most commonly cause anaphylaxis. Although more comprehensive studies are needed to comment on the development of tolerance, especially in patients with anaphylaxis, responsible fruit avoidance is still the most important strategy.

Blueberry (Vaccinium myrtillus) Induced Anaphylaxis in a Chinese Child with Lipid Transfer Protein Sensitization

Purpose

Fruits have been identified as the primary triggers of anaphylaxis in older children in the Chinese population, especially among individuals with pollen sensitization. To date, no allergies have been reported after blueberry ingestion in the Chinese population.

Case Report

A 12-year-old girl experienced one episode of anaphylaxis within 30 minutes of having breakfast (including milk, egg, wheat bread, and blueberry) while walking to school. She menstruated during this episode. Prompt treatment with epinephrine and fluid therapy led to full recovery within 24 h. Specific IgE was conducted using ImmunoCAP, and the patient exhibited sensitization to several pollens, mainly Japanese hop (74.3 kUa/L) and mugwort (26.5 kUa/L). Regarding specific IgE to allergen components, the patient showed sensitization primarily to lipid transfer protein (LTP) components from mugwort Art v 3 (79.7 kUa/L), wheat Tri a 14 (12.4 kUa/L) and peach Pru p 3 (2.15 kUa/L), but tested negative for omega-5 gliadin. The prick test results were positive for blueberries (wheal size 9.5 mm), cherries (wheal size 6.5 mm), kiwifruits (wheal size 6 mm), and pears (wheal size 4.5 mm). Our patient was provided with an epi-pen and was advised to avoid consuming relevant fruits. After four months of follow-up, the patient had not experienced any episodes of anaphylaxis since these recommendations were implemented.

Conclusion

We report for the first time a Chinese child with severe IgE-mediated immediate-type anaphylactic reaction to blueberries, in whom we identified LTP as the suspected allergen component.

Revisiting Fruit Allergy: Prevalence across the Globe, Diagnosis, and Current Management

Fruit allergies manifest with a diverse array of clinical presentations, ranging from localized contact allergies and oral allergy syndrome to the potential for severe systemic reactions including anaphylaxis. The scope of population-level prevalence studies remains limited, largely derived from single-center or hospital-based investigations. In this comprehensive review, we conducted a systematic literature search spanning the years 2009 to 2023, with full acknowledgment of potential analytical biases, to provide a global overview of fruit allergy prevalence. The primary mechanistic underpinning of fruit allergies stems from cross-reactivity between aeroallergens and food allergens, a consequence of structurally similar epitopes-a phenomenon recognized as pollen food allergy syndrome (PFAS). In the era of molecular allergology, numerous studies have dissected allergen components with substantial clinical relevance. Within this review, we explore important allergenic molecules found in plant-based foods, scrutinize pertinent cross-reactivity patterns, and offer insights into management recommendations. Additionally, we compare guideline recommendations to enhance clinical understanding and inform decision making.

Epinephrine treatment of food-induced and other cause anaphylaxis in United States and Canadian Emergency Departments: a systematic review and meta-analysis

INTRODUCTION

Studies from more than 10 years ago showed epinephrine treatment of food-induced anaphylaxis in the emergency department (ED) was unacceptably low. We investigated whether epinephrine treatment of food-induced and other cause anaphylaxis in United States and Canadian EDs has changed over time.

METHODS

Guided by a health sciences librarian, we performed a systematic search in Medline, Embase, and Web of Science on 11 January 2023. We included observational studies that reported epinephrine use to treat anaphylaxis in the ED. We stratified by anaphylaxis etiology (food-, venom-, medication-induced, or any cause). Associations between year and epinephrine use were tested using Spearman correlation and proportional meta-analysis.

RESULTS

Of 2458 records identified in our initial search, 40 met inclusion criteria. Of these, 14 examined food-induced, 4 venom-induced, 0 medication-induced, and 24 any cause anaphylaxis. For epinephrine treatment of food-induced anaphylaxis in the ED, among studies using similar definition of anaphylaxis, meta-analysis showed a pooled value of 20.7% (95% CI 17.8, 23.8) for studies performed >10 years ago and 45.1% (95% CI 38.4, 52.0) from those in the last 10 years. For anaphylaxis of any cause, there was no change over time, with a pooled value of 45.0% (95% CI 39.8, 50.3) over the last 10 years.

DISCUSSION

Epinephrine treatment of food-induced anaphylaxis in the ED has increased over time. There was no clear change for anaphylaxis of any cause. Over the last 10 years, approximately 45% of ED patients with anaphylaxis received epinephrine. A limitation of the evidence is heterogeneity in anaphylaxis definitions.

