Wheat Anaphylaxis in Adults Differs from Reactions to Other Types of Food

AAAAI-EAACI PRACTALL: Standardizing oral food challenges-2024 Update

This common statement of the American Academy of Allergy, Asthma and Immunology (AAAAI) and The European Academy of Allergy and Clinical Immunology (EAACI) provides an update of the 2012 published guidelines on food challenges. The guidelines equally address food challenges in the research and the clinical settings. They first address the diagnostic tests which can guide the decision to conduct a challenge. Safety of food challenges is prime, and the various procedures and safety issues as well as medications potentially involved in challenges are extensively discussed. Challenges are suggested to be conducted with semi-logarithmic incremental doses based on the protein content, typically for IgE-mediated food allergy with intervals of 20-30 min between doses. Specific protocols for other types of reactions such atopic dermatitis or gastrointestinal food allergy are detailed separately. Proper stopping criteria are essential in order to reduce the risk of false-positive diagnoses, but also severe reactions. The guidelines recommend criteria based on "go on," "stop," or "observation." These revised guidelines will clearly provide much needed guidance for food challenges in the research and clinical settings. They will continue to evolve with new diagnostic tests or new needs in the field of food allergy.

A case report of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab

Food-dependent exercise-induced anaphylaxis (FDEIA) is a rare and complex clinical condition in which allergic reactions are triggered by specific foods combined with physical activity, even though the food allergen and exercise are tolerated individually. Wheat is the most common culprit food leading to wheat dependent exercise induced anaphylaxis (WDEIA). Management of FDEIA is challenging due to the unpredictability of attacks and the lack of approved prophylactic medications. This report presents a case of successful symptom control in a young woman with WDEIA through the addition of omalizumab to the treatment regimen. To our knowledge, this is the first reported case of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab as the primary indication. We also summarize the pathophysiology, diagnosis and treatment of FDEIA. The need for heightened awareness and innovative therapeutic approaches is crucial for those affected by FDEIA.

Food-triggered anaphylaxis in adults

PURPOSE OF REVIEW

Adult food allergy, either unresolved from childhood, or new-onset in adult-life, is known to be increasingly prevalent. Although much of the reported anaphylaxis in adults is due to drug reactions, foods are becoming an increasingly important trigger, affecting adults of all ages, with a wide variation in food triggers which are often quite different to those reported in children.

RECENT FINDINGS

Peanuts are well known to cause anaphylaxis in some adult populations, but other legumes such as soy may be more relevant in others. Reactions to natto, fermented soybeans, are currently mainly reported in Japan, but changing dietary practices and an increase in plant-based eating mean natto, other forms of soy and other legumes are increasingly linked to anaphylaxis in Western countries. Anaphylaxis to red meat, caused by sensitization to galactose-α-1,3-galactose and first reported in North America, is now a more world-wide concern. Co-factor induced anaphylaxis is increasingly associated with both wheat allergy and lipid transfer protein allergy.

SUMMARY

More research is urgently needed to characterize adult food allergy, its triggers and symptom severity. Unusual food triggers and potential co-factors should be considered, so that anaphylaxis in adults can be correctly managed, not merely labelled as idiopathic.

Test Panel of Hidden Allergens for "Idiopathic Anaphylaxis" Reveals Wheat Allergy Dependent on Augmentation Factors as Common Final Diagnosis

BACKGROUND

Idiopathic anaphylaxis (IA) is an unresolved concern. Hidden allergens may be relevant in IA and in nonsteroidal anti-inflammatory drug hypersensitivity (NSAID-HS).

OBJECTIVE

To identify hidden elicitors for IA and NSAID-HS by a skin prick test (SPT) (13 allergens) and allergen-specific IgE (sIgE) panel (12 allergens) and to determine the value of each tested allergen.

METHODS

We retrospectively included all patients from 2018 to 2021 referred with a suspicion of IA or NSAID-HS by history in whom SPT and/or sIgE to allergens of the IA panel were performed. Patient characteristics from patients' records included comorbidities, history and symptoms of anaphylaxis, serum baseline tryptase level, total IgE level, SPT, sIgE, challenge results, and final diagnoses.

RESULTS

A total of 134 patients (77 female, mean age 39.7 ± 14.6 years) were included. Median serum baseline tryptase and total IgE levels were 4.23 μg/L and 133.5 kU/L, respectively. Allergologic workup with the IA panel resulted in positive SPT and sIgE in 61 (47%) and 66 (60%) patients, respectively. In those, confirmation or exclusion of allergy, mostly by challenge, led to a definitive diagnosis in 61 of 134 patients (46%). Skin prick test was most frequently positive to gluten (22.4%) and sIgE to ω5-gliadin (21.6%), which correlated with the history (r = 0.310, P < .001; and r = 0.407, P < .001, respectively). In 28 of 134 patients (21%) with initially suspected IA or NSAID-HS, challenges confirmed occult food allergy in which wheat allergy dependent on augmentation factors was the most frequent cause of anaphylaxis (19%).

