Characteristics of Anaphylaxis in 907 Chinese Patients Referred to a Tertiary Allergy Center: A Retrospective Study of 1,952 Episodes

Food-Pollen Cross-Reactivity and its Molecular Diagnosis in China

PURPOSE OF REVIEW

Plant-derived foods are one of the most common causative sources of food allergy in China, with a significant relationship to pollinosis. This review aims to provide a comprehensive overview of this food-pollen allergy syndrome and its molecular allergen diagnosis to better understand the cross-reactive basis.

RECENT FINDINGS

Food-pollen cross-reactivity has been mainly reported in Northern China, Artemisia pollen is the major related inhalant source, followed by tree pollen (Betula), while grass pollen plays a minor role. Pollen allergy is relatively low in Southern China, with allergies to grass pollen being more important than weed and tree pollens. Rosaceae fruits and legume seeds stand out as major related allergenic foods. Non-specific lipid transfer protein (nsLTP) has been found to be the most clinically relevant cross-reacting allergenic component, able to induce severe reactions. PR-10, profilin, defensin, chitinase, and gibberellin-regulated proteins are other important cross-reactive allergen molecules. Artemisia pollen can induce allergenic cross-reactions with a wide range of plant-derived foods in China, and spring tree pollens (Betula) are also important. nsLTP found in both pollen and plant-derived food is considered the most significant allergen in food pollen cross-reactivity. Component-resolved diagnosis with potential allergenic proteins is recommended to improve diagnostic accuracy and predict the potential risk of causing allergic symptoms.

Trends in Childhood Anaphylaxis in Singapore: 2015-2022

BACKGROUND

There has been limited data regarding the incidence of anaphylaxis in Asia. We aim to describe patterns in patient characteristics, triggers and clinical presentation of childhood anaphylaxis in Singapore.

METHODS

This was a retrospective review of emergency electronic medical records of children with anaphylaxis. Patients with the allergy-related diagnoses of anaphylaxis, angioedema, allergy and urticaria based on ICD-9 codes were screened. Cases fulfilling the World Allergy Organization criteria for anaphylaxis were included.

RESULTS

A total of 1188 cases of anaphylaxis were identified with a median age of 6.3 years. Extrapolating data from the study sites, from 2015 to 2022, the incidence rate of childhood anaphylaxis emergency visits in Singapore doubled from 18.9 to 38.8 per 100,000 person-years, with an incidence rate ratio (IRR) of 2.06 (95% confidence interval [CI] 1.70-2.49). In 2022, the incidence rate of food anaphylaxis was 30.1 per 100,000 person-years, IRR 2.39 (95% CI 1.90-3.01) and drug anaphylaxis was 4.6 per 100,000 person-years, IRR 1.89 (95% CI 1.11-3.25). The incidence rate in children aged 0-4 years quadrupled during the study period. Common triggers were egg (10.4%), peanut (9.3%), tree nut (8.8%), milk (8%), shellfish (7.8%) and non-steroidal anti-inflammatory drug (4.4%). The majority (88.6%) of patients were treated with intramuscular adrenaline. Total number of allergy-related visits did not increase over time between 2015 and 2019. Rates of severe anaphylaxis, namely anaphylactic shock and admission to high-dependency and intensive care, did not increase over time, with a mean incidence of 1.6, IRR 0.85 (95% CI 0.40-1.83) and 0.7, IRR 1.77 (95% CI 0.54-5.76) per 100,000 person-years, respectively.

CONCLUSION

While the number of emergency visits due to childhood anaphylaxis has increased, the number of cases of allergy-related visits, anaphylactic shock and anaphylaxis requiring high-dependency and intensive care did not rise.

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.

Pru p 3-specific IgE affinity is crucial in severe peach-allergy patients

Background

Peach allergy is common food allergen. Allergen components-specific antibodies of different isotypes in peach-allergy patients are poorly studied. Factors other than Pru p 3-sIgE levels may be related to severe symptoms.

Objective

To evaluated peach component-specific-IgE, IgG1, and IgG4 characteristics in individuals with and without peach allergy, and Pru p 3-sIgE affinity in patients with different clinical symptoms.

Methods

Fifteen healthy controls and 32 peach-allergy patients were enrolled. sIgE, sIgG1, and sIgG4 to 5 Escherichia coli-expressed peach-allergen components were determined by enzyme-linked immunosorbent assays. Pru p 3-sIgE affinity was measured in Pru p 3-sIgE-positive patients, using immunoadsorbance.

Results

Patients were divided into oral allergy syndrome (OAS) and peach-induced anaphylaxis (PIA) groups. Serum Pru p 1-, Pru p 2-, Pru p 3-, Pru p 4-, and Pru p 7-sIgG1s were detected. Pru p 1- and Pru p 2-sIgG1 levels were higher in healthy controls, but Pru p 3-sIgG1 levels were significantly higher in peach-allergy patients. Pru p 1-, Pru p 3-, and Pru p 4-sIgG4-positivity was significantly greater among patients than among controls. Pru p 3 was the predominant allergen in peach-allergy patients. Allergen-sIgG1 and sIgG4 were similar between OAS and PIA patients. Pru p 3-sIgE levels were significantly higher in PIA patients, but Pru p 3-sIgE-positivity was similar in both groups. In Pru p 3-sIgE-positive patients, Pru p 3-sIgE affinity was significantly higher in PIA than OAS patients.

Conclusions

Allergen-sIgG1 was associated with allergen exposure. Both Pru p 3-sIgE levels and affinity are key factors in severe peach-allergy patients.

Prevention of Anaphylaxis Episodes in Idiopathic Anaphylaxis by Omalizumab

INTRODUCTION

In 15-35 percent of patients with anaphylaxis, the triggering allergen cannot be found; therefore, a diagnosis of idiopathic anaphylaxis (IA) is made. We report on the outcomes in patients with IA treated with omalizumab.

METHODS

We included consequent omalizumab-treated IA adult patients treated with omalizumab 300 mg every 4 weeks.

RESULTS

Out of 7 patients, 6 were female, median age 40 years with the frequency of anaphylaxis episodes from 3 in 2 years to 5 in 4 months. Baseline tryptase ranged from 1.71 to 12.0 μg/L. An increase in tryptase during anaphylaxis was documented in 6 patients. Activating KIT p.D816V variant was detected in 2 patients. One patient also had hereditary alpha-tryptasemia (HαT). The duration of omalizumab treatment was 0.5-7.5 years. None of the patients have experienced an anaphylactic reaction since the start of treatment. Mild systemic reactions were reported in 6 patients (86%). The presence of underlying cMCD had no impact on the treatment outcome.

