Food-dependent exercise-induced anaphylaxis in the celery-mugwort-birch-spice syndrome

Isotretinoin-associated exercise-induced anaphylaxis in a patient with birch pollinosis and soybean sensitization: case presentation and literature review

Background

Peanut and soybean allergies are listed as contraindication in the package leaflet of isotretinoin, a widely used treatment of acne vulgaris. Cross-reactivity between PR10-proteins in peanut, tree nuts, and soybean is particularly common in patients with birch pollinosis and may lead to anaphylactic reactions in sensitized patients after intake of soybean oil containing isotretinoin capsules.

Case presentation

Here, we describe a young man with hazelnut and birch pollen allergy, who experienced exercise-induced anaphylaxis after isotretinoin intake on the third day of treatment. A complete allergy work-up was carried out, and sensitization to both peanut and soybean PR10-proteins was confirmed. However, oral provocation with isotretinoin remained negative in the absence of intense physical activity and longterm treatment was well tolerated.

Conclusion

To our knowledge, this is the first report of an exercise-induced anaphylaxis due to isotretinoin therapy. Our literature review to assess tolerability of isotretinoin in patients allergic to peanut, tree nuts or soybean revealed only one other case of anaphylaxis in a cashew-nut allergic patient sensitized to soybean PR10-protein Gly m 4. While there are no reports on soybean allergic patients treated with isotretinoin, the vast majority of peanut or tree nut allergic patients tolerated isotretinoin. Therefore, we conclude that sensitization to soybean, peanut or tree nuts should not preclude isotretinoin therapy. Particular caution is however warranted in patients with soybean sensitization. Pre-treatment oral challenges with isotretinoin may be recommended and physicians should be aware of the potential role of cofactors.

Update on pollen-food allergy syndrome

INTRODUCTION

Allergies affect 20-30% of the population and respiratory allergies are mostly due to pollen grains from anemophilous plants. One to 5% of people suffer from food allergies and clinicians report increasing numbers of pollen-food allergy syndrome (PFAS), such that the symptoms have broadened from respiratory to gastrointestinal, and even to anaphylactic shock in the presence of cofactors. Thirty to 60% of food allergies are associated with pollen allergy while the percentage of pollen allergies associated to food allergy varies according to local environment and dietary habits.

AREAS COVERED

Articles published in peer-reviewed journals, covered by PubMed databank, clinical data are discussed including symptoms, diagnosis, and management. A chapter emphasizes the role of six well-known allergen families involved in PFAS: PR10 proteins, profilins, lipid transfer proteins, thaumatin-like proteins, isoflavone reductases, and β-1,3 glucanases. The relevance in PFAS of three supplementary allergen families is presented: oleosins, polygalacturonases, and gibberellin-regulated proteins. To support the discussion a few original relevant results were added.

EXPERT OPINION

Both allergenic sources, pollen and food, are submitted to the same stressful environmental changes resulting in an increase of pathogenesis-related proteins in which numerous allergens are found. This might be responsible for the potential increase of PFAS.

Efficacy of Treatment of Non-hereditary Angioedema

Non-hereditary angioedema (AE) with normal C1 esterase inhibitor (C1INH) can be presumably bradykinin- or mast cell-mediated, or of unknown cause. In this systematic review, we searched PubMed, EMBASE, and Scopus to provide an overview of the efficacy of different treatment options for the abovementioned subtypes of refractory non-hereditary AE with or without wheals and with normal C1INH. After study selection and risk of bias assessment, 61 articles were included for data extraction and analysis. Therapies were described for angiotensin-converting enzyme inhibitor-induced AE (ACEi-AE), for idiopathic AE, and for AE with wheals. Described treatments consisted of ecallantide, icatibant, C1INH, fresh frozen plasma (FFP), tranexamic acid (TA), and omalizumab. Additionally, individual studies for anti-vitamin K, progestin, and methotrexate were found. Safety information was available in 26 articles. Most therapies were used off-label and in few patients. There is a need for additional studies with a high level of evidence. In conclusion, in acute attacks of ACEi-AE and idiopathic AE, treatment with icatibant, C1INH, TA, and FFP often leads to symptom relief within 2 h, with limited side effects. For prophylactic treatment of idiopathic AE and AE with wheals, omalizumab, TA, and C1INH were effective and safe in the majority of patients.

