Latex-fruit syndrome

Natural rubber latex immunoglobulin E-mediated hypersensitivity is probably one of the most relevant challenges that has been faced in the treatment of allergies during recent years. Additionally, allergen cross-reactivity has arisen as another very important problem, in the difficulty in diagnosing it and in its clinical implications. It is clear that some latex allergens cross-react with plant-derived food allergens, the so-called latex-fruit syndrome, with evident clinical consequences. Although the foods most frequently involved are banana, avocado, kiwi, and chestnut, several others are also implicated. Investigations point to a group of defense-related plant proteins, class I chitinases, which cross-react with a major latex allergen, hevein, as the panallergens responsible for the syndrome. This review focuses on our current understanding of the latex-fruit syndrome.     

Latex allergy in children.

Allergic or immediate hypersensitivity reactions to natural rubber latex have been reported in children with increasing frequency in the last few years, although severe anaphylactic reactions are rare. Indubitably rubber has been employed in thousands and thousands of everyday products for over a century, yet only recently has natural rubber latex allergy been recognized as a substantial medical problem. Children with spina bifida undergoing multiple surgical procedures, as well healthy babies appear at high risk for natural rubber latex allergy, with life-threatening reactions reported during surgery or while playing with balloons. Skin prick testing is the preferred diagnostic method, especially in the prick by prick version. Parents of children with latex allergy should take caution that their babies avoid contact with rubber products, and that a latex-free environment is set during procedures. Since even minimal contact with natural rubber latex products may produce reactions, the primary treatment for latex allergy is avoidance. In this paper we review the new natural rubber latex allergens, as well as the cross-reactions regarding the latex-fruit syndrome since the recent characterization of a number of profilins has also greatly widened the number of possible reactions.     

Food allergy in gastroenterologic diseases： Review of literature

INTRODUCTION Food allergy is recognized as a common worldwide prob- lem, and, like other atopic disorders, its incidence seems to increase. Moreover, food-related allergic disorders are the leading cause of anaphylactic reactions treated in the emer- genc…     

Identification of latex UDP glucose pyrophosphorylase (Hev b UDPGP) as a novel cause of latex fruit allergy syndrome

Based on a recently published unusual ase of food allergy in a latex-allergic patients, the present study identifies Hev b UDPGP as a novel allergen in natural rubber latex able to cause latex-fruit allergy syndrome and as a novel, potential pan-allergen in vegetable foods.     

Latex allergy: Review of recent advances

Latex allergy is an IgE-dependent immediate hypersensitivity reaction to latex proteins. Risk factors for latex allergy are contact with latex products and atopy. Children who undergo multiple surgical procedures and healthcare workers are the major groups at risk. Powdered latex gloves are an important source of sensitization. Preventive measures are leading to reduction in latex sensitization and allergic reactions. The prevalence of latex allergy in the general population may be as low as 0.1%, whereas the frequency of latex sensitization is reported to be 7%; this may be due to cross-reacting antipollen IgE. The most important latex allergens have been purified, and some have been cloned and sequenced. Many latex-allergic patients are also allergic to common plant-derived aeroallergens and foods. The structural and biologic relationships among plant-derived food allergens, including latex, explain these clinically important cross-reactions.     

Allergy to cassava: a new allergenic food with cross-reactivity to latex.

Patients who are allergic to latex (Hevea brasiliensis) may exhibit cross-hypersensitivity with foods. We present a case of anaphylaxis due to cassava in a patient suffering from pollinosis, latex allergy, and latex-fruit syndrome. We performed sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting with cassava, avocado, chestnut, banana, kiwi, and latex extracts in order to analyze the protein bands and their molecular weights, and identify immunoglobulin (Ig) E-binding bands. Immunoblot inhibition and enzyme-linked immunosorbent assay (ELISA) inhibition were performed with latex in order to assess cross-reactivity. Cassava exhibited numerous protein bands, 5 of which were IgE-binding (89.75, 46.28, 26.68, 21.38, and 19.49 kd). These cassava IgE-binding bands were 100% inhibited by preincubation of the patient's serum with latex extract. The ELISA inhibition between latex and cassava was 23%. Our results confirm cassava as another food with clinical cross-reactivity in patients suffering from latex allergy.     