CONCLUSION

All patients in our study had complete responses to omalizumab. The presence of KIT p.D816V and HαT did not influence the response to omalizumab treatment.

Anaphylaxis management in a French pediatric emergency department: Lessons from the ANA-PED study

BACKGROUND

Anaphylaxis is a serious systemic hypersensitivity reaction that requires immediate recognition and prompt administration of epinephrine/adrenaline. The present study aimed to assess the appropriateness of epinephrine/adrenaline use in children identified as allergic by physicians in the emergency department (ED) at the time of the reaction, and to identify factors that are possibly associated with epinephrine/adrenaline administration, auto-injector prescription, and further referral to an allergist.

METHODS

We performed a retrospective cross-sectional study at the pediatric ED of the University Hospital of Montpellier, France. We included all consecutive children who attended the ED between 2016 and 2020 with an allergy-related diagnosis at discharge.

RESULTS

We included 1056 allergy-related visits, including 224 (21.2%) with a diagnosis of anaphylaxis at discharge; only 17.0% of them received an epinephrine/adrenaline injection, and 57.1% consulted an allergist after the acute episode. An auto-injector was prescribed to 63 (28.1%) patients at discharge from the ED. Besides the severity of the clinical presentation, factors associated with a guidelines-based management of the anaphylactic reaction and with an increased administration rate of epinephrine/adrenaline included presence of asthma symptoms and presence of extended skin reactions.

CONCLUSIONS

Our study underlines persistent gaps in the management of pediatric anaphylaxis in ED, focusing on hereby identified levers. By disseminating current knowledge and guidelines on anaphylaxis and allergies, specialists could work together with emergency physicians to establish effective management algorithms and improve anaphylaxis management and care pathways for children experiencing allergic reactions, especially anaphylaxis.

TRAIL REGISTRATION

Clinical Trials, number NCT05112367.

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.

Comparison of two diagnostic criteria in the diagnosis of anaphylaxis in a tertiary adult allergy clinic

Background

Anaphylaxis is a very dynamic issue with its incidence and trigger profile changing over the years. We aimed to compile the characteristics of anaphylaxis cases diagnosed in our clinic prospectively and to make a comparison between diagnostic criteria proposed by National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) and World Allergy Organization (WAO).

Method

Three-item diagnostic criteria recommended by NIAID/FAAN (2006) were used in the diagnosis of anaphylaxis. The clinical features of the cases, risk factors, etiologies, severity of anaphylaxis, and treatment approach were determined. The same patients were also classified by current WAO diagnostic criteria.

Results

A total of 204 patients (158F/46 M, median age 45.3 years) were included. Drugs (65.2%), venom (9.8%) and food allergies (9.3%) were the top 3 etiologies. Among drug triggers, chemotherapeutics were the most common (17.7%), followed by antibiotics (15.3%) and non-steroidal anti-inflammatory drugs (14.2%). The patients were mostly diagnosed with the second criterion (84.8%), followed by the first criterion (11.8%) and the third criterion (3.4%) of the NIAID/FAAN criteria. In terms of WAO criteria, 82.8% of the patients were diagnosed with the first criterion, and 14.3% with the second criterion while 2.9% of the patients did not meet the WAO criteria. The severity of anaphylaxis was evaluated as grade-2, 3 and 4 in 30.9%, 64.2%, and 4.9% of the patients, respectively. Adrenaline was administered to 31.9% of the patients especially who had angioedema and bronchospasm (p = 0.04).

Conclusion

Our data suggest that covering more details in patient's history may prevent possible underdiagnosis and WAO diagnostic criteria seem to be insufficient in some patients. We believe that our results will contribute to the literature on anaphylaxis and would be groundwork for future studies.

Temporal trends in anaphylaxis ED visits over the last decade and the effect of COVID-19 pandemic on these trends

BACKGROUND

Anaphylaxis is an acute systemic and potentially fatal allergic reaction. We evaluated trends in yearly rates of anaphylaxis in a pediatric Emergency Department (ED) in Montreal, Canada.

METHODS

A prospective and retrospective recruitment process was used to find families of children who had presented with anaphylaxis at the Montreal Children's Hospital between April 2011 and April 2021. Using a uniform recruitment form, data were collected. Anaphylaxis patterns were compared to clinical triggers using descriptive analysis.

RESULTS

Among 830,382 ED visits during the study period, 2726 (26% recruited prospectively) presented with anaphylaxis. The median age was 6 years (IQR: 0.2, 12.00), and 58.7% were males. The relative frequency of anaphylaxis cases doubled between 2011-2015, from 0.22% (95% CI, 0.19, 0.26) to 0.42 March 2020, the total absolute number of anaphylaxis cases and relative frequency declined by 24 cases per month (p < 0.05) and by 0.5% of ED visits (p < 0.05).

CONCLUSIONS

The rate of anaphylaxis has changed over the years, representing modifications in food introduction strategies or lifestyle changes. The decrease in the frequency of anaphylaxis presenting to the ED during the COVID pandemic may reflect decreased accidental exposures with reduced social gatherings, closed school, and reluctance to present to ED.

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.

Prevalence, clinical presentation, and associated atopic diseases of pediatric fruit and vegetable allergy: A population-based study

BACKGROUND

In children, fruit and vegetable allergies are often overlooked compared with well-known allergies such as those to eggs, milk, and shellfish. Therefore, this study aimed to analyze fruit and vegetable allergies in children, including prevalence, types of food allergens, clinical presentation, management, and associated comorbid atopic diseases.

METHODS

In 2012, a nationwide, cross-sectional, random sampling questionnaire-based survey for common fruit and vegetable allergies was conducted in Taiwan. Information regarding these plant food allergies was collected. Physicians diagnosed food allergies according to the descriptions of convincing symptoms. Enrolled questionnaires were reviewed by expert pediatricians.

RESULTS

A total of 9,982 valid questionnaires were analyzed. The overall prevalence of fruit and vegetable allergies was 5.6% (n = 560) and 3.0% (n = 304), respectively. The most common fruit allergen was mango, followed by kiwifruit, whereas taro and bamboo shoot were the most common vegetable allergens. Meanwhile, most allergic symptoms were of the mucocutaneous tissue, followed by the upper airway and gastrointestinal tract. Most only required avoidance of allergens and not medical treatment. Children with fruit or vegetable allergies had a higher percentage of comorbid atopic dermatitis, allergic rhinitis, and asthma than those without food allergies; additionally, the proportion of comorbid atopic diseases was similar between fruit and vegetable allergies and shellfish allergy. One child developed anaphylaxis due to a corn allergy.

