In the second part of the article on food allergies (the first part appeared in DERMATOLOGIE PRAXIS 4/2013), pollen-associated food allergies, oral allergy syndrome, rare food allergy trigger pathways such as derivative allergy, kissing allergy, “connubial allergy,” and oral desensitization are discussed.
It was not until the late 1970s that Scandinavian allergists observed that 30-50% of patients with pollinosis to birch, hazel, and alder pollen reported feeling itching in the lips and palate after eating raw apples. Less frequently, the symptomatology occurred after consumption of other stone fruits, raw carrot and celery. Sensitization could be detected by scratch or prick tests with fresh material. In this enoral contact urticaria syndrome. or oral allergy syndrome (OAS), the most common symptom is not only itching of the lips and tongue or a furry sensation in the oral cavity or palate, but also a sensation of pain and discomfort immediately after eating certain foods, such as various fruits, especially apples, raw vegetables, especially carrots and celery, and nuts, especially hazelnuts and almonds. lip and tongue swelling (angioedema), hoarseness due to discrete laryngeal edema, difficulty swallowing and shortness of breath are also possible accompanying symptoms. Furthermore, sneezing, rhinorrhea, obstruction of nasal breathing and conjunctivitis are observed.
Classic immediate symptoms of gastrointestinal food allergy such as stomach cramps, vomiting, nausea, abdominal pain, abdominal colic, and diarrhea rarely present with OAS. As later studies after the introduction of molecular diagnostics with recombinant allergens showed, OAS occurs in allergic patients with sensitization to birch pollen, specifically to the thermolabile birch pollen major antigen Bet v1. Depending on the patient population studied, birch pollen-associated food allergy occurs in 40-93% of birch pollen allergic patients.
The celery mugwort spice syndrome
In the early 1980s, authors – independently of each other – from Finland, Sweden, Germany, Austria, France, and ourselves reported anaphylactic reactions or shock fragments after consumption of celery and their association with herb pollen and spice allergy. The term celery-mugwort-spice syndrome or celery-carrot-mugwort-spice syndrome was suggested. It was pointed out that in this constellation, consumption of celeriac, even cooked or as a seasoning, e.g. in soups, triggered severe reactions, in contrast to the birch pollen-celery association, in which symptoms occurred only on raw celery. In this context, it should be noted that the first report of a celery allergy originated in Zurich and was first detected by DBPCFC in 2000. In 1926, Jadassohn and Zaruski described a young woman (Marg. Z.) who became