Impact of Reaction Setting on the Management, Severity, and Outcome of Pediatric Food-Induced Anaphylaxis: A Cross-Sectional Study

BACKGROUND

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).

OBJECTIVE

We sought to investigate the setting, management, and severity of pediatric FIA.

METHODS

We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.

RESULTS

We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.

CONCLUSIONS

Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Anaphylaxis across Europe: are pollen food syndrome and lipid transfer protein allergy so far apart?

PURPOSE OF REVIEW

Traditionally pollen-food syndrome (PFS) is considered to be a mild cross-reacting food allergy affecting only Northern Europe, with lipid transfer protein (LTP) allergy being more severe and mainly occurring in Southern Europe. This review seeks to update the reader on both types of plant food allergy and to determine whether the stereotypical presentations of these plant food allergies remain the same, with a particular focus on reaction severity.

RECENT FINDINGS

Recent findings suggest that both these types of plant food allergy occur in children and adults. Although it is true that PFS allergy is more prevalent in Northern Europe and LTP allergy is more well known in Southern Europe, these conditions are not hidebound by geography, and the increasing spread and allergenicity of pollen due to global warming continues to change their presentation. Both conditions have a spectrum of symptom severity, with PFS sometimes presenting with more severe symptoms, including anaphylaxis and LTP allergy with milder reactions.

SUMMARY

It is important to consider that in many parts of Europe, reactions to plant foods, especially fruits or vegetables, could be mediated either by pollen cross-reactivity or primary sensitization to LTP allergens. All those presenting with symptoms to plant foods will benefit from a detailed clinical history and appropriate tests so that an accurate diagnosis can be made, and correct management implemented.

Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis

This rapid review summarizes the most up to date evidence about the risk factors for severe food-induced allergic reactions. We searched three bibliographic databases for studies published between January 2010 and August 2021. We included 88 studies and synthesized the evidence narratively, undertaking meta-analysis where appropriate. Significant uncertainties remain with respect to the prediction of severe reactions, both anaphylaxis and/or severe anaphylaxis refractory to treatment. Prior anaphylaxis, an asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors. Some molecular allergology markers may be helpful. Hospital presentations for anaphylaxis are highest in young children, yet this age group appears at lower risk of severe outcomes. Risk of severe outcomes is greatest in adolescence and young adulthood, but the contribution of risk taking behaviour in contributing to severe outcomes is unclear. Evidence for an impact of cofactors on severity is lacking, although food-dependent exercise-induced anaphylaxis may be an exception. Some medications such as beta-blockers or ACE inhibitors may increase severity, but appear less important than age as a factor in life-threatening reactions. The relationship between dose of exposure and severity is unclear. Delays in symptom recognition and anaphylaxis treatment have been associated with more severe outcomes. An absence of prior anaphylaxis does not exclude its future risk.

Sesame-induced anaphylaxis in pediatric patients from the cross-Canada anaphylaxis registry

BACKGROUND

Sesame can cause severe allergic reactions and is a priority allergen in Canada.

OBJECTIVE

To assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment.

METHODS

Between 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages.

RESULTS

Of all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02).

CONCLUSION

In Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities.

Comprehensive Review on Banana Fruit Allergy: Pathogenesis, Diagnosis, Management, and Potential Modification of Allergens through Food Processing

The pulp of the banana fruit is rich in bioactive compounds like dietary fibers, low glycemic carbohydrates, natural sugars, vitamins, minerals and antioxidants. These beneficial compounds are responsible for the proper functioning of immune system and enhance prevention against various deadly diseases like cancer, diabetes and heart diseases. Despite having, positive effects, the fruit are recognized as an important source for causing allergy to 0.6% of people in general population and up to 67 and 46% for people with asthma or atopic dermatitis. Fruit allergy is one of the most common food allergies witnessed worldwide. Banana fruit allergy results from the abnormal immune response to the banana proteins soon after its consumption. Symptoms range from oral allergy syndrome (OAS) to the life-threatening anaphylaxis. IgE reactivity of banana is associated with different proteins of which six proteins have been identified as major allergens, viz., Mus a1 (Profilin-actin binding protein), Mus a 2 (Class 1 chitinase), Mus a 3 (Nonspecific lipid transfer protein), Mus a 4 (Thaumatin like protein), Mus a 5 (Beta 1,3 glucanase) and Mus a 6 (Ascorbate peroxidase). This review focuses on pathogenesis, clinical features, diagnosis, and different food processing methods to mitigate the allergenicity of banana fruit.