CONCLUSIONS

Fruits and vegetables are common food allergens in Taiwanese children who present with diverse and potentially severe symptoms. Children with plant food allergies had a percentage of comorbid atopic diseases similar to that of shellfish allergy, the most common allergen. These findings indicate the importance of considering fruit and vegetable allergies in children.

Anaphylaxis in Chinese Children: Different Clinical Profile Between Children with and without a History of Asthma/Recurrent Wheezing

Purpose

Asthma and recurrent wheezing (RW) have been identified as risk factors for anaphylaxis; however, little is known about the characteristics of anaphylaxis in children with a history of asthma or RW in Chinese children.

Patients and Methods

This was a retrospective, observational chart review of children who were diagnosed with anaphylaxis in a tertiary children's hospital between 2014 and 2021. Patients' demographics, symptoms, triggers and presence of physician-diagnosed asthma/RW history were collected from medical charts.

Results

A total of 399 anaphylactic reactions in 264 patients were analyzed; 119 patients (45.1%) had a history of asthma/RW. Food was the most common cause (85.5%, 341/399). Compared with patients without a history of asthma/RW, buckwheat-induced anaphylaxis was significantly more common in the asthma/RW group (9.4% vs 0.5%, p < 0.001), patients with a history of asthma/RW had higher rates of oropharyngeal symptoms (17.3% vs 8.6%, p = 0.011) and wheezing (34.5% vs 15.9%, p < 0.001). Ninety-one reactions (22.8%, 91/399) presented as severe anaphylaxis, but no difference existed between asthma/RW and non-asthma/RW groups. Children with a history of asthma/RW were more likely to receive inhaled β agonists than children without a history of asthma/RW (11.8% vs 2.5%, p = 0.003). A larger proportion of children without asthma/RW history were treated with epinephrine (11.7%) than children with asthma/RW history (6.9%).

Conclusion

Our finding revealed that different clinical profiles of anaphylaxis in children with and without a history of asthma/RW. Our study did not find that children with a history of asthma/RW have more severe anaphylactic reactions compared with children without asthma/RW. Buckwheat-induced anaphylaxis was more common in the asthma/RW group, wheezing and oropharyngeal symptoms affected a higher proportion of the asthma/RW group.

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.

A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020)

Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.

Predisposition of hypersensitivity in patients with exfoliative cheilitis

Background/purpose

Exfoliative cheilitis (EC) is a chronic and reversible inflammatory disease of the lips without definite etiology. Clinically, different types of allergens can be found in exfoliative cheilitis patients, however, few studies have focused on the relationship between exfoliative cheilitis and hypersensitivity. This research aimed to investigate the prevalence of hypersensitivity in EC patients.

Materials and methods

A prospective study was conducted in 30 patients with exfoliative cheilitis and 30 healthy controls, matched in age and sex. Laboratory tests included serum total IgE, allergen-specific IgE, and food-specific IgG.

Results

Increased serum total IgE level, positive food-specific IgG were seen more frequently in exfoliative cheilitis patients than in healthy control (P < 0.05). Special IgE level to FX5 and the degree of food-specific IgG to wheat were seen higher in exfoliative cheilitis patients than in healthy control (P < 0.05).

Conclusion

This study suggests that patients with exfoliative cheilitis may have predisposition of hypersensitivity. The detection of allergens should be strengthened in the future clinical work.

Environmental Influences and Allergic Diseases in the Asia-Pacific Region: What Will Happen in Next 30 Years?

Asia-Pacific is a populous region with remarkable variations in socioeconomic development and environmental exposure among countries. The prevalence rates of asthma and allergic rhinitis appear to have recently reached a plateau in Western countries, whereas they are still increasing in many Asian countries. Given the large population in Asia, even a slight increase in the prevalence rate will translate into an overwhelming number of patients. To reduce the magnitude of the increase in allergic diseases in next few decades in Asia, we must understand the potential factors leading to the occurrence of these disorders and the development of potential preventive strategies. The etiology of allergic disorders is likely due to complex interactions among genetic, epigenetic, and environmental factors for the manifestations of inappropriate immune responses. As urbanization and industrialization inevitably progress in Asia, there is an urgent need to curtail the upcoming waves of the allergy epidemic. Potentially modifiable risk exposure, such as air pollution, should be minimized through timely implementation of effective legislations. Meanwhile, re-introduction of protective factors that were once part of the traditional farming lifestyle might give new insight into primary prevention of allergy.

Global patterns in anaphylaxis due to specific foods: A systematic review

BACKGROUND

There are increasing global data relating to prevalence of food allergy and food-induced anaphylaxis; however, this is often based on surrogate measures of sensitization rather than objective symptoms at food challenge. In terms of protecting food-allergic consumers from reactions, to our knowledge, there has been no global survey assessing geographic differences in the proportion of anaphylaxis triggered by specific foods.

OBJECTIVE

We sought to identify common triggers for food-induced anaphylaxis and how these vary from country to country.

METHODS

Systematic review of relevant reports published between January 2010 and November 2020. Results were reported following PRISMA guidelines. Publications were screened and data extracted by 2 independent reviewers, and the risk of bias was assessed.

RESULTS

Sixty-five studies (encompassing 41 countries and all 6 regions as defined by the Food and Agriculture Organization of the United Nations) were included. Significant regional variations in the most common triggers of food anaphylaxis were seen; however, in general, there was good agreement between local legislative requirements for allergen disclosure and the most common allergens for each region or nation.

CONCLUSIONS

Local legislation for allergen disclosure generally reflects those allergens commonly responsible for food anaphylaxis. Cow's milk and crustaceans appear to cause a higher proportion of anaphylaxis compared to peanut in some regions.

Pilot Project of Special Emergency Medical Service Team for Anaphylaxis in Gangwon-do, Korea: Results from an Online Questionnaire Survey

BACKGROUND

Early recognition and prompt intramuscular epinephrine administration are critical for the treatment of anaphylaxis. The special emergency medical service team (SEMST) is a reorganization plan that incorporates first-level emergency medical technicians (EMTs) and nurses from Korea to give the authority to administer epinephrine. This study evaluates the experience of SEMST and aims to investigate further needs in the pre-hospital management of anaphylaxis.

METHODS

An online survey of 29 questions on the Gangwon-do 119 EMST was conducted. IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA) and R ver.4.0.3. were used for statistical analysis.