Food allergy in adolescents and adults

There has been an increase in the prevalence of food allergy in the last few decades. Adult food allergy may represent persistence of reactions that commenced in infancy and early childhood or it may be initiated in adulthood through new sensitizations. Persistence of peanut allergy is an example of the former situation. Approximately 20% of children will develop tolerance to peanuts, so there will be an increasing number of individuals reaching adulthood where this problem will need ongoing management. In addition to peanut, tree nuts, fruits, vegetables and seafood are implicated as common causes of food allergy in adulthood. Sensitization may occur directly to a food allergen or indirectly through cross-reactivity with an aeroallergen. Adults may present with a spectrum of clinical manifestations from oral allergy syndrome to fatal anaphylaxis. The management of food allergy consists of appropriate education regarding avoidance of implicated foods, modifying potential risk factors for anaphylaxis, such as asthma and prompt recognition and treatment of acute reactions.     

IgE-mediated food allergy--extensive review of the literature

Adverse reactions to food, i.e. food allergy and intolerance have gained considerable attention. This overview focuses on the diagnosis and management of IgE-mediated food allergy that is believed to be responsible for most immediate-type food-induced hypersensitivity reactions. Clinically, these reactions are characterised by a variety of signs and symptoms that occur within minutes or hours after consumption of the offending food. Reactions may be limited or more generalised with involvement of the skin, nose, eyes, and/or lungs. In more severe cases, cardiovascular symptoms including hypotension, shock, cardiac dysrhythmias and death can occur. In food-allergic individuals, IgE is produced against naturally occurring food components, primarily glycoproteins that usually retain their allergenicity after heating and/or proteolysis. While adults tend to be allergic to fish, crustaceans, peanuts and tree nuts, children tend to be allergic to cow's milk, egg white, wheat and soy more frequently. "Emerging" food allergens include tropical fruits, sesame seeds, psyllium, spices and condiments. These allergies frequently represent a cross-allergy to an allergen derived from another source, e.g. pollens or natural rubber latex. The evaluation of IgE-mediated food allergy relies on a careful history, physical examination, appropriate skin testing or in vitro testing with food extracts, and/or double blind, placebo-controlled food challenges. Avoidance remains the mainstay of therapy. However, allergens may be "hidden" and labelling can be non-precise or misleading, thereby severely hampering prevention. Patients with severe allergies should keep at hand an emergency kit with adrenaline, an antihistamine and an injectable rapid onset-of-action corticosteroid. At present there is no evidence to support the use of immunotherapy, except for research purposes. Production of "hypoallergenic" food is hampered by incomplete methods for assessing the allergenic potential of such novel foods.     

IGE-mediated natural rubber latex allergy: an update

In the past 2 decades, IgE-mediated NRL allergy has become a well-defined condition with recognised risk groups, established diagnostic tools, and adequate prevention strategies (1-3). Furthermore, molecular biology and biochemical techniques have significantly improved our knowledge of the proteins responsible to cause the disease. Clinical manifestations will not be addressed in this review, nor will broad preventive strategies be proposed; these have been discussed elsewhere (4, 5). After a brief introduction this review will focus on specific issues: (1) How do we estimate the prevalence of NRL allergy and who is at risk for clinical sensitisation? (2) What specific allergens cause NRL allergy? How does sensitisation for these allergens occur? Are all patients sensitised for the same allergens? Threshold allergen exposure levels. (4) What is the latex-fruit syndrome? What is the clinical relevance of a positive plant food specific IgE quantification in patients with NRL allergy? (5) How do we diagnose NRL allergy? What are the strengths and weaknesses of currently available diagnostic tools? (7) How do we manage NRL allergy? What is the role of medication and immunotherapy in the treatment of NRL allergy? How do we select an appropriate non-NRL alternative for NRL gloves? Which regulatory provisions have been implemented?     

Natural rubber latex allergy: a problem of interdisciplinary concern in medicine

In the past 10 years, IgE-mediated allergy to natural rubber latex has become a significant health problem in industrialized countries, especially among health care workers, patients with congenital malformations, and children with a history of multiple surgical interventions. Curative treatment inducing immunological tolerance in formerly sensitized patients is experimental and not yet generally available. Therefore, it is important to be aware of the seriousness of latex allergy and to understand the risk factors leading to this allergy. Preventive measures are needed to decrease the incidence of natural rubber latex sensitization. This article gives a brief review of the current state of knowledge concerning latex allergy, including a definition of latex, epidemiological data, identified allergens, the clinical spectrum, diagnostic procedures, cross-reactions, preventive measures, the legislative background, and economics.     