Anaphylaxis in Chinese Children with Pollen Sensitization: Triggers, Clinical Presentation, and Acute Management

Purpose

Pollen sensitization is increasing in children. However, there is little evidence regarding the characteristics of anaphylaxis in individuals with pollen sensitization.

Patients and Methods

We conducted a retrospective study of patients with anaphylaxis combined with pollen sensitization who attended an allergy department in a tertiary children’s hospital from 2014 to 2021.

Results

A total of 157 anaphylaxis events in 108 patients were analyzed; the mean age at the reaction was 5.8 ± 4.17 years. A total of 99.1% (107/108) of the patients came from northern China. The most common sensitizing pollen was mugwort (93.5%,101/108), followed by ragweed (68.5%, 74/108) and birch (40.7%, 44/108). A total of 76.9% (83/108) of the patients showed polysensitization to pollen. Allergic rhinitis/conjunctivitis was the most common comorbidity (87.0%, 94/108). Children with severe anaphylaxis were more likely to have a history of recurrent urticaria (16.1% vs 3.9%, p = 0.028). The most frequently implicated foods were fruits/vegetables (22.3%, 35/157), followed by wheat (8.9%, 14/157) and milk (8.3%, 13/157), and the most common fruit allergen was peach (n = 7). Of 14% (22/157) exercise-induced reactions, 63.6% (14/22) occurred in pollen season. Skin symptoms were the most frequent (86.0%, 135/157) symptoms, followed by respiratory (73.9%, 116/157) and gastrointestinal (21%, 33/157) symptoms. Regarding acute management, only 7.4% of the patients were treated with epinephrine.

Conclusion

Our findings revealed the characteristics of anaphylaxis in children with pollen sensitization. Fruits/vegetables accounted for a substantial percentage of anaphylaxis triggers. The suboptimal use of epinephrine highlights the need for educational programs promoting the use of epinephrine.

Economic burden of food allergy in Canada: Estimating costs and identifying determinants

BACKGROUND

Limited data exist on the economic burden of food allergy (FA).

OBJECTIVE

To assess FA-related direct (healthcare and out-of-pocket) and indirect (lost productivity) costs and their determinants in Canadian children and adults self-reporting FA.

METHODS

FA-individuals self-reporting a convincing history or physician diagnosis were recruited through FA registries, an anaphylaxis registry, and advocacy associations, and electronically surveyed regarding FA-related healthcare use, out-of-pocket expenditures, and time lost from paid and unpaid labor. Direct and indirect costs (2020 Canadian dollars [CAD]) were stratified on severe reaction vs mild, moderate or no reaction, and children vs adults; multivariate regressions assessed the association between costs and sociodemographic and disease characteristics.

RESULTS

Between May 2018 and July 2019, 2692 eligible individuals responded (2189 convincing history and 503 physician diagnosis only); 1020 experienced a severe reaction; 1752 were children. Per FA-individual, annual healthcare, out-of-pocket, and indirect costs were $1267, $2136, and $7950. Those with a severe reaction had higher healthcare and out-of-pocket costs than those with mild, moderate or no reaction. FA-children vs FA-adults had higher healthcare and out-of-pocket costs, and lower indirect costs. Multivariate results showed that lower age, a severe reaction ever, multiple FAs, and fair or poor general health were associated with higher healthcare and out-of-pocket costs. Higher age, lower household education and income, and fair or poor general health were associated with higher indirect costs.

CONCLUSION

The economic burden of FA in Canada is substantial, particularly for those with a severe reaction ever, multiple FAs, and fair or poor general health. It is crucial that those most adversely affected are allocated appropriate resources to support disease management.

Natural immunomodulating substances used for alleviating food allergy

Food allergy is a serious health problem affecting more than 10% of the human population worldwide. Medical treatments for food allergy remain limited because immune therapy is risky and costly, and anti-allergic drugs have many harmful side effects and can cause drug dependence. In this paper, we review natural bioactive substances capable of alleviating food allergy. The sources of the anti-allergic substances reviewed include plants, animals, and microbes, and the types of substances include polysaccharides, oligosaccharides, polyphenols, phycocyanin, polyunsaturated fatty acids, flavonoids, terpenoids, quinones, alkaloids, phenylpropanoids, and probiotics. We describe five mechanisms involved in anti-allergic activities, including binding with epitopes located in allergens, affecting the gut microbiota, influencing intestinal epithelial cells, altering antigen presentation and T cell differentiation, and inhibiting the degranulation of effector cells. In the discussion, we present the limitations of existing researches as well as promising advances in the development of anti-allergic foods and/or immunomodulating food ingredients that can effectively prevent or alleviate food allergy. This review provides a reference for further research on anti-allergic materials and their hyposensitizing mechanisms.