RESULTS

A total of 428 (44.6%) participants responded to the questionnaire, and 55.6% (238/428) experienced anaphylaxis. The common presumed cause was insect sting/animal bites at 84.5% (201/238), followed by food (7.6%, 18/238), and drugs (6.3%, 15/238). The frequency of occurrence was highest for tourist attractions (58.6%, 167/285), followed by homes (31.9%, 91/285) and workplace (3.5%, 10/285). Among 136 medical personnel (31.8%) who were currently active or had been active as the SEMST, 95 (70.0%) experienced anaphylaxis, and 58 (61.1%) used epinephrine, which was significantly lower in the non-SEMST group (n = 36, 25.2%). The biggest difficulty in pre-hospital treatment was the limitation of drug administration authority (23.4%, 22/95). The lack of experience and tricky treatment are the chief difficulties in pediatric anaphylaxis. The percentage of correct answers regarding anaphylaxis awareness was significantly higher in the educated (n = 374) than in the non-educated group (n = 54), both for diagnosis (24.9% vs. 11.1%) and treatment (73.5% vs. 37.0%).

CONCLUSION

Proper administration of epinephrine is particularly important for pre-hospital anaphylaxis management in rural areas. Expanding SEMST and conducting periodic education using virtual experiences is necessary.

Age-related differences in characteristics of anaphylaxis in Chinese children from infancy to adolescence

BACKGROUND

Little is known about anaphylaxis in Chinese children. This study aimed to determine the age-specific patterns of anaphylaxis in Chinese children.

METHODS

We conducted a retrospective study of anaphylaxis cases attending an allergy department in a tertiary children's hospital.

RESULTS

A total of 279 anaphylactic reactions in 177 patients were analyzed. Overall, 57.6% (102/177) of first anaphylaxis events occurred in infants (0-2 ys). Foods were the most common culprits (88.5%), followed by food + exercise/exercise (4.7%), and drugs (4.3%). The main food allergens were cow's milk (32.9%), egg (21.4%), and wheat (20.7%) in infants, compared with fruits/vegetables at 35.9% in preschool-age children (3-6 ys) and 31.6% in school-age children (7-12 ys). The most commonly implicated drug triggers were vaccines (n = 5, comprising DTaP n = 2, group A + C meningococcal polysaccharide vaccine n = 1, Sabin vaccine n = 1, and not specified n = 1). Among the 5 vaccine-induced anaphylaxis patients, 4 had severe cow's milk allergy. The clinical manifestations were mainly mucocutaneous (86.0%), followed by respiratory (68.8%), gastrointestinal (23.7%), neurological (10.4%), and cardiovascular (0.7%). Compared with patients of other ages, infants had higher rates of hives (0-2ys 77.4%, 3-6ys 50%,7-12ys 57.9%, 13-17ys 38.9%, p = 0.016) and vomiting (0-2ys 20.7%, 3-6ys 1.6%,7-12ys 8.8%, p < 0.001), while wheezing was more frequent in school-age children (0-2ys 21.4%, 3-6ys 25%, 7-12ys 38.6%, 13-17ys 5.6%, p = 0.017) and abdominal pain was more common in adolescents (0-2ys 2.1%,3-6ys 15.6%, 7-12ys 14.0%, 13-17ys 72.3%, p < 0.001). Regarding treatment, 9.3% of anaphylaxis events and 24.1% of life-threatening reactions were treated with epinephrine.

CONCLUSIONS

We observed age-related clinical patterns of anaphylaxis in this study, with hives and vomiting most commonly reported in infants and cardiovascular symptoms rarely reported in children. Wheat was the third most culprit food allergen after egg and milk in infancy. Education regarding more aggressive use of epinephrine in the emergency setting is clearly needed. Recognition of age-related symptoms in anaphylaxis can aid physicians in prompt diagnosis and acute management.

Recent update on the management of anaphylaxis

Anaphylaxis is a life-threatening systemic allergic reaction presenting various clinical manifestations. Its prevalence has increased in almost all age groups and both sexes. Food, venom, and drugs are major causes in both children and adults; a higher prevalence of food-induced anaphylaxis is noted in children, while a higher prevalence of drug-induced anaphylaxis is noted in adults. The pathogenic mechanism is mediated by immunologic and nonimmunologic mechanisms, where mast cells and basophils are key cells that release mediators. A diagnosis of anaphylaxis is mainly based on clinical symptoms and physical findings; however, an increased serum tryptase level is a useful biomarker. Epinephrine is the first-line drug to treat acute symptoms, and an epinephrine auto-injector should be prescribed for each patient. Antihistamines and systemic corticosteroids are used to relieve symptoms. This review updates current issues in the management of anaphylaxis as well as the new guidelines for proper diagnosis and treatment.

Allergenicity assessment and allergen profile analysis of different Chinese wheat cultivars

Backgrounds

As one of the most important cereals, wheat (Triticum aestivum) can cause severe allergic reactions, such as baker's asthma, allergic rhinitis, and atopic dermatitis. A growing number of people are developing allergies to Chinese wheat; however, only a few wheat cultivars have been screened on allergenicity in China.

Objective

The aim of the present study was to assess the allergenicity of different Chinese wheat cultivars and characterize wheat allergen profiles of patients with allergic rhinitis.

Methods

We determined protein (soluble protein, gliadin, and glutenin) composition in Chinese wheat by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), and the immunoglobulin E (IgE) binding capacity by enzyme-linked immunosorbent assay (ELISA) and Western blot using 10 positive sera from wheat allergy patients. We identified 5 gel bands with significant IgE binding capacity using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Results

Soluble protein, albumin, and globulin, showed the highest allergenicity, followed by gliadin, while glutenin only had slight allergenicity. In soluble protein, 5 protein bands with molecular weights of 27, 28, 53, 58, and 62 kDa showed very significant allergenicity. Meanwhile, the relative abundances of 28 kDa-protein and 58 kDa-protein were significantly positively correlated with the IgE-binding capacity of Chinese wheat cultivars, which were identified as rRNA N-glycosidase and β-amylase, respectively, among other proteins in those highly complex gel bands.

Conclusion and clinical relevance

28 kDa-protein (rRNA N-glycosidase) and 58 kDa-protein (β-amylase) were speculated to be the main allergens of Chinese wheat causing baker's asthma and allergic rhinitis. These results provide new insights into the prevention and treatment of wheat allergy and the development of hypoallergenic wheat products, whose clinical significance is worth further evaluation.