Asthma and food allergy

PURPOSE OF REVIEW: Food allergy associated clinical and social burdens have increased substantially in prevalence in the past decade. Coexisting asthma is a significant problem as food reactions tend to be more severe when they involve the lung. Food allergy also increases asthma morbidity in adults and children. RECENT FINDINGS: Especially in early infancy, food allergy can be related to the development of future asthma. For diagnosis, cut-off values are very important for both specific IgE levels and skin-prick test when interpreting food allergy. For the treatment, oral immunotherapy is showing promise for refractory patients with IgE-mediated food allergies. SUMMARY: Food allergies can be classified as IgE-mediated or non-IgE-mediated. Besides foods, some additives and preservatives can also trigger asthma in certain people. Asthma may develop in about 5% of individuals who suffer from food allergy and current asthma may be triggered by foods among 6-8% of children and 2% of adults. Because of the difficulty of confirming diagnosis of food allergy, novel approaches are currently being investigated and new therapy modalities are being sought. For total asthma control and for better quality of life, steps should be taken to avoid foods in cases of food allergy.     

Prevalence of food allergy in 137 latex-allergic patients.

There have been reports of increased prevalence of certain food allergies in patients with Type I latex allergy (LA). A detailed food allergy history was obtained from 137 patients with LA. Latex allergy was defined by positive history of IgE mediated reactions to contact with latex and positive skin prick test to latex and/or positive in vitro test (AlaSTAT and/or Pharmacia CAP). Food allergy was diagnosed by a convincing history of possible IgE mediated symptoms occurring within 60 minutes of ingestion. We identified 49 potential allergic reactions to foods in 29 (21.1%) patients. Foods responsible for these reactions include banana 9 (18.3%), avocado 8 (16.3%), shellfish 6 (12.2%), fish 4 (8.1%), kiwi 6 (12.2%), tomato 3 (6.1%), watermelon, peach, carrot 2 (4.1%) each, and apple, chestnut, cherry, coconut, apricot, strawberry, loquat, one (2.0%) each. Reactions to foods included local mouth irritation, angioedema, urticaria, asthma, nausea, vomiting, diarrhea, rhinitis, or anaphylaxis. Our study confirms the earlier reports of increased prevalence of food allergies in patients with LA. We also report increased prevalence of shellfish and fish allergy not previously reported. The nature of cross reacting epitopes or independent sensitization between latex and these foods is not clear.     

Allergic reactions occurring during anaesthesia: diagnostic approach

Anaphylactic and anaphylactoid reactions to anaesthetic and associated agents used during the perioperative period have been increasingly reported during the last 3 decades. The frequency of life-threatening hypersensitivity reactions occurring during anaesthesia has been estimated to vary between 1/1.000 and 1/25.0000 procedures, with muscle relaxants being involved in almost three quarters of the cases. The mortality from these reactions is in the range of 3-6%. Nowadays, natural rubber latex also accounts for a significant number of perioperative anaphylaxis, particularly in children. Clinical manifestations do not allow to differentiate between IgE-mediated anaphylaxis and anaphylactoid reactions resulting from non-specific mediator release. Successful management of these patients requires multidisciplinary approach and includes prompt recognition and stabilisation of the acute event by the attending anaesthetist, determination of the responsible agent(s) with avoidance of subsequent administration of incriminated compound(s). The latter is based upon correct identification of the responsible drug and potentially cross-reactive compounds by the allergist and requires a detailed review of the anaesthetic report as well as appropriate in vitro and in vivo allergy tests. At present, the overall performance of skin tests makes them the "gold standard" for diagnosis of muscle relaxant-induced perioperative hypersensitivity reactions. In addition, given their good negative predictive value, skin tests have been proven to be a useful tool to tailor the appropriate therapeutic alternative. For other compounds diagnosis is more difficult but newer techniques such as analysis of in vitro activated basophils can be helpful.     

