An internet-based survey on the circumstances of food-induced reactions following the diagnosis of IgE-mediated food allergy

BACKGROUND: Despite careful avoidance measures, food allergic patients have a significant risk of anaphylactic episodes. Risk situations need to be identified for more efficient preventive measures. METHODS: Responders to an internet-based survey on the awareness of food anaphylaxis were invited to relate the circumstances of their most severe reaction following the diagnosis of IgE-mediated food allergy. Items of the questionnaire included the circumstances of the reaction and the treatment, as well as questions related to reactions occurring at specific categories of sites (i.e. home, schools, or restaurants). RESULTS: Fifty-one of the returned questionnaires (34.1%) corresponded to the study criteria. The median age of the subjects was 7 years (range 0.5-61), with 33/51 (64.7%) being less than 16 years of age. Reactions were reported to peanuts (24/51; 47.1%), milk (12/51; 23.5%), tree nuts (6/51; 11.8%), fish and shellfish (5/51; 9.8%), and others (3/51; 5.8%). Reactions occurred at home (13/51; 25.5%), in restaurants (9/51; 17.6%), at school or daycare or kindergarten (8/51; 15.7%), at a relative or friend's home (7/51; 13.7%), at sites of leisure activities (6/51; 11.8%), at work (3/51; 5.9%), in church or a hospital ward (2/51; 3.9% each), or in a food store (1/51; 2.0%). In severe reactions (37/51; 72.5%) epinephrine was administered in 28/37 (75.7%) of the responders. Finally, while most reactions happened after ingestion of the food (40/51; 78.4%), others were reported after skin contact exclusively (8/51; 16%), or after inhalation (3/51; 5.9%). CONCLUSION: Food induced-anaphylaxis in patients aware of their allergy happens most often at sites considered as safe (i.e. home, schools, workplace, hospitals). Better strategies to avoid accidental reactions include clear labelling of forbidden foods and increased information at all levels. These might dramatically reduce the risk of food-induced anaphylaxis in food allergy sufferers.     

Exercise-induced anaphylactic reaction to hazelnut

Reproducible, exercise-induced anaphylactic reactions occur in some patients only after certain foods have been eaten before exercise. We describe a patient in whom hazelnuts were a triggering factor for exercise-induced anaphylaxis. Skin tests and RAST were positive for nuts and grass and weed pollen. The exercise challenge test after hazelnut ingestion was positive. Food hypersensitivity should be investigated in all cases of exercise-induced anaphylaxis.     

Severe anaphylactic reaction to thymostimulin

Thymostimulin is a partially purified extract of calf thymus, consisting of a group of polypeptides with a total molecular weight of approximately 12,000 D. It is used as an immunologic response modifier in primary and secondary immunodeficiencies. We report a patient who had a severe anaphylactic reaction with the first injection of thymostimulin. Type I hypersensitivity to thymostimulin was suggested by an immediate skin test response, specific IgE determination by indirect ELISA and a positive histamine release test. This patient also reacted to bovine serum albumin (BSA), fetal calf serum (FCS) and cow hair and dander. The controls did not react to any of these tests. Clinicians need to be aware that the use of medical products of xenogeneic origin may lead to severe allergic reactions.     

Fatalities due to anaphylactic reactions to foods

Fatal anaphylactic reactions to foods are continuing to occur, and better characterization might lead to better prevention. The objective of this report is to document the ongoing deaths and characterize these fatalities. We analyzed 32 fatal cases reported to a national registry, which was established by the American Academy of Allergy, Asthma, and Immunology, with the assistance of the Food Allergy and Anaphylaxis Network, and for which adequate data could be collected. Data were collected from multiple sources including a structured questionnaire, which was used to determine the cause of death and associated factors. The 32 individuals could be divided into 2 groups. Group 1 had sufficient data to identify peanut as the responsible food in 14 (67%) and tree nuts in 7 (33%) of cases. In group 2 subjects, 6 (55%) of the fatalities were probably due to peanut, 3 (27%) to tree nuts, and the other 2 cases were probably due to milk and fish (1 [9%] each). The sexes were equally affected; most victims were adolescents or young adults, and all but 1 subject were known to have food allergy before the fatal event. In those subjects for whom data were available, all but 1 was known to have asthma, and most of these individuals did not have epinephrine available at the time of their fatal reaction. Fatalities due to ingestion of allergenic foods in susceptible individuals remain a major health problem. In this series, peanuts and tree nuts accounted for more than 90% of the fatalities. Improved education of the profession, allergic individuals, and the public will be necessary to stop these tragedies.     