The Diagnosis and Management of Allergic Reactions Caused by Chinese Materia Medica

Traditional Chinese medicines (TCM) have been used in China for thousands of years. Although TCM has been generally perceived to be safe, adverse reactions to Chinese materia medica (CMM) have been reported. Most of the adverse reactions are allergic in nature, but other mechanisms may play a role. This review focuses on the mechanism and clinical presentation of these allergic reactions. Allergic reactions can occur as a result of the active and inactive ingredients of CMM. Impurities and chemicals generated during the production process can also lead to allergic or adverse reactions. Environmental factors such as temperature, humidity, and light can cause changes in the allergenicity of drugs. Human error in formulating CMM drugs also contributes to adverse drug reactions. The management of allergic reactions to CMM includes taking a good history, avoidance of medications in the same class as those which caused prior reactions, the proper training of staff, adherence to manufacturer guidelines and expiration dates, evaluation of benefit and risk balance, and the formulation of a risk management strategy for the use of CMM. A small test dose of a considered drug before using, improvements in drug purification technology, and proper storage and clinical administration help reduce allergic reactions due to CMM.

China Consensus Document on Allergy Diagnostics

The prevalence of allergic diseases has increased dramatically in recent years in China, affecting the quality of life in 40% of the population. The identification of allergens is the key to the diagnosis of allergic diseases. Presently, several methods of allergy diagnostics are available in China, but they have not been standardized. Additionally, cross-sensitization and co-sensitization make allergy diagnostics even more complicated. Based on 4 aspects of allergic disease (mechanism, diagnosis procedures, allergen detection in vivo and in vitro as well as the distribution map of the most important airborne allergens in China) and by referring to the consensus of the European Society of Allergy and Clinical Immunology, the World Allergy Organization, and the important literature on allergy diagnostics in China in recent years, we drafted this consensus of allergy diagnostics with Chinese characteristics. It aims to standardize the diagnostic methods of allergens and provides a reference for health care givers. The current document was prepared by a panel of experts from the main stream of professional allergy associations in China.

Feasibility of a 3-step protocol of wheat oral immunotherapy in children with severe wheat allergy

Background

Wheat allergy is not an uncommon event among Thai children. Despite strict avoidance, some patients developed reactions after accidental exposure to minute amount of wheat and thus disturbed their quality of life. Wheat oral immunotherapy (OIT) has been reported to be an alternative treatment for such patients.

Objective

We designed a new 3-step wheat OIT protocol for treatment of severe wheat allergy in Thai patients. The feasibility of the protocol is evaluated and is reported here in this paper.

Methods

We retrospectively reviewed medical records of 26 patients who had undergone wheat OIT during a 30-month period. The 3-step protocol consisted of an initial phase of double-blind, placebo-controlled food challenge (DBPCFC) and initiation of OIT, a build-up phase, and a maintenance phase. Patient retention in the protocol was the main outcome for this feasibility study. Adverse effects during OIT were recorded. Correlation between serum specific IgE (SpIgE) to wheat and eliciting dose in phase I was determined.

Results

Fourteen females and 12 males with a median age of 6 years were studied. Their median age when wheat allergy began was 8 months. Median SpIgE to wheat was high (198 kU_A/L). All patients developed reactions during DBPCFC with 17 of 26 patients had moderate to severe reactions required adrenaline injections. Median of eliciting dose of wheat was exceedingly low, i.e., 20 mg of wheat protein. At the end of the study, 23 of 26 patients (88%) were still in the study. Adverse reactions during the build-up phase was frequent (13 patients, 50%), with adrenaline required in 6 occasions. Six patients reached maintenance phase.

Conclusion

The new 3-step wheat OIT protocol was feasible in these highly wheat-sensitized patients. Despite a high retention rate, a high rate of adverse effects was observed both during DBPCFC and build-up phases.

A multicenter anaphylaxis registry in Korea: Clinical characteristics and acute treatment details from infants to older adults

Background

Although the prevalence of anaphylaxis is increasing worldwide, the large-scale studies in Asia evaluating anaphylaxis in all age groups are limited. We aimed to collect more precise and standardized data on anaphylaxis in Korea using the first multicenter web-based registry.

Methods

Twenty-two departments from 16 hospitals participated from November 2016 to December 2018. A web-based case report form, designed by allergy specialists, was used to collect anaphylaxis data.

Results

Within the 2-year period, 558 anaphylaxis cases were registered. The age of registered patients ranged from 2 months to 84 years, and 60% were aged <18 years. In children and adolescents, foods (84.8%) were the most common cause of anaphylaxis, followed by drugs (7.2%); in adults, drugs (58.3%) were the most common cause, followed by foods (28.3%) and insect venom (8.1%). The onset time was ≤10 min in 37.6% of patients. Among the 351 cases registered via the emergency department (ED) of participating hospitals, epinephrine was administered to 63.8% of patients. Among those receiving epinephrine in the ED, 13.8% required 2 or more epinephrine shots. Severe anaphylaxis accounted for 23.5% cases (38.1% in adults; 13.7% in children); patients with drug and insect venom-induced anaphylaxis had higher rates of severe anaphylaxis.

Conclusion

This multicenter registry provides data on anaphylaxis for all age groups for the first time in Asia. The major causes and severity of anaphylaxis were remarkably different according to age group, and the acute treatment features of anaphylaxis in the EDs were examined in detail.

Gut microbiome alterations in patients with wheat-dependent exercise-induced anaphylaxis

The intestinal microbiota plays a critical role in food allergy development. However, little is known regarding the structure and composition of the intestinal microbiota in patients with wheat-dependent exercise-induced anaphylaxis (WDEIA). We examined the gut microbiota alterations in patients with WDEIA and the microbiota's association with WDEIA. Fecal samples were collected from 25 patients with WDEIA and 25 healthy controls. Environmental exposure factors were obtained, serum total IgE, IgE specific to wheat, gluten, and ω-5 gliadin were measured. Fecal samples were profiled using 16S rRNA gene sequencing. The relative abundances of the bacterial genera Blautia (P < 0.05), Erysipelatoclostridium (P < 0.01), Akkermansia (P < 0.05) and Lachnospiraceae_NK4A136_group (P < 0.05) were significantly increased, while those of Lactobacillus (P = 0.001) and Dialister (P < 0.05) were significantly decreased in subjects with WDEIA. The microbial diversity did not differ between WDEIA patients and healthy controls. IgE specific to ω-5 gliadin was positively associated with the Oscillospira (r = 0.48, P < 0.05) and negatively associated with Leuconostoc (r = -0.49, P < 0.05). Total IgE levels were significantly negatively correlated with Bifidobacterium (P < 0.05). The gut microbiome compositions in WDEIA patients differed from those of healthy controls. We identified a potential association between the gut microbiome and WDEIA development. Our findings may suggest new methods for preventing and treating WDEIA.