L’allergie aux Rosacées chez l’enfant : à propos de vingt-deux cas

Rosaceae allergy is the fourth most frequent food allergy in Spanish children whereas it is rare in French children. The aim of the present study was to analyse the natural history of Rosaceae allergy in French children living in the Mediterranean area and to underline its specificities. We reviewed the case records of 22 children. The diagnosis of Rosaceae allergy was based on the clinical history and confirmed by skin prick tests with fresh foods and with commercial extracts and the Pharmacia CAP-RAST. Sensitivity to birch was also assessed by prick tests. The patients were divided into two groups: 12 children who were sensitised to Rosaceae and to birch pollen and eight who were sensitised to Roseacea only. The diagnostic value of prick tests with commercial extracts for Roseacea allergy was poor in both of these groups. The birch-negative group had become allergic to peaches first, and all of these children were sensitive to extracts of the cooked native fruits that were responsible for their clinical reactivity. Severe allergic reactions had occurred more frequently in this group. Prick tests with commercial extracts were positive only in this group. In contrast, the birch-positive group was more frequently allergic to apples, and the oral allergy syndrome was common among them. The median level of sensitisation to fresh fruits was also higher in this group. French children living in the Mediterranean appear to have a specific Rosaceae sensitisation profile: 60% of them have a Northern Europe profile (birch–apple allergy) and 40% of them have a Spanish–Italian profile (lipid-transfer protein allergy).     

Microarray based IgE detection in poly-sensitized allergic patients with suspected food allergy - an approach in four clinical cases

BackgroundComponent-resolved diagnosis and microarray technology have been recently introduced into clinical allergy practice, and may be particularly useful in poly-sensitized allergic patients.MethodsWe compare the clinical usefulness of a microarray-based IgE detection assay (ISAC^®) with skin tests and specific IgE with standard allergens (sIgE) or their monocomponents in four case reports of patients poly-sensitized to aeroallergens and food.ResultsCase 1: a woman with rhinitis, oral allergy syndrome to several fruits and anaphylaxis to cherry. Diagnostic tests supported non-specific lipid transfer proteins (nsLTPs) primary sensitization.Case 2: a woman with exercise-induced asthma, rhino-conjunctivitis and oral allergy syndrome to fresh fruits of different families. A diagnosis of primary grass and weed pollen allergy with profilin and pathogenesis-related protein family 10 (PR-10) cross-reactive food allergy was proposed.Case 3: a man with atopic eczema, asthma, rhinitis, and multiple anaphylactic episodes with cashew nuts and oral allergy syndrome to fruits. The diagnostic workup supported a primary birch pollen allergy with PR-10 and nsLTPs cross-reactive food allergy.Case 4: a woman with rhino-conjunctivitis, per-operative anaphylaxis due to latex and recent pharyngeal angio-oedema episodes. The diagnosis was a primary grass and weed pollen allergy with equivocal profilin sensitization and no obvious cross-reactivity mediated by nsLTPs sensitization.ConclusionsThe possibility to carry out multiple sIgE measurements with single protein allergens, in particular with the microarray technique, is a useful, simple and non-invasive diagnostic tool in complex poly-sensitized allergic patients.     

Food allergy and the respiratory tract

Previous studies have confirmed that IgE-mediated, food allergy-induced respiratory tract symptoms occur, typically accompanied by cutaneous or gastrointestinal symptoms. The possibility that respiratory tract symptoms are food allergy induced should be considered in patients who have a current or past history of one or more of the following: atopic dermatitis, wheezing (or experiencing anaphylactic symptoms) after ingesting a particular food or foods, and confirmed food allergy. Moreover, the work-up of food allergy in asthma should be considered in patients in whom asthma is poorly controlled despite persistent use of appropriate asthma medications. A definitive diagnosis of food allergy should be based on clinical history, appropriate laboratory testing, and, when indicated, well-controlled oral food challenges. Treatment is based on establishing a safe elimination diet and an emergency plan for managing reactions caused by accidental ingestion.     