Diagnosis of exercise-induced anaphylaxis: current insights

Exercise-induced anaphylaxis (EIAn) is defined as the occurrence of anaphylactic symptoms (skin, respiratory, gastrointestinal, and cardiovascular symptoms) after physical activity. In about a third of cases, cofactors, such as food intake, temperature (warm or cold), and drugs (especially nonsteroidal anti-inflammatory drugs) can be identified. When the associated cofactor is food ingestion, the correct diagnosis is food-dependent EIAn (FDEIAn). The literature describes numerous reports of FDEIAn after intake of very different foods, from vegetables and nuts to meats and seafood. One of the best-characterized types of FDEIAn is that due to ω5-gliadin of wheat, though cases of FDEIAn after wheat ingestion by sensitization to wheat lipid transfer protien (LTP) are described. Some pathophysiological mechanisms underlying EIAn have been hypothesized, such as increase/alteration in gastrointestinal permeability, alteration of tissue transglutaminase promoting IgE cross-linking, enhanced expression of cytokines, redistribution of blood during physical exercise leading to altered mast-cell degranulation, and also changes in the acid–base balance. Nevertheless, until now, none of these hypotheses has been validated. The diagnosis of EIAn and FDEIAn is achieved by means of a challenge, with physical exercise alone for EIAn, and with the assumption of the suspected food followed by physical exercise for FDEIAn; in cases of doubtful results, a double-blind placebo-controlled combined food–exercise challenge should be performed. The prevention of this particular kind of anaphylaxis is the avoidance of the specific trigger, ie, physical exercise for EIAn, the assumption of the culprit food before exercise for FDEIAn, and in general the avoidance of the recognized cofactors. Patients must be supplied with an epinephrine autoinjector, as epinephrine has been clearly recognized as the first-line intervention for anaphylaxis.

Anaphylaxis in an urban Belgian emergency department: epidemiology and aetiology

OBJECTIVES

Anaphylaxis is an emergency condition of which reliable epidemiological data are lacking. This study focusses on epidemiology and aetiology of anaphylactic reactions in an urban Belgian emergency department (ED).

METHODS

Patient data were collected from 04/2009 to 04/2013.During this period, emergency doctors completed a questionnaire for adult patients (>15 years) with anaphylaxis presenting at the ED. Inclusion criteria were based on the Sampson criteria of anaphylaxis. Data were analysed using a Microsoft Excel database.

RESULTS

Anaphylaxis accounted for 0.04% of all emergency visits in this 4-year period. In both women and men, dyspnoea and urticaria were noted most frequently. 51.7% of cases were possibly elicited by foods, 46.1% by drugs and 3.4% by hymenoptera stings. Women more often reported allergic diseases in their personal history. 55.7% of patients, who had a history of allergy, reported a suspected food-related allergy, 24.6% a drug-related allergy and 8.2% a hymenoptera venom-related allergy. In 76.5% of patients who reported a history of food allergy, food was the presumed elicitor of anaphylaxis. For patients with history of drug allergy, 88.2% had a presumed drug anaphylaxis at the time of presentation at the ED. 81% of cases presented with grade 4 or 5 anaphylaxis. With increasing age, the severity of anaphylaxis increased. Higher tryptase levels correlated with a higher grade of anaphylaxis.

CONCLUSION

In this Belgian urban population, foods and drugs were by far the most common suspected elicitors of anaphylaxis. Personal history of allergic diseases was present in more than half of the cases.

Food Allergy: Common Causes, Diagnosis, and Treatment

Food allergy is a growing concern, and recognition of symptoms, knowledge of common food allergens, and management of reactions are important for patients and practitioners. Symptoms of a classic IgE-mediated food allergy vary in severity and can include any combination of laryngeal edema, wheezing, nausea, vomiting, diarrhea, urticaria, angioedema, and hypotension. Many foods can induce an allergic reaction, but the most commonly implicated foods include cow's milk, egg, peanut, tree nut, soy, wheat, fish, and shellfish. Milk and egg allergy generally develop and are outgrown in childhood. Peanut and tree nut allergy can occur during childhood or adulthood, are less likely to be outgrown, and tend to cause more fatal reactions. Given the possibility of life-threatening reactions, it is important to recognize the potential for cross-reactivity among food groups. Diagnosis of food allergy includes skin prick testing, specific serum IgE testing, and oral food challenges. Management is centered on avoidance of allergenic and cross-reacting foods and early recognition and immediate treatment of reactions. Treatment protocols to desensitize patients to food are currently under investigation.

Elicitors and co-factors in food-induced anaphylaxis in adults

Food-induced anaphylaxis (FIA) in adults is often insufficiently diagnosed. One reason is related to the presence of co-factors like exercise, alcohol, additives and non-steroidal anti-inflammatory drugs. The objective of this analysis was to retrospectively investigate the role of co-factors in patients with FIA. 93 adult patients with suspected FIA underwent double-blind, placebo-controlled food challenges with suspected allergens and co-factors.