Regional Differences in Food Allergies

The prevalence of food allergies is increasing worldwide. To understand the regional specificities of food allergies and develop effective therapeutic interventions, extensive regional epidemiological studies are necessary. While data regarding incidence, prevalence, regional variation, and treatment in food allergies are available for western countries, such studies may not be available in many Asian countries. China accounts for almost 20% of the world's population and has a vast ethnic diversity, but large-scale meta-analyses of epidemiological studies of food allergy in China are lacking. A literature search revealed 22 publications on the prevalence of food allergy in Chinese populations. A review of these studies showed that the prevalence of food allergies in China is comparable to that in western countries, even though the Chinese diet is vastly different from that of the West and may vary even greatly within China, and finally, specific antigenic triggers of food allergy vary between China and the West and also within China. Current clinical management of food allergy in China includes allergen-specific immunotherapy, Chinese herbal medicine, acupuncture, and Western medicine. This study demonstrates an unmet need in China for a thorough investigation of the prevalence of food allergies in China, the specific foods involved, and characterization of the specific antigenic triggers of food allergy with respect to ethnicity, age, and diet in China.

Anaphylaxis - Lessons learnt when East meets West

The rapidly increasing prevalence of allergic disorders over the past 2 decades highlights the need to understand the epidemiology of anaphylaxis. In Europe, the United States, and Australia, the incidence of anaphylaxis is estimated to be between 60 and 950 cases per 100 000 population, with a lifetime prevalence of anaphylaxis of 0.05%-2%. The incidence appears to be increasing over time. Although the existing Asian literature is heterogeneous and limited by under-reporting, it also suggests a similar increasing trend in anaphylaxis incidence in Asia. Anaphylaxis triggers in Asia, such as the predominance of shellfish and wheat in older children and adolescents, differ from those seen in Western populations. Triggers unique to Asia such as traditional Chinese medications, galacto-oligosaccharides, and food delicacies have also been reported. Low usage of adrenaline as first-line treatment of anaphylaxis is evident across all countries and is particularly concerning. There is a need to establish prospective, standardized protocols for anaphylaxis data collection and reporting, to enhance the collective understanding of anaphylaxis and its burden, gaps in management and to identify areas for future research and intervention in each region. Understanding of the underlying reasons explaining the difference between East and West will facilitate future primary preventive strategies.

Idiopathic anaphylaxis yardstick: Practical recommendations for clinical practice

Anaphylaxis is considered idiopathic when there is no known trigger. The signs and symptoms of idiopathic anaphylaxis (IA) are identical to those of anaphylaxis because of a known cause and can include cutaneous, circulatory, respiratory, gastrointestinal, and neurologic symptoms. Idiopathic anaphylaxis can be a frustrating disease for patients and health care providers. Episodes are unpredictable, and differential diagnosis is challenging. Current anaphylaxis guidelines have little specific guidance regarding differential diagnosis and long-term management of IA. Therefore, the objective of the Idiopathic Anaphylaxis Yardstick is to use published data and the authors' combined clinical experience to provide practical recommendations for the diagnosis and management of patients with IA.

Clinical utility of basophil activation test in diagnosis and predicting severity of mugwort pollen-related peach allergy

Background

Cross-reactivity between pollen and plant foods results in low specificity of food-IgE and skin prick testing, which may cause over-diagnosis. A test that can accurately diagnose pollen-related food allergy and identify patients at risk of developing severe reactions is needed. This study evaluates basophil CD63 expression as a biomarker for diagnosis and predicting severity of mugwort pollen-related peach allergy.

Methods

Based on their allergic reactions to peach, an oral allergy symptom group (OAS, n ​= ​15), a systemic reaction group (SR, n ​= ​23), a peach-sensitized but tolerant group (PST, n ​= ​21) and a non-peach-sensitized nonallergic group (NSE, n ​= ​10) were identified among mugwort pollen allergic patients. Measurements of specific IgE to peach and its components, and basophil activation test (BAT) were performed.

Results

Upon stimulation with peach extract, BAT in peach-allergic patients (OAS and SR groups) showed a significant dose-dependent upregulation of CD63 compared with PST patients, but showed no difference between SR and OAS groups. BAT to Pru p 3 could discriminate not only between sensitization and clinical allergy, but also between OAS and systemic reactions. BAT to Pru p 3 revealed 92% sensitivity, 95% specificity, 92% positive predictive value, and 92% negative predictive value. Receiver operating characteristic curves showed that BAT to Pru p 3 had the largest area under the curve.

Conclusions

In the diagnosis of mugwort pollen-related peach allergy, BAT to Pru p 3 is superior to testing for IgE specific for peach and its components. Additionally, basophil activation can predict clinical severity.

Food-Induced Anaphylaxis: Role of Hidden Allergens and Cofactors

Food anaphylaxis is on the increase, with those who have an allergy to peanuts, tree nuts, milk, and seafood at the highest risk of developing such a reaction. However, the diet in many societies is increasingly varied, much of the food consumed is prepared outside the home, and meals are often composed of many different ingredients. Anaphylaxis may occur to a composite food, and it may be unclear whether the reaction is due to contamination or to a culprit allergen present in an added ingredient. Composite foods can contain many allergic proteins present in small amounts, which do not always have to be labeled, unless they feature in European or US labeling regulations. These "hidden" allergens include mustard, celery, spices, lupine, pea, natural food colourings, and preservatives, but can occasionally include allergenic material from contaminants such as cereal mites. Hidden allergens can provoke severe reactions to seemingly unconnected foods which might then lead to a diagnosis of idiopathic anaphylaxis. The same problem can arise with two well-known types of food allergy; wheat-dependant exercise induced anaphylaxis and allergy to non-specific Lipid Transfer Protein allergens, both of which might only manifest when linked to a cofactor such as exercise. Many of these risk factors for food anaphylaxis have a common link; the public's engagement with popular concepts of health and fitness. This includes the development of a food and exercise culture involving the promotion and marketing of foods for their health-giving properties i.e., meat substitutes, wheat substitutes, supplements and alternative, or "natural" remedies for common ailments. Some of these foods have been reported as the cause of severe allergic reactions, but because they are often viewed as benign unlikely causes of severe allergic reactions, could be considered to be hidden allergens. The best resource to elicit the likelihood of a hidden allergen provoking an allergic reaction is to take a detailed history of the allergic reaction, presence of co-factors, foods suspected, type of food and where it was consumed. A good knowledge of commonly used ingredients, and list of potential hidden allergen suspects are essential tools for the food allergy detective.