Cross-reactivity between fruit and vegetables

Vegetable foods are the most frequent cause of food allergy after the age of 5 years. The most commonly implicated foods are fruit and dried fruits, followed in Spain by legumes and fresh garden produce. In patients allergic to fruit and garden produce, multiple sensitizations to other vegetable products, whether from the same family or taxonomically unrelated, are frequent, although they do not always share the same clinical expression. Furthermore, more than 75 % of these patients are allergic to pollen, the type of pollen varying in relation to the aerobiology of the area. The basis of these associations among vegetable foods and with pollens lies in the existence of IgE antibodies against "panallergens", which determines cross-reactivity. Panallergens are proteins that are spread throughout the vegetable kingdom and are implicated in important biological functions (generally defense) and consequently their sequences and structures are highly conserved. The three best-known groups are allergens homologous to Bet v 1, profilins, and lipid transfer proteins (LTP). Allergens homologous to Bet v 1 (major birch pollen allergen) constitute a group of defense proteins (PR-10), with a molecular weight of 17 kDa, which behave as major allergens in patients from northern and central Europe with allergy to vegetables associated with birch pollen allergy. In these patients, the primary sensitization seems to be produced through the inhalation route on exposure to birch pollen. The symptomatology characteristically associated with sensitization to this family of allergens is oral allergy syndrome (OAS). Profilins are highly conserved proteins in all eukaryotic organisms and are present in pollen and a wide variety of vegetable foods. They have a molecular weight of 14 kDa and present a high degree of structural homology as well as marked cross-reactivity among one another. The presence of anti-profilin IgE broadens the spectrum of sensitizations to vegetable foods detected through skin tests and/or in vitro tests but whether it correlates with the clinical expression of food allergy is unclear.LTPs are the most commonly implicated allergens in allergy to Rosaceae fruits in patients from the Mediterranean area without birch pollen sensitization. LTPs are a family of 9kDA polypeptides, widely found in the vegetable kingdom and implicated in cuticle formation and defense against pathogens (PR-14). They are thermostable and resistant to pepsin digestion, which makes them potent food allergens and explains the frequent development of systemic symptoms (urticaria, anaphylaxis) in patients allergic to Rosaceae fruits in Spain. LTPs have also been identified in other vegetable foods and in pollens and a marked degree of cross-reactivity among them has been demonstrated, which may explain (together with profilin) the frequency of individuals sensitized to vegetable foods in the Mediterranean area.     

Anaphylaxis following ingestion of mango fruit.

Allergic reactions to fresh fruits and nuts have become increasingly common. Mango (Mangifera indica) is a popular fruit eaten all over the world. We report the case of a 43-year-old woman who experienced oropharyngeal itching, swelling of the face and other parts of the body, and difficulty breathing within a few minutes of eating ripe mango fruit. The woman had no history of pollen or latex allergy. However, she reported instances of milder food allergic reactions to Indian dill and cashew apple. Skin prick tests using mango fruit pulp, Indian dill, and cashew apple extracts were positive. Prick tests with a panel of common grass and weed pollen extracts were negative. Enzyme-linked immunosorbent assay for mango-specific serum immunoglobulin (Ig) E was positive. A specific protein allergen in mango could not be detected by immunoblotting. Based on the strongly positive clinical history and results of allergy testing, it was concluded that the woman had IgE-mediated anaphylactic reactions to mango fruit.     

Allergies associated with both food and pollen

Recent progress in understanding structural relationships between allergens has allowed their classification into molecular families. Proteins belonging to a molecular family often show some degree of IgE cross-reactivity. These cross-reactions can lead to a clinical association like birch-apple syndrome whose basis is a sensitization to a PR-10 protein (birch pollen Bet v 1) and then oral symptoms in contact to apple Mal d 1, another PR-10 family member. Food allergens implicated into pollen-food allergy syndromes differ from those linked to crustacea or milk cross-allergies: they seem unable to sensitize the patient through oral route. As a result, they most often induce weaker clinical reactions than complete allergens like those present in shrimp or cow milk. Numerous molecular families have been isolated from pollens. PR-10 and profilins have a well established role in inducing clinical reactions to food like fruits and vegetables. Some molecular families need more studies to delineate their true impact on pollen-driven food reactions: polygalacturonases, pectate lyases, isoflavone reductases, thaumatin-like, cyclophilins.... Others are found in pollen but not in eaten products: 2-EF-hand calcium binding proteins, beta expansins,... Lipid transfer proteins (LTP) are widespread plant food allergens (e.g. in peach): these proteins seem able to directly sensitize the patient through oral route. But recent data have suggested a possible additional effect of some LTP present in pollens (mugwort, olive, pellitory).     

Hidden fish substance triggers allergy.

Food allergy (hypersensitivity) is a form of adverse food reaction caused by an immunological response to a particular food. IgE-mediated food allergy is responsible for most immediate-type food-induced hypersensitivity reactions. The prevalence of food allergy in the general population, not including oral allergy syndrome, is about 1-2%. While adults might tend to be allergic to fish, crustaceans, peanuts, and tree nuts, children, on the other hand, tend to be allergic to cow's milk, egg white, wheat, and soy. Food is the most common eliciting factor of anaphylaxis (45%), followed by drugs (29%), and insect stings (21%). Our study describes a 3 1/2-year-old boy who is allergic to fish consumed via ingestion and inhalation. This case is a good example of how easily people with food allergies can unintentionally consume foods to which they allergic, and is a clear demonstration of the dangers of such effects.