CONCLUSIONS

Wheat allergy dependent on augmentation factors should be considered in all patients with anaphylaxis of unknown cause or after NSAID intake.

The top 100 most cited articles in the past 30 years of wheat allergy: a bibliometric analysis

Background

Wheat allergy (WA), characterized by immunological responses to wheat proteins, is a gluten-related disorder that has become increasingly recognized in recent years. Bibliometrics involves the quantitative assessment of publications within a specific academic domain.

Objectives

We aimed to execute an extensive bibliometric study, focusing on the past 30 years of literature related to wheat allergy.

Methods

We searched the Web of Science database on 5th Dec 2023. We used the keywords "wheat allergy or wheat anaphylaxis or wheat hypersensitivity," "gliadin allergy or gliadin anaphylaxis or gliadin hypersensitivity," "wheat-dependent exercise-induced anaphylaxis," and "baker's asthma" for our search. All items published between 1993 and 2023 were included. The top 100 most cited articles were identified and analyzed.

Results

Our study conducted an in-depth bibliometric analysis of the 100 most-cited articles in the field of wheat allergy, published between 2002 and 2019. These articles originated from 20 different countries, predominantly Japan and Germany. The majority of these articles were centered on the pathogenesis and treatment of wheat allergy (WA). The Journal of Allergy and Clinical Immunology (JACI) was the most prolific contributor to this list, publishing 14 articles. The article with the highest citation count was published by Biomed Central (BMC) and garnered 748 citations. The peak citation year was 2015, with a total of 774 citations, while the years 1998, 2001, and 2005 saw the highest publication frequency, each with 7 articles.

Conclusion

Our study aims to provide physicians and researchers with a historical perspective for the scientific progress of wheat allergy, and help clinicians effectively obtain useful articles that have a significant impact on the field of wheat allergy.

Detection of Sensitization Profiles with Cellular In Vitro Tests in Wheat Allergy Dependent on Augmentation Factors (WALDA)

Wheat allergy dependent on augmentation factors (WALDA) is the most common gluten allergy in adults. IgE-mediated sensitizations are directed towards ω5-gliadin but also to other wheat allergens. The value of the different in vitro cellular tests, namely the basophil activation test (BAT) and the active (aBHRA) and passive basophil histamine-release assays (pBHRA), in the detection of sensitization profiles beyond ω5-gliadin has not been compared. Therefore, 13 patients with challenge-confirmed, ω5-gliadin-positive WALDA and 11 healthy controls were enrolled. Specific IgE (sIgE), skin prick tests, BATs, aBHRA, and pBHRA were performed with allergen test solutions derived from wheat and other cereals, and results were analyzed and compared. This study reveals a distinct and highly individual reactivity of ω5-gliadin-positive WALDA patients to a range of wheat allergens beyond ω5-gliadin in cellular in vitro tests and SPT. In the BAT, for all tested allergens (gluten, high-molecular-weight glutenin subunits, α-amylase/trypsin inhibitors (ATIs), alcohol-free wheat beer, hydrolyzed wheat proteins (HWPs), rye gluten and secalins), basophil activation in patients was significantly higher than in controls (p = 0.004-p < 0.001). Similarly, significant histamine release was detected in the aBHRA for all test substances, exceeding the cut-off of 10 ng/mL in all tested allergens in 50% of patients. The dependency of tests on sIgE levels against ω5-gliadin differed; in the pBHRA, histamine release to any test substances could only be detected in patients with sIgE against ω5-gliadin ≥ 7.7 kU/L, whereas aBHRA also showed high reactivity in less sensitized patients. In most patients, reactivity to HWPs, ATIs, and rye allergens was observed. Additionally, alcohol-free wheat beer was first described as a promising test substance in ω5-gliadin-positive WALDA. Thus, BAT and aBHRA are valuable tools for the identification of sensitization profiles in WALDA.

Food-Dependent Exercise-Induced Anaphylaxis: A Distinct Form of Food Allergy-An Updated Review of Diagnostic Approaches and Treatments

Food-dependent exercise-induced allergic reactions (FDEIA) represent a distinct clinical phenomenon where symptoms arise during exercise following the consumption of specific trigger foods, with the most severe manifestation being anaphylaxis-a condition distinct from typical exercise-induced or food-induced anaphylaxis. In FDEIA, patients can either exercise or tolerate specific foods separately without experiencing any allergic reactions. Diagnosis relies on patient history and provocation testing, requiring rigorous implementation within a supervised hospital environment. Positive symptoms and clinical signs during testing confirm FDEIA, while negative outcomes do not preclude its presence. Exercise stands as the primary trigger, followed by nonsteroidal anti-inflammatory drugs (NSAIDs) and alcohol. The utilization of various protocols for food cofactor challenges to confirm FDEIA yields differing diagnostic outcomes. We highlight the updated concept of food cofactor challenges, incorporating protocols reported in the literature, and summarize current recommendations and comprehensive management approaches for FDEIA patients.