The elicitors of anaphylaxis were identified in 44/93 patients. 27 patients reacted to food allergens upon challenge, 15 patients reacted only when a co-factor was co-exposed with the allergen. The most common identified allergens were celery (n = 7), soy, wheat (n = 4 each) and lupine (n = 3). Among the co-factors food additives (n = 8) and physical exercise (n = 6) were most frequent. In 10 patients more than one co-factor and/or more than one food allergen was necessary to elicit a positive reaction.

The implementation of co-factors into the challenge protocol increases the identification rate of elicitors in adult food anaphylactic patients.

Food-induced anaphylaxis

Food-induced anaphylaxis (FIA) is a serious allergic reaction that may cause death rapidly in otherwise healthy individuals. There is no universal agreement on its definition or criteria for diagnosis. Hospital admissions for FIA have more than doubled in the last decade. Food is one of the most common causes of anaphylaxis, with most surveys indicating that food-induced reactions account for 30% to 50% of cases. The most commonly implicated foods are peanut, tree nuts, milk, eggs, sesame seeds, fish, and shellfish. The only life-saving treatment for anaphylaxis is allergen avoidance, and epinephrine injection if an anaphylactic event occurs.

An update on epidemiology of anaphylaxis in children and adults

PURPOSE OF REVIEW

The purpose of the present review is to describe the epidemiology of food-induced, medication-induced, drug-induced, and insect sting-induced anaphylaxis; to summarize recent changes in the incidence of anaphylaxis internationally; and to discuss recent insights into potential risk factors for anaphylaxis.

RECENT FINDINGS

Recent studies confirm that the incidence of anaphylaxis, particularly food-induced anaphylaxis, is increasing world-wide. The rise in anaphylaxis incidence appears most pronounced in children under the age of 5 years, which is also the age group most at risk of hospitalization for food-induced anaphylaxis. Identification of factors that may increase the risk of episodes of anaphylaxis remains an important research priority. Recently, two large cohort studies using data from electronic medical records confirmed that individuals with asthma are at higher risk of anaphylaxis and those with severe asthma have the highest risk of all. With respect to modifiable lifestyle factors, several studies have demonstrated a link between latitude and anaphylaxis, with areas with less year-round sunlight reporting a higher prevalence of food-induced anaphylaxis.

SUMMARY

Reports of an increasing incidence of anaphylaxis internationally highlight the need for identification of modifiable risk factors for anaphylaxis. Emerging evidence suggests that low vitamin D levels may be associated with risk of anaphylaxis and food allergy; however, further studies are required to confirm this.

A 71-year-old man with anaphylaxis after eating grits

The allergist is frequently called on to evaluate patients after episodes of anaphylaxis to determine the cause and implement preventive measures that will reduce the patient's risk from future episodes. The etiology of anaphylaxis can be the result of numerous causes that may go undiagnosed if a thorough evaluation is not performed. We present a 71-year-old man with no history of food allergy or atopy who presented to the emergency room and then our allergy clinic for evaluation after suffering anaphylaxis after a meal of grits and shrimp. The underlying diagnosis, which was subsequently determined, requires a high index of suspicion and should be included in the differential diagnosis of any patient presenting with unexplained anaphylaxis.

Spice allergy

OBJECTIVES

To provide a review on spice allergy and its implementation in clinical practice.

DATA SOURCES

PubMed searches were performed using spice allergy as the keyword for original and review articles. Selected references were also procured from the reviewed articles' references list.

STUDY SELECTION

Articles were selected based on their relevance to the topic.

RESULTS

Spices are available in a large variety and are widely used, often as blends. Spice allergy seems to be rare, reportedly affecting between 4 and 13 of 10,000 adults and occurring more often in women because of cosmetic use. No figures were available on children. Most spice allergens are degraded by digestion; therefore, IgE sensitization is mostly through inhalation of cross-reacting pollens, particularly mugwort and birch. The symptoms are more likely to be respiratory when exposure is by inhalation and cutaneous if by contact. Studies on skin testing and specific IgE assays are limited and showed low reliability. The diagnosis primarily depends on a good history taking and confirmation with oral challenge. The common use of spice blends makes identifying the particular offending component difficult, particularly because their components are inconsistent.

CONCLUSION

Spices are widely used and contain multiple allergens, yet spice allergy is probably markedly underdiagnosed. There is a need for reliable skin testing extracts and serum specific IgE assays. Currently, the diagnosis depends on a good history taking and well-designed titrated challenge testing. Until immunotherapy becomes developed, treatment is strict avoidance, which may be difficult because of incomplete or vague labeling.

World allergy organization guidelines for the assessment and management of anaphylaxis

The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.