Wheat allergy in patients with recurrent urticaria

Background

Clinical observation revealed that most of wheat-induced anaphylaxis (WIA)/wheat-dependent exercise-induced anaphylaxis (WDEIA) patients showed a history of recurrent urticaria. We aim to determine the association between recurrent urticaria and anaphylaxis in wheat allergy.

Methods

Population-based cohort study involved patients with WIA (n = 193, including WDEIA n = 104), recurrent urticaria (n = 177), non-wheat-related anaphylaxis (n = 584), atopic disease (excluding anaphylaxis, n = 221) and healthy control (n = 95) from 2009 to 2016. Detailed course of urticaria and anaphylaxis were obtained from medical records and following-up questionnaire. Serum IgE specific to wheat, gluten and ω-5 gliadin and skin prick test to wheat were examined. Clinical and laboratory data were statistically analyzed.

Results

In recurrent urticaria patients, wheat allergy was not rare, and 6.8% (n = 12) was diagnosed as wheat-induced urticaria. Patients with WIA/WDEIA had higher prevalence of recurrent urticaria history than those with non-wheat-related anaphylaxis (164/193, 84.9% vs 85/584, 14.5%), and 70.4% of them (136/193) had recurrent urticaria prior to their first anaphylactic attack. Among patients with WIA/WDEIA and previous urticaria, 46.3% experienced an exacerbation of urticaria. The value of serum specific IgE to ω-5 gliadin was significantly higher in patients with WIA/WDEIA than those with wheat-induced urticaria.

Conclusions

We recommend screening wheat allergy in recurrent urticaria to identify patients who have a potential risk to develop severe reactions earlier.

A New Diagnostic Criteria of Wheat-Dependent, Exercise-Induced Anaphylaxis in China

Background:

Wheat-dependent, exercise-induced anaphylaxis (WDEIA) is an allergic reaction induced by intense exercise combined with wheat ingestion. The gold standard for diagnosis of WDEIA is a food exercise challenge; however, this test is unacceptable for Chinese WDEIA patients and unable to be approved by the Ethics Committee of Chinese hospitals due to substantial risk. There are no diagnostic criteria for Chinese WDEIA patients. The aim of present study was to propose new practical diagnosis criteria for Chinese WDEIA patients.

Methods:

We prospectively included 283 clinically diagnosed WDEIA patients from January 1, 2010 to June 30, 2014, and in the meanwhile, three groups were enrolled which included 133 patients with the history of anaphylaxis induced by food other than wheat, 186 recurrent urticaria patients, and 94 healthy participants. Clinical comprehensive evaluation by allergists used as the reference gold standard, receiver operator characteristic (ROC) curves were plotted, areas under curve (AUC) for specific immunoglobin E (sIgE) were compared to evaluate the diagnostic value of IgE specific to wheat, gluten, and ω-5 gliadin. Patients were followed up by telephone questionnaire 1 year after diagnosis.

Results:

We reviewed 567 anaphylactic reactions in 283 WDEIA patients. Of these anaphylactic reactions, 415 (73.3%) reactions were potentially life-threatening anaphylaxis. Among the 567 anaphylactic reactions, 75% (425/567) occurred during exercise. The highest AUC (0.910) was observed for sIgE for gluten, followed by omega-5 gliadin (AUC 0.879). Combined gluten- and ω-5 gliadin-specific IgE testing provided sensitivity and specificity of 73.1% and 99.0%, respectively. During the 1-year follow-up period, repeat anaphylaxis was rare when patients observed strict avoidance of wheat products combined with exercise or other triggering agents.

Conclusions:

In this study, we proposed diagnostic criteria and management of WDEIA patients in China. Our present study suggested that confirmed anaphylactic reactions triggered by wheat with positive sIgE to gluten and omega-5-gliadin may provide supportive evidence for clinicians to make WDEIA diagnosis without performing a food exercise challenge.

Allergen immunotherapy for food allergy from the Asian perspective: key challenges and opportunities

Introduction: Prevalence of food allergy is rising in different regions of the world. Asia has not been spared from this epidemic, but epidemiological data have revealed a different pattern of food allergens in this continent. Allergen-specific immunotherapy (AIT) for food allergy, which has been revolutionary as the main focus of research in recent years, needs to be adapted for the different populations in Asia. Areas covered: Recent evidence shows increasing popularity and superiority of AIT over strict food avoidance as the cornerstone of food allergy management. Asia is a distinctive continent with specific food allergy triggers, in particular, seafood, and wheat. Peanut, on the contrary, is not a common food allergen in most parts of Asia. The common Asian food allergens, as well as the rapidly developing food-specific AIT in this region will be covered in this article. Expert commentary: Evidence on oral immunotherapy for wheat allergy and preclinical data on shellfish AIT are promising. Further work should be done on resolving cross-sensitization between environmental allergens with wheat and shellfish allergens, and a modified AIT approach to enhance the safety and effectiveness of food-specific immunotherapy.

Asian children living in Australia have a different profile of allergy and anaphylaxis than Australian-born children: A State-wide survey

BACKGROUND

Asian children born in Australia have higher rates of eczema and nut allergy than non-Asian children. However, it is not known whether this country of birth differential exists for other allergies or anaphylaxis risk.

OBJECTIVE

We investigated the influence of maternal and child's country of birth on the prevalence of parent-reported eczema, asthma, food allergy and being diagnosed by a doctor as being "at risk of anaphylaxis."

METHODS

We assessed the relationship between mother and child country of birth and allergies using the 2010 School Entrant Health Questionnaire, completed for 57 005 5-year old children (85.8% response rate) in Victoria, Australia. Analyses were conducted using logistic regression with results presented as odds ratios (OR) with 95% confidence intervals (CIs).

RESULTS

Children born in Australia to Asian-born mothers were more likely to have parent-reported food allergy (OR 2.33, 95%CI 1.96-2.77) and eczema (OR 2.04, 95%CI 1.73-2.41), but not more likely to have asthma (OR 0.87, 95% CI 0.74-1.02) than non-Asian children. By contrast, children born in Asia who subsequently migrated to Australia had a lower risk of food allergy (OR 0.33, 95%CI 0.20-0.55), eczema (OR 0.37, 95%CI 0.24-0.57) and asthma (OR 0.29, 95% CI 0.21-0.40). Patterns of anaphylaxis risk differed depending on the trigger. Compared with Australian-born non-Asian children, Australian-born Asian children were more likely to be diagnosed as being at risk of both food-induced and non-food-induced anaphylaxis. For children born in Asia, risk was lower for anaphylaxis to milk, peanut and tree nuts compared to non-Asian children, but higher for soy, wheat and non-food triggers.

CONCLUSIONS AND CLINICAL RELEVANCE

Patterns of allergy/anaphylaxis risk and their triggers differed according to both ethnicity and country of birth, suggesting a gene-environment factor is in play. The difference in patterns for asthma compared with other atopic diseases is surprising and warrants further exploration.

Prevalence triggers and clinical severity associated with anaphylaxis at a tertiary care facility in Saudi Arabia: A cross-sectional study

Anaphylaxis is a systemic and hypersensitive allergic reaction caused by various triggers such as environmental, food, drug, and insects. The aim of this study was to identify the prevalence, triggers, and clinical severity of anaphylaxis in 2 emergency departments (EDs) in Saudi Arabia.A cross-sectional study based on a screening of medical records was conducted between January 2015 and August 2017, to identify confirmed cases of anaphylaxis. Patient characteristics were age, sex, previously known allergies, and the triggering allergens. The clinical severity was measured on the basis of the anaphylaxis international assessment tool (mild, moderate, severe). Factors associated with triggers and severities were identified.The period prevalence of anaphylaxis among ED admissions was 0.00026%. Pediatric cases (age 1-16 years) were 98 (60.9%), while adults (age 17-40 years) were 63 (39.1%). Triggers of anaphylaxis were food 63 (39.1%), insects 62 (38.5%), drugs 28 (17.4%), and environmental 8 (5.0%). Mild symptoms were observed in 41 (25%) of the sample, while moderate and severe symptoms were observed in 116 (72%) and 4 (3%) of the cases, respectively. Adults were 1.25 times more likely to endure drug allergy rather than food allergy, than pediatrics with adj.P = .015. ED admissions in summer season were 1.29 less likely to be due to drug allergy rather than insect allergy, compared with admissions in winter season, adj.P = .01. Cases with known allergy were 1.72 times less likely to endure drug allergy rather than food allergy, compared with those with unknown allergy, adj.P = .001. Adults were 4.79 more likely to endure severe symptoms than pediatrics with adj.P = .001.Although the prevalence of anaphylaxis was higher in pediatrics, yet the disease was more severe in adults. Special consideration should be paid to anaphylaxis triggered by insect bites in summer, and food allergy among cases with unknown allergy upon ED admission.

Traditional Chinese medicine and drug-induced anaphylaxis: data from the Beijing pharmacovigilance database

Background Traditional Chinese medicine (TCM) is one of the major triggers for drug-induced anaphylaxis (DIA). Objective We aimed to use the Beijing pharmacovigilance database (BPD) to analyze TCM-induced DIAs in Beijing, China. Setting Drug allergy case reports from the BPD provided by the Beijing Center for Adverse Drug Reaction Monitoring. Method Drug allergy cases from January 2004 to December 2014 were adjudicated. DIA triggered by TCMs were analyzed and compared with those triggered by non-TCM drugs by calculating the reported risk ratio (RRR). We also calculated the RRRs based on severe DIA and death outcomes. Main outcome measure TCMs implicated in DIAs were identified and compared with non-TCM drugs. Results TCMs accounted for 1651 (18.2%) of the total 9074 allergic cases, in which 84.4% (1393/1651) were triggered by injections. Of the TCM allergic cases, 8.5% (141) were DIAs and 7.3% (120) were severe DIAs, and three patients died from injections. The RRR between TCMs and non-TCM-induced DIAs was 0.63. When anaphylactic cases were compared between TCMs to the top four non-TCM drug triggers, RRRs were 0.73 (95% CI 0.61-0.87) for antibiotics, 0.36 (95% CI 0.29-0.44) for radiocontrast agents, 0.55 (95% CI 0.43-0.68) for chemotherapeutics, and 0.29 (95% CI 0.23-0.37) for biologics. Compared to TCM oral or topic formulations, TCM injections had higher RRRs in each of the above comparisons. Conclusion TCM was associated with a decreased risk of DIA compared to non-TCM drugs in drug allergy cases, and the risk was higher for TCM injections.

When nutrition and allergy collide: the rise of anaphylaxis to plant foods

PURPOSE OF REVIEW

Interest in nutrition is increasing, but in the world of internet health gurus, whilst the nutritional benefits of fruits and vegetables are extolled, wheat is often vilified. This review will assess the positive nutritional effects of plant foods in relation to allergy prevention, the effectiveness of gluten-avoidance and the likelihood of anaphylaxis to fruits and vegetables.

RECENT FINDINGS

Although the numbers of people who report gluten sensitivity is rising, hard evidence of mass sensitivity to gluten is scant. Also, the avoidance of wheat containing foods could lead to nutritional imbalance and effects on the gut microbiome. The evidence that fruits and vegetables have a protective effect on the development of allergy is inconsistent, although fruit juices may promote beneficial changes to gut microflora. Fruits and vegetables can cause severe allergic reactions, especially due to the presence of lipid transfer proteins, but this is not just a Mediterranean phenomenon, and not limited to peaches.

SUMMARY

These findings emphasise the importance of a keeping an open mind about reported reactions to plant foods, to ensure the correct diagnosis is made and nutrition is optimised to prevent any adverse effects of avoidance on the gut microbiome.

Pediatric allergy and immunology in China

Over the past 30 years, China has enjoyed rapid economic development along with urbanization at a massive scale that the world has not experienced before. Such development has also been associated with a rapid rise in the prevalence of allergic disorders. Because of the large childhood population in the country, the burden of childhood allergic disorders has become one of the major challenges in the healthcare system. Among the Chinese centers participating in the International Study of Asthma and Allergies in Childhood, the data clearly showed a continuing rise in the prevalence of asthma, allergic rhinitis, and atopic eczema. However, the discipline of pediatric allergy in mainland China is still in its infancy due to the lack of formal training program and subspecialty certification. Clinicians and researchers are increasingly interested in providing better care for patients with allergies by establishing pediatric allergy centers in different regions of the country. Many of them have also participated in national or international collaborative projects hoping to answer the various research questions related to the discipline of pediatric allergy and immunology. It is our hope that the research findings from China will not only improve the quality of care of affected children within this country but also the millions of patients with allergies worldwide.