Validation of the NUT CRACKER Diagnostic Algorithm and Prediction for Cashew and Pistachio Co-Allergy

BACKGROUND

Because of the high cross-sensitization among tree nuts, the NUT CRACKER (Nut Co-reactivity-Acquiring Knowledge for Elimination Recommendations) study proposed a diagnostic algorithm to minimize the number of required oral food challenges (OFCs).

OBJECTIVE

To validate the algorithm for cashew and pistachio allergy and determine markers for allergic severity.

METHODS

Patients (n = 125) with a median age of 7.8 (interquartile range, 5.9-11.2) years with suspected tree nut allergy were evaluated prospectively with decision tree points on the basis of skin prick test (SPT), basophil activation test (BAT), and knowledge of the coincidence of allergies. Validation of allergic status was determined by OFC. Markers of clinical severity were evaluated using the combined original and prospective cohort (n = 187) in relationship to SPT, BAT, and Ana o 3-sIgE.

RESULTS

Reactivity to cashew in SPT, BAT, and Ana o 3-sIgE and the incidence of abdominal pain on challenge were significantly higher in dual-allergic cashew/pistachio patients (n = 82) versus single cashew allergic patients (n = 18) (P = .001). All 3 diagnostic tests showed significant inverse correlation with log10 reaction doses for positive cashew OFC. The algorithm reduced overall the total number of OFCs by 72.0%, with a positive predictive value and negative predictive value of 93.0% and 99.0%, respectively. Cashew false-positives were observed primarily in hazelnut-allergic patients (P = .026). In this population, Ana o 3-specific IgE could diagnose cashew allergy with a sensitivity of more than 90% and a specificity of more than 95%.

CONCLUSIONS

The NUT CRACKER diagnostic algorithm was validated and reduced the number of diagnostic OFCs required. Markers for severity phenotypes may guide oral immunotherapy protocols, improving the risk/benefit ratio for patients.

Immunoglobulin E-Binding Pattern of Canadian Peanut Allergic Children and Cross-Reactivity with Almond, Hazelnut and Pistachio

Peanut allergic individuals can be both co-sensitized and co-allergic to peanut and tree nuts. At the moment, standard diagnostic approaches do not always allow differentiation between clinically relevant sensitization and nonsignificant cross-reactions, and the responsibility of each allergen remains unclear. The objective of this study was therefore to determine a peanut sensitization profile in a cohort of Canadian peanut allergic children and assess the immunoglobulin E (IgE) molecular cross-reactivity between peanut, almond, hazelnut and pistachio. The specific IgE (sIgE) levels of each patient serum were determined by ImmunoCAP, indirect ELISA and immunoblot to examine their sIgE-binding levels and profiles to peanut proteins. Reciprocal inhibition ELISA and immunoblotting were used to study sIgE cross-reactions between peanut and the selected tree nuts using an adjusted and representative serum pool of the nine allergic patients. The results showed that the prepared peanut and tree nut protein extracts allowed for the detection of the majority of peanut and selected tree nut known allergens. The reciprocal inhibition ELISA experiments showed limited sIgE cross-reactivities between peanut and the studied tree nuts, with peanut being most likely the sensitizing allergen and tree nuts the cross-reactive ones. In the case of hazelnut and pistachio, a coexisting primary sensitization to hazelnut and pistachio was also demonstrated in the serum pool. Reciprocal inhibition immunoblotting further revealed that storage proteins (2S albumin, 7S vicilin and 11S legumin) could possibly account for the observed IgE-cross-reactions between peanut and the studied tree nuts in this cohort of allergic individuals. It also demonstrated the importance of conformational epitopes in the exhibited cross-reactions.