Challenge-confirmed diagnosis restores quality of life in cofactor-dependent wheat allergy

BACKGROUND

Food allergies including cofactor-dependent allergies such as cofactor-dependent wheat allergy (CDWA) decrease the quality of life (QOL) of patients.

OBJECTIVE

To define the health-related QOL and fears in patients with CDWA and to evaluate the impact of diagnosis confirmation by oral challenge test (OCT).

METHODS

Patients with CDWA diagnosed by clinical history, sensitization, and OCT were invited to participate. Clinical characteristics, patients' fears, self-perceived overall QOL, the Food Allergy Quality of Life Questionnaire-Adult Form score, and the risks and benefits of OCT were evaluated after the final diagnosis.

RESULTS

A total of 22 adults with CDWA (13 male, 9 female; mean age 53.5 years; median 5 years until diagnosis) were included. Specific immunoglobulin E (IgE) levels for gluten proteins were inversely correlated with the reaction threshold (P < .05). Higher reaction severity in the patients' histories correlated with increased basal serum tryptase levels (P = .003) and gluten and gliadin specific IgE (P < .05), but not to QOL. After the first allergic reaction, patients reported a drop in QOL (P < .001). Challenge-confirmed diagnosis and medical consultation could restore the patients' QOL (P < .05) and reduce their fear of further reactions (P < .01). No severe reactions occurred during OCT, which was rated as not stressful and highly beneficial. Compared with patients with CDWA diagnosed without OCT in the literature, health-related QOL was less impaired (mean Food Allergy Quality of Life Questionnaire-Adult Form score 3.8), especially regarding the emotional impact (P < .001 vs existing literature).

CONCLUSION

Until final diagnosis, patients with CDWA have a severe physical and psychological burden. OCT is a safe method to confirm the diagnosis, restore the patients' severely affected QOL, and reduce their fear of further reactions.

Wheat-dependent exercise-induced anaphylaxis: Subtypen, Diagnostik und Management

Die wheat‐dependent exercise‐induced anaphylaxis (Anstrengungs‐getriggerte Weizenallergie, WDEIA) ist eine IgE‐vermittelte Nahrungsmittelallergie, bei der es nur zu allergischen Symptomen kommt – welche von intermittierender Urtikaria bis hin zu schweren Anaphylaxien reichen können –, wenn Weizen im zeitlichen Zusammenhang mit verstärkenden Kofaktoren wie körperlicher Bewegung, nichtsteroidalen Antirheumatika oder Alkohol verzehrt wird. In den meisten Fällen weisen die Patienten eine Sensibilisierung auf ω5‐Gliadin in der Glutenfraktion des Weizens auf. ω5‐Gliadin‐negative Subtypen der WDEIA sind oft schwierig zu diagnostizieren und können durch Tri a 14 (Weizen‐Lipid‐Transferprotein), durch perkutane Sensibilisierung mit hydrolysierten Weizenproteinen oder, in seltenen Fällen, durch eine Gräserpollenkreuzreaktivität verursacht werden. Die Diagnose wird anhand der Anamnese in Kombination mit dem serologischen IgE‐Profil, Hauttests, Basophilenaktivierungstests und einer Provokationstestung mit Weizengluten und Kofaktoren gestellt. Die individuelle Ernährungsberatung ist nach wie vor die zentrale Säule im Management von Patienten mit WDEIA. Eine komplett weizenfreie Diät stellt eine mögliche Option dar, jedoch scheint diese die Toleranz weniger zu fördern als der weitergeführte regelmäßige Verzehr glutenhaltiger Getreidesorten, dieses allerdings nur bei gleichzeitiger Meidung von Kofaktoren. Alle Patienten sollten ein Notfallset zur Selbstbehandlung inklusive einem Adrenalin‐Autoinjektor erhalten und entsprechend geschult werden. Zur sublingualen Immuntherapie bei WDEIA, einer potenziell vielversprechenden therapeutischen Perspektive, werden weitere Daten benötigt. Dieser Artikel gibt einen Überblick über den aktuellen Wissensstand zur Diagnostik und zum Management bei WDEIA, einschließlich eines optimierten Provokationsprotokolls mit Weizengluten und Kofaktoren.

Wheat-dependent exercise-induced anaphylaxis: subtypes, diagnosis, and management

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is an IgE-mediated food allergy with allergic symptoms ranging from intermittent urticaria to severe anaphylaxis that occurs when wheat ingestion is combined with augmenting cofactors such as exercise, non-steroidal anti-inflammatory drugs, or alcohol. In most cases, patients are identified by sensitization to ω5-gliadins in the gluten fraction of wheat. ω5-gliadin-negative subtypes of WDEIA are often difficult to diagnose and may be caused by Tri a 14 (wheat lipid transfer protein), after percutaneous sensitization with hydrolyzed wheat proteins, or, in rare cases, by cross-reactivity to grass pollen. Diagnosis is established based on the patients' history in combination with serum IgE profile, skin testing, basophil activation tests, and challenge tests with cofactors. Individual dietary counselling remains the central pillar in the management of WDEIA patients. A completely wheat-free diet is a possible option. However, this appears to promote tolerance less than continued regular consumption of gluten-containing cereals in the absence of cofactors. All patients should have an emergency set for self-treatment including an adrenaline autoinjector and receive adequate instruction. More data are needed on sublingual immunotherapy for WDEIA, a potentially promising therapeutic prospect. This article provides an overview of current knowledge on the diagnosis and management of WDEIA including an optimized challenge protocol using wheat gluten and cofactors.

Food-Induced Anaphylaxis: Data From the European Anaphylaxis Registry

BACKGROUND

Food is one of the most common elicitors of anaphylaxis, with an increasing incidence over recent years.

OBJECTIVES

To characterize elicitor-specific phenotypes and identify factors enhancing the risk or severity of food-induced anaphylaxis (FIA).

METHODS

We analyzed data from the European Anaphylaxis Registry applying an age- and sex-matched analysis of associations (Cramer's V) for single food triggers and calculated odds ratios (ORs) for severe FIA.

RESULTS

We identified 3,427 cases of confirmed FIA showing an age-dependent elicitor ranking (for children: peanut, cow's milk, cashew, and hen's egg; and for adults: wheat flour, shellfish, hazelnut, and soy). The age- and sex-matched analysis revealed defined symptom patterns for wheat and cashew. Wheat-induced anaphylaxis was more frequently associated with cardiovascular symptoms (75.7%; Cramer's V = 0.28) and cashew-induced anaphylaxis with gastrointestinal symptoms (73.9%; Cramer's V = 0.20). Furthermore, concomitant atopic dermatitis was slightly associated with anaphylaxis to hen's egg (Cramer's V = 0.19) and exercise was strongly associated with anaphylaxis to wheat (Cramer's V = 0.56). Additional factors influencing the severity were alcohol intake in wheat anaphylaxis (OR = 3.23; CI, 1.31-8.83) and exercise in peanut anaphylaxis (OR = 1.78; CI, 1.09-2.95).

CONCLUSIONS

Our data show that FIA is age-dependent. In adults, the range of elicitors inducing FIA is broader. For some elicitors, the severity of FIA seems to be related to the elicitor. These data require confirmation in future studies considering a clear differentiation between augmentation and risk factors in FIA.

Case report-wheat-dependent exercise-induced anaphylaxis in a patient with chronic spontaneous urticaria: A diagnostic challenge

Wheat-dependent exercise-induced anaphylaxis is a rare but severe form of anaphylaxis that occurs after consuming wheat products and engaging in physical activity. A case study of a 30-year-old woman suffering from chronic urticaria for the last 5 years highlights the difficulty in diagnosing this condition, as specific triggers were not identified. A diagnostic study called MADx revealed a positive analysis for omega-5-gliadin, leading to a diagnosis of wheat-dependent exercise-induced anaphylaxis. Delayed diagnosis is a common issue, and it can be challenging to distinguish wheat-dependent exercise-induced anaphylaxis from other conditions with similar symptoms. The treatment involves avoiding wheat products and always carrying an epinephrine auto-injector. When evaluating patients with similar symptoms, healthcare providers should include wheat-dependent exercise-induced anaphylaxis in their differential diagnosis. Patients should be educated about the symptoms, triggers, and management to seek immediate medical attention in an emergency.

Clinical profiles of patients with wheat-induced anaphylaxis at various ages of onset

Background

Wheat-induced anaphylaxis (WIA) is a serious and potentially life-threatening wheat allergy, more common in adults than in children. Little is known about the differences in clinical profiles in WIA among patients of various ages in China.

Methods

We analyzed data retrospectively from an allergy department in a tertiary hospital that included 248 patients (208 adults and 40 children and adolescents) with a history of WIA.

Results

We found that alcohol was more frequent in patients aged ≥50 years [older adults] (19.0%, 4/21) than in those aged 12-17 years [adolescents] (0%, 0/33; p = 0.019). The frequency of NSAID use in older adults (42.9%, 9/21) was significantly higher than that in adolescents (0%, 0/33; p < 0.001), and patients aged 18-49 years [young adults] (2.8%, 5/178; p < 0.001). During WIA, cardiovascular symptoms in children were less frequent than those in other age groups (children, 28.6%; adolescents, 87.9%; young adults, 93.0%; older adults, 95.2%; p < 0.001). The consciousness loss rate in adults (both age groups; p < 0.001) and the hypotension rate in older adults (p = 0.006) were higher than those in other age groups. Compared with adults (young and older adults), children had a higher rate of allergic comorbidities (p = 0.004, 0.001, respectively) and a higher rate of other food allergies (p < 0.001, <0.001, respectively). Compared with the mild-to-moderate anaphylaxis group, the severe anaphylaxis group had a higher onset age (p = 0.001), higher cofactor prevalence (p = 0.004), lower allergic comorbidity rate (p = 0.014), and higher positive rate of specific IgE to omega-5 gliadin (ω-5 gliadin) (p = 0.023).

Conclusion

Clinical profiles of patients with WIA are different among various onset age/severity groups. An improved understanding of WIA symptoms in various age/severity groups could help accelerate diagnosis, suggest preventive measures, and contribute to improved patient care.

A Meta-Analysis of the Prevalence of Wheat Allergy Worldwide

Wheat allergy is a primary disease of food allergy, and its global prevalence is unclear. This study aimed to characterize the latest worldwide prevalence of wheat allergy based on five different diagnostic methods. Study searches were conducted in Web of Science, PubMed, Ovid LWW, and Cochrane database, with a time limit of 1 January 2007 to 1 September 2022. The review and screening of the articles was undertaken by two independent reviewers. The statistical analysis was conducted by R. A total of 56 articles were finally included. The prevalence of wheat allergy was 0.63% (95% CI: 0.43-0.87%) for self-reported, 0.70% (95% CI: 0.18-1.22%) for self-reported physician-diagnosed, 0.22% (95%CI: 0.07-0.65%) for skin prick test positive, 0.97% (95% CI: 0.43-2.20%) for specific immunoglobulin E positive, and 0.04% (95% CI: 0-0.16%) for food challenge. However, food challenge can be largely subjective, and the results were only based two countries, so the prevalence of wheat allergy confirmed by food challenge may be not entirely trustworthy. In conclusion, investigating the prevalence of wheat allergy in the real world as accurately as possible will contribute to the prevention, management, and risk assessment of wheat allergy.

Cow's milk and hen's egg anaphylaxis: A comprehensive data analysis from the European Anaphylaxis Registry

BACKGROUND

Cow's milk (CM) and hen's egg (HE) are leading triggers of anaphylaxis in early childhood. The aim of this study was to identify clinical phenotypes and therapeutic measures for CM anaphylaxis (CMA) compared to HE anaphylaxis (HEA) in children up to 12 years of age, based on a large pan-European dataset from the European Anaphylaxis Registry.

METHODS

Data from 2007 to 2020 on clinical phenotypes and treatment from 10 European countries, as well as Brazil, were analysed. The two-step cluster analysis was used to identify the most frequent phenotypes. For each trigger, three clusters were extracted based on sex, age, and existence of symptoms in four vitally important systems.

RESULTS

Altogether 284 children with CMA and 200 children with HEA were identified. They were characterised as male (69% vs. 64%), infants (65% vs. 61%), with a most frequent grade III of Ring&Messmer classification (62% vs. 64%), in CMA versus HEA, respectively. Respiratory symptoms occurred more often in CMA (91% vs. 83%, p = 0.010), especially in infants (89% vs. 79%, p = 0.008). Cardiovascular symptoms were less frequent in CMA (30% vs. 44%, p = 0.002), in both infants (33% vs. 46%, p = 0.027), and older children (25% vs. 42%, p = 0.021). The clusters extracted in the CMA group were characterised as: (1) mild dermal infants with severe GI (40%), 2. severe dermal (35%), 3. respiratory (25%). While in HEA group: 1. infants with severe GI and/or reduction of alertness (40%), (2) conjunctival (16%), (3) mild GI without conjunctivitis (44%). The severity of the reaction was independent from the amount of ingested allergen protein, regardless of trigger. The first-line adrenaline application differed between the countries (0%-92%, as well as the reasons for not administering adrenaline, p < 0.001).

CONCLUSIONS

Despite the similarity of their age, sex, and severity grade, the clinical profiles differed between the CMA and HEA children. Adrenaline was underused, and its administration was country dependent. Further studies are needed to assess to what extent the differences in the clinical profiles are related to matrix and/or absorption effects, and/or the allergen itself.

Idiopathic Anaphylaxis? Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland

The most common causes of anaphylaxis, according to various authors and depending on the age of the studied groups, are: Hymenoptera venom, food, and medications. Unfortunately, we are not always able to indicate the cause of anaphylaxis. There are data in the literature where as many as 41% of all cases are idiopathic anaphylaxis. Since the introduction of new diagnostic methods such as molecular diagnostics (MD) in our centre, the percentage of idiopathic anaphylaxis in the Anaphylaxis Register has significantly decreased. The purpose of this study was to identify possible causes of idiopathic anaphylaxis in patients with a history of moderate to severe anaphylactic reactions. After using MD, the causative agent was found in another 29 people. The proportion of people with idiopathic anaphylaxis in the Registry decreased from 9.2% to 3.5%. There were no significant differences in the incidence, although men appear to be slightly more common in primary idiopathic anaphylaxis. The mean age of primary idiopathic anaphylaxis was 40 years, but this was as high as 51 for anaphylaxis with alpha-gal allergy. Exercise may or may not be present as a cofactor despite its established role, e.g., in wheat-dependent exercise-induced anaphylaxis (WDEIA). In most of the analyzed cases, i.e., 70%, the reaction took place within an hour. The longest time interval from exposure to the development of symptoms is in the case of alpha-gal allergy; in this analysis, it was at least 5 h after ingestion of the so-called "red meat". Patients are not aware of the disease, or further attacks cannot be prevented. As many as 80% had idiopathic anaphylaxis prior to visiting the centre, and 80% developed anaphylaxis after visiting the centre, which emphasizes the need to not stop the medical team in their search for the causes. As many as 93% of cases required medical intervention, of which adrenaline was used only in 34.5%, antihistamines in 86%, systemic glucocorticosteroids (sCS) in 75%, and fluids in 62% of cases. A total of 83% of patients received an emergency kit for self-administration. Idiopathic anaphylaxis can be resolved as known-cause anaphylaxis after a thorough medical history and, if possible, without exposing the patient after using appropriate, modern in vitro diagnostic methods, including molecular diagnostics. The diagnosis of idiopathic anaphylaxis should extend the diagnosis to include alpha-gal syndrome, LTP syndrome and WDEIA.

Optimization of a novel, gluten-free bread's formulation based on chickpea, carob and rice flours using response surface design

This study aimed to develop nutritious, gluten-free bread with high quality characteristics using a mixture of chickpea, carob and rice flours as substitutes of wheat flour. To optimize the bread formulation, a Box-Behnken experimental design was conducted to evaluate the effect of the corresponding flour blend addition, proofing time and water amount addition on the physicochemical, technological and sensory properties of the obtained formulated bread. The optimized formulation was calculated to contain 70% of mixture flour and 100% of water, with a proofing time of 40 minutes. This formulation produced bread with greater specific volume ( 3.73 ± 0.37 cm3/g) and less baking loss ( 22.98 ± 0.94 % ) than those of control (+) bread ( 2.93 ± 0.21 cm3/g and 31.65 ± 0.72 % , respectively). Findings proved that the mixture flour based on chickpeas, carob and rice represents a good alternative to make gluten-free bread with acceptable baking properties.

Elicitors and phenotypes of adult patients with proven IgE-mediated food allergy and non-immune-mediated food hypersensitivity to food additives

BACKGROUND

Food allergy is a growing health concern with a prevalence of 2%-3% in the adult population in Europe. Non-immune-mediated food hypersensitivities, which include reactions after ingestion of food additives, affect 1% of adults and may resemble IgE-induced allergic reactions without identifiable immunologic sensitization. A double-blind placebo-controlled food challenge (DBPCFC) is the gold standard for the diagnosis of any food hypersensitivity.

OBJECTIVE

We analysed a large group of adult patients with suspected food hypersensitivity, who had undergone DBPCFC, to better understand IgE-mediated food allergy and non-immune-dependent food hypersensitivity to food additives in adults regarding elicitors, symptoms and positivity rates of oral challenges.

METHODS

Data from 541 patients with suspected food hypersensitivity were analysed, who underwent an oral food challenge between 2010 and 2019.

RESULTS

IgE-dependent food allergy was confirmed in 114 of 329 adult patients (34.6%). The confirmation rate was lower in the group of patients with suspected non-immune-mediated reactions to food additives (65 of 286, 22.7%). Urticaria and angioedema appeared more frequently in patients with IgE-mediated food allergies. By contrast, flush and diarrhoea were the most frequent symptoms after a challenge in the group with the non-immune-mediated reactions to food additives. Wheat and celery were the most frequently identified food allergens in adults, whereas colourings and preservatives were the most frequent elicitors of non-immune-mediated food hypersensitivity.

CONCLUSION

The importance of oral food challenges for the diagnosis of food hypersensitivity is confirmed. IgE-dependent food allergy is more frequently proven, reaching a positivity rate of one-third and only about 20% for non-immune-mediated hypersensitivity. Future studies should elaborate on the mechanisms of non-immune-mediated food hypersensitivity and the clinical impact of cofactors in this setting.

Safety Assessment of Foods and Drinks Consumed by People on a Gluten-Free Diet

Naturally gluten-free foods and processed foods that do not contain information about the potential presence of gluten in them pose a hypothetical threat to people with food allergies and celiac disease. Patients who should follow a strict gluten-free diet do not always do so. Therefore, the aim of this research was to analyze certified “gluten-free” and naturally gluten-free products without labeled “may contain gluten” information in terms of their content of gluten proteins. The enzyme immunoassay AgraQuant Gluten G12 ELISA test kit was used for the analysis. Of all the products used in the research, only 5.8% were found to contain gluten above 20 ppm. Only one product labeled “gluten-free” was contaminated with gluten at 79.3 ppm (cider cake). In addition, our research also examined the gluten content of commercial beers containing barley malt not labeled as “gluten-free”. Research has shown that 60% of samples are not safe for those on a strict gluten-free diet. Our research clearly shows that many manufacturers, although they do not monitor their products for the presence of gluten in them, offer safe products, although they cannot be recommended in a gluten-free diet. Therefore, there is a strong need to increase the frequency of testing by food manufacturers for the presence of gluten in their products, so that the number of products approved for people on a gluten-free diet continues to increase.

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.

Clinical features and outcomes of patients with wheat-dependent exercise-induced anaphylaxis: a retrospective study

Background

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a serious and potentially life-threatening form of wheat allergy. Further episodes can only be prevented by avoiding wheat ingestion or avoiding exercise after wheat intake. Anaphylaxis may recur in some patients post-diagnosis. This study aimed to analyze the clinical features and management/outcomes of WDEIA in China.

Methods

We retrospectively analyzed the clinical characteristics, and laboratory testing of 197 patients with WDEIA. After diagnosis, the patients were followed up as outpatients to evaluate dietary/exercise choice and clinical outcomes.

Results

Among the 197 WDEIA patients (median age, 37 years), 53.8% were male and 28.4% had other allergic disorders. The median duration of anaphylaxis before diagnosis was 16 months. Significant delays in diagnosis (> 1 years) were recorded in 52.7% of the patients, which has not decreased by years (P = 0.064). Exercise (83.8%), alcohol (12.2%), and nonsteroidal anti-inflammatory drugs (7.1%) were the most common cofactors. The most common clinical features were urticaria (100%), loss of consciousness (82.7%), dyspnea (50.8%), and hypotension (47.2%). Of the 197 eligible patients, 155 responded (78.7%), and 124 (80.0%) of which had no anaphylaxis post-diagnosis. A wheat-free diet prevented future anaphylaxis in 91.7% of the patients, followed by the avoidance of wheat combined with exercise (87%) and reduced wheat intake combined with exercise avoidance (80.5%).

Conclusion

The diagnosis of WDEIA is frequently delayed. Therefore, when patients present with unexplained anaphylaxis, the possibility of WDEIA should be considered. A wheat-free diet or avoiding wheat combined with exercise or reduced wheat combined with exercise avoidance helps to significantly reduce the onset of future anaphylaxis. However, approximately one-fifth of patients continue to experience anaphylaxis post-diagnosis. Thus, these patients must always carry epinephrine autoinjectors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13223-022-00702-1.

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.

Effective Use of Plant Proteins for the Development of "New" Foods

Diversity in our diet mirrors modern society. Affluent lifestyles and extended longevity have caused the prevalence of diabetes and sarcopenia, which has led to the increased demand of low-carb, high-protein foods. Expansion of the global population and Westernization of Asian diets have surged the number of meat eaters, which has eventually disrupted the supply–demand balance of meat. In contrast, some people do not eat meat for religious reasons or due to veganism. With these multiple circumstances, our society has begun to resort to obtaining protein from plant sources rather than animal origins. This “protein shift” urges food researchers to develop high-quality foods based on plant proteins. Meanwhile, patients with food allergies, especially gluten-related ones, are reported to be increasing. Additionally, growing popularity of the gluten-free diet demands development of foods without using ingredients of wheat origin. Besides, consumers prefer “clean-label” products in which products are expected to contain fewer artificial compounds. These diversified demands on foods have spurred the development of “new” foods in view of food-processing technologies as well as selection of the primary ingredients. In this short review, examples of foodstuffs that have achieved tremendous recent progress are introduced: effective use of plant protein realized low-carb, high protein, gluten-free bread/pasta. Basic manufacturing principles of plant-based vegan cheese have also been established. We will also discuss on the strategy of effective development of new foods in view of the better communication with consumers as well as efficient use of plant proteins.

MRGPRX2-Mediated Degranulation of Human Skin Mast Cells Requires the Operation of Gαi, Gαq, Ca++ Channels, ERK1/2 and PI3K—Interconnection between Early and Late Signaling

The recent discovery of MRGPRX2 explains mast cell (MC)-dependent symptoms independently of FcεRI-activation. Because of its novelty, signaling cascades triggered by MRGPRX2 are rudimentarily understood, especially in cutaneous MCs, by which MRGPRX2 is chiefly expressed. Here, MCs purified from human skin were used following preculture or ex vivo and stimulated by FcεRI-aggregation or MRGPRX2 agonists (compound 48/80, Substance P) in the presence/absence of inhibitors. Degranulation was assessed by β-hexosaminidase or histamine release. Phosphorylation events were studied by immunoblotting. As a G protein-coupled receptor, MRGPRX2 signals by activating G proteins; however, their nature has remained controversial. In skin MCs, G_αi and G_αq were required for degranulation, but G_αi was clearly more relevant. Ca++ channels were likewise crucial. Downstream, PI3K was essential for granule discharge initiated by MRGPRX2 or FcεRI. ERK1/2 and JNK were additional participants, especially in the allergic route. Addressing possible points of intersection between early and later events, pERK1/2 and pAKT were found to depend on G_αi, further highlighting its significance. G_αq and Ca++ channels made some contributions to the phosphorylation of ERK. Ca++ differentially affected PI3K activation in FcεRI- vis-à-vis MRGPRX2-signaling, as channel inhibition increased pAKT only when triggered via FcεRI. Collectively, our study significantly extends our understanding of the molecular framework behind granule secretion from skin MCs.

Peanut Can Be Used as a Reference Allergen for Hazard Characterization in Food Allergen Risk Management: A Rapid Evidence Assessment and Meta-Analysis

Regional and national legislation mandates the disclosure of “priority” allergens when present as an ingredient in foods, but this does not extend to the unintended presence of allergens due to shared production facilities. This has resulted in a proliferation of precautionary allergen (“may contain”) labels (PAL) that are frequently ignored by food-allergic consumers. Attempts have been made to improve allergen risk management to better inform the use of PAL, but a lack of consensus has led to variety of regulatory approaches and nonuniformity in the use of PAL by food businesses. One potential solution would be to establish internationally agreed “reference doses,” below which no PAL would be needed. However, if reference doses are to be used to inform the need for PAL, then it is essential to characterize the hazard associated with these low-level exposures. For peanut, there are now published data relating to over 3000 double-blind, placebo-controlled challenges in allergic individuals, but a similar level of evidence is lacking for other priority allergens. We present the results of a rapid evidence assessment and meta-analysis for the risk of anaphylaxis to a low-level allergen exposure for priority allergens. On the basis of this analysis, we propose that peanut can and should be considered an exemplar allergen for the hazard characterization at a low-level allergen exposure.

Genome-wide association study reveals an association between the HLA-DPB1∗02:01:02 allele and wheat-dependent exercise-induced anaphylaxis

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a life-threatening food allergy triggered by wheat in combination with the second factor such as exercise. The identification of potential genetic risk factors for this allergy might help high-risk individuals before consuming wheat-containing food. We aimed to identify genetic variants associated with WDEIA. A genome-wide association study was conducted in a discovery set of 77 individuals with WDEIA and 924 control subjects via three genetic models. The associations were confirmed in a replication set of 91 affected individuals and 435 control individuals. Summary statistics from the combined set were analyzed by meta-analysis with a random-effect model. In the discovery set, a locus on chromosome 6, rs9277630, was associated with WDEIA in the dominant model (OR = 3.95 [95% CI, 2.31-6.73], p = 7.87 × 10-8). The HLA-DPB1∗02:01:02 allele displayed the most significant association with WDEIA (OR = 4.51 [95% CI, 2.66-7.63], p = 2.28 × 10-9), as determined via HLA imputation following targeted sequencing. The association of the allele with WDEIA was confirmed in replication samples (OR = 3.82 [95% CI, 2.33-6.26], p = 3.03 × 10-8). A meta-analysis performed in the combined set revealed that the HLA-DPB1∗02:01:02 allele was significantly associated with an increased risk of WDEIA (OR = 4.13 [95% CI, 2.89-5.93], p = 1.06 × 10-14). Individuals carrying the HLA-DPB1∗02:01:02 allele have a significantly increased risk of WDEIA. Further validation of these findings in independent multiethnic cohorts is needed.