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects

This review highlights some of the research advances in anaphylaxis and hypersensitivity reactions to foods, drugs, and insects and in allergic skin disease that were reported primarily in the Journal in 2006. Advances in diagnosis include identification of food proteins to which IgE binding is associated with severe reactions; elucidation of diagnostic relationships of skin prick test wheal size with outcomes of egg, tree nut, and sesame allergy; evaluation of the diagnostic utility of atopy patch testing for food; and the observation that yellow jacket sting outcomes are influenced by species. Mechanistic observations include the following: heating of birch pollen-related foods disrupts IgE binding but not T-cell epitopes; a simple imbalance of T(H)1/T(H)2 response does not explain variations in clinical expression of peanut allergy; and elucidation of the role of dendritic cells in drug hypersensitivity. With regard to treatment, a rapidly disintegrating epinephrine tablet showed promise for sublingual treatment of anaphylaxis, RNA interference techniques showed promise in creating lower-allergenic foods, and anti-IL-5 showed promise for treatment of eosinophilic esophagitis. Progress in our understanding of the immunology and the etiology of skin barrier dysfunction in atopic dermatitis has also been made. These observations will likely contribute toward optimizing management of these common allergic disorders.     

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2007

This review highlights some of the research advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects that were reported primarily in the Journal in 2007. Advances in diagnosis include possible biomarkers for anaphylaxis, improved understanding of the relevance of food-specific serum IgE tests, identification of possibly discriminatory T-cell responses for drug allergy, and an elucidation of irritant responses for vaccine allergy diagnostic skin tests. Mechanistic studies are discerning T-cell and cytokine responses central to eosinophilic gastroenteropathies and food allergy, including the identification of multiple potential therapeutic targets. Regarding treatment, clinical studies of oral immunotherapy and allergen vaccination strategies show promise, whereas several clinical studies raise questions about whether oral allergen avoidance reduces atopic risks and whether probiotics can prevent or treat atopic disease. The importance of skin barrier dysfunction has been highlighted in the pathogenesis of atopic dermatitis (AD), particularly as it relates to allergen sensitization and eczema severity. Research has also continued to identify immunologic defects that contribute to the propensity of patients with AD to have viral and bacterial infections. New therapeutic approaches to AD, urticaria, and angioedema have been reported, including use of sublingual immunotherapy, anti-IgE, and a kallikrein inhibitor.     

Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011

This review highlights some of the research advances in anaphylaxis; hypersensitivity reactions to foods, drugs, and insects; and allergic skin diseases that were reported in the Journal in 2011. Food allergy appears to be increasing in prevalence and carries a strong economic burden. Risk factors can include dietary ones, such as deficiency of vitamin D and timing of complementary foods, and genetic factors, such as filaggrin loss-of-function mutations. Novel mechanisms underlying food allergy include the role of invariant natural killer T cells and influences of dietary components, such as isoflavones. Among numerous preclinical and clinical treatment studies, promising observations include the efficacy of sublingual and oral immunotherapy, a Chinese herbal remedy showing promising in vitro results, the potential immunotherapeutic effects of having children ingest foods with baked-in milk if they tolerate it, and the use of anti-IgE with or without concomitant immunotherapy. Studies of allergic skin diseases, anaphylaxis, and hypersensitivity to drugs and insect venom are elucidating cellular mechanisms, improved diagnostics, and potential targets for future treatment. The role of skin barrier abnormalities, as well as the modulatory effects of the innate and adaptive immune responses, are major areas of investigation.     

An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions

Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate‐type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.     

Allergic reactions in the community: a questionnaire survey of members of the anaphylaxis campaign

BACKGROUND: Allergic reactions to food are well recognized in both children and adults, but because of their relative infrequency their typical features may not be readily recognized by patients and their medical care givers who are not allergists. OBJECTIVE: We sought to investigate the circumstances and clinical characteristics of food allergies in adults and children in the community. METHODS: Self-completed questionnaire responses over a 6-month period from 109 members of the Anaphylaxis Campaign, the major British patient resource group for people who have suffered severe allergic reactions. RESULTS: One hundred and nine respondents reported 126 reactions during the study period. Seventy-five were children (under 16 years, median age 6 years at the time of reaction). Predictably more boys than girls were reported to have had reactions but more women reported reactions than men (P<0.05). Although the groups were equally aware of their food allergies the children had undergone diagnostic tests more often (P<0.001). Foods were implicated in 112 (89%) of reports. Restaurants were implicated less often (14%) than in other series, probably reflecting British eating habits. Children with asthma reported more severe reactions than those without asthma (P=0.008), although frequency or severity of recent asthma symptoms was not associated with severity of allergic reaction reported. When available, self-injectable adrenaline was used in 35% of severe reactions and 13% of non-severe reactions (P=0.01). A quarter of adults who received one dose of adrenaline also received a second dose. CONCLUSION: The allergens implicated in this report reflect previous data from similar patient groups in North America. Asthmatic children suffer more severe reactions than non-asthmatic children. It appears that British adults need better access to expert care of their allergies. Even when it is prescribed and available self-injectable adrenaline appears under-used in severe reactions. The incidence of severe but non-fatal allergic reactions in the UK may have been underestimated in the past.