Pistachio nut allergy: An updated overview

Pistachio nut (Pistacia vera) is highly appreciated for its organoleptic characteristics and potential health benefits. However, this tree nut is also responsible for triggering moderate to severe IgE-mediated reactions in allergic individuals. Currently, pistachio nut allergy has gained some special attention, mainly due to its intrinsic relation with cashew nut allergy. Like for other nuts, the prevalence of pistachio nut allergy seems to be increasing at a global scale. Until now, there are five allergenic proteins officially listed for pistachio nut (Pis v 1, Pis v 2, Pis v 3, Pis v 4 and Pis v 5). Relevant data on their biochemical classification has become available, enabling establishing a correlation with the respective clinical symptoms. The establishment of an effective allergen risk assessment is a key issue for the food industry, policy makers and regulatory agencies. Thus, the availability of fast, specific and sensitive methods to detect trace amounts of allergens in processed foods is crucial. In the specific case of pistachio nut, there are some protein- and DNA-based methods for its detection/quantification in foods, which can aid to verify label information. Accordingly, all relevant research advances on this topic were summarised, updated and critically discussed in this review.

Pistachio (Pistacia vera L.) Detection and Quantification Using a Murine Monoclonal Antibody-Based Direct Sandwich Enzyme-Linked Immunosorbent Assay

A commercially available direct sandwich enzyme-linked immunosorbent assay (ELISA) (BioFront Technologies, Tallahassee, FL, USA) using murine anti-pistachio monoclonal antibodies (mAbs) as capture and detection antibodies was evaluated. The assay was sensitive (limit of detection = 0.09 ± 0.02 ppm full fat pistachio, linear detection range = 0.5-36 ppm, 50% maximum signal concentration = 7.9 ± 0.7 ppm), reproducible (intra- and inter-assay variability < 24% CV), and rapid (post-extraction testing time ∼ 1.5 h). The target antigen was stable and detectable in whole pistachio seeds subjected to autoclaving (121 °C, 15 psi, 15, 30 min), blanching (100 °C, 5, 10 min), frying (191 °C, 1 min), microwaving (500, 1000 W, 3 min), and dry roasting (140 °C, 30 min; 168 °C, 12 min). No cross-reactivity was observed in 156 food matrices, each tested at 100,000 ppm, suggesting the ELISA to be pistachio specific. The pistachio recovery ranges for spiked (10 ppm) and incurred (10-50000 ppm) food matrices were 93.1-125.6% and 35.7-112.2%, respectively. The assay did not register any false-positive or -negative results among the tested commercial and laboratory prepared samples.

Pistachio allergy-prevalence and in vitro cross-reactivity with other nuts

BACKGROUND

Tree nut allergy is characterized by a high frequency of life-threatening reactions and is typically lifelong persistent. Some people with a pistachio nut allergy, which is common in the pistachio rich area of Iran, develop a hypersensitivity to other tree nuts as well. The aim of this study was to investigate the prevalence of pistachio nut allergy in Iran, the major pistachio cultivation region in the world. The study also addressed the presence of allergenic cross-reactivity between pistachio and other nuts, including almond, peanut, and cashew in pistachio allergic patients.

METHODS

A survey was conducted to determine whether the prevalence of pistachio allergy is affected by exposure to this nut in pistachio cultivation regions, as well as possible cross-reactivity between pistachio and other nuts including cashew, almond, and peanut. Inhibition Western blot and inhibition ELISA studies were conducted to assess the presence of allergenic cross-reactivity between pistachio and the other tree nuts.

RESULTS

Our results revealed that the prevalence of pistachio allergy is twice as much in pistachio cultivation regions than other areas. Western blotting and inhibition ELISA presented high percentages of inhibition with pistachio and cashew, followed by almond and, to some degree, peanut which indicates different levels of allergenic cross-reactivity.

CONCLUSIONS

The results indicate that exposure of people to pistachio significantly affects the prevalence of its allergic reactions. In addition, it was observed that, among pistachio allergic subjects, such exposure may affect the co-sensitivities with other nuts, including cashew and almond. The plant taxonomic classification of pistachio and other tree nuts does appear to predict allergenic cross-reactivity.

Influence of processing on the allergenic properties of pistachio nut assessed in vitro

Pistachio (Pistacia vera) is a tree nut that has been reported to cause IgE-mediated allergic reactions. This study was undertaken to investigate the distinctions between different cultivars of pistachio nut and the influence of different processing on the IgE-binding capacity of whole pistachio protein extracts. The influence of different processes on allergenicity was investigated using competitive inhibition ELISA and Western blotting assays. The Western blotting results of extracts from pistachio cultivars showed no marked difference among them. The IgE-binding capacity was significantly lower for the protein extract prepared from steam-roasted than from raw and dry-roasted pistachio nuts. The results of sensory evaluation analysis and hedonic rating proved no significant differences in color, taste, flavor, and overall quality of raw, roasted, and steam-roasted pistachio nut treatments. The most significant finding of the present study was the successful reduction of IgE-binding by pistachio extracts using steam-roast processing without any significant changes in sensory quality of product.

Clinical features of four cases with cashew nut allergy and cross-reactivity between cashew nut and pistachio

BACKGROUND

Few cases of cashew nut (CN) allergy have been reported in Japan. We evaluated the clinical features of 4 cases with CN allergy and investigated the allergens involved.

METHODS

In order to investigate the cross-reactivity between CN and pistachios, we performed ImmunoCAP inhibition tests using sera of 4 cases with positive histories of CN allergy and positive results of specific IgE measurement (ImmunoCAP) and skin prick tests. Furthermore, we analyzed the molecular weights of allergens of CN and pistachios by IgE-immunoblotting.

RESULTS

Of the 4 cases (male : female = 1:3), there were 3 cases (patient #2-4) and 1 case (patient #1) of anaphylaxis and oral allergy syndrome, respectively. The initial symptom was an oropharyngeal symptom in 3 of the 4 cases, of which 2 cases developed anaphylaxis within 10 minutes after eating only a few pieces of CN. All 4 cases reacted positively to the skin prick test with CN, although 1 case of anaphylaxis tested negatively for CN by ImmunoCAP. Additionally, in 2 cases, IgE-binding to CN and pistachio were inhibited with both pistachios and CN, indicating cross-reactivity between CN and pistachios. IgE-immunoblotting of CN using sera from the 4 cases revealed 2 bands at molecular weights of approximately 33 kd and 42 kd, whereas that of pistachios showed a single band at 36 kd. However, IgE in all 4 sera did not bind to rAna o 2.

CONCLUSIONS

In CN allergy, a small amount of CN could induce a severe anaphylactic reaction. Moreover, in cases of suspected CN allergy, reactions to not only CN but also pistachio, which could be cross-reactive to CN, should be examined.

Identification of hidden allergens: Detection of pistachio traces in mortadella

An analytical method based on the detection of specific DNA was developed and applied to mortadella samples with and without pistachio (Pistacia vera). The method is proposed for the detection of traces of pistachio deriving from previous processes or from accidental contamination, since in predisposed individuals pistachios can cause allergic reactions leading to anaphylactic shock. Three pairs of primers were identified and tested by polymerase chain reaction (PCR) on mortadella samples prepared with pistachio. Accidental contamination was also simulated. The optimized PCR was able to detect the presence of pistachio, even at low concentrations. The primers pair PSTC 1-2 is suggested for unambiguous identification of pistachio in mortadella. The limit of detection for this primers pair was 100 mg kg-1. No interference was observed from other spices or ingredients utilized in the formulation of the mortadella. The method enabled the identification of possible traces of pistachio remaining in the production plant after less than thorough washing.

Food-dependent exercise-induced anaphylaxis to pistachio

We report the case of a 16-year-old male who, 30 minutes after beginning to play football with previous ingestion of pistachio nuts, experienced an anaphylactic reaction. Prick-by-prick test with roasted pistachios was negative. Specific IgE antibodies to pistachio, cashew nuts and mango were negative. An open oral challenge test with pistachio in resting conditions was negative. Treadmill ergonometric stress in a fasting state and 60 minutes after a meal without pistachio gave negative results. A specific food exercise challenge 60 minutes after ingestion of 50 g pistachio nuts was positive, showing mild diffuse erythema and small wheals in face and thorax. To the best of our knowledge, this is the first described case of specific food dependent exercise-induced anaphylaxis to pistachio. Negative allergologic tests is an unusual condition, since most cases appear to be IgE-mediated. In this case, a positive specific food exercise challenge test provided a definite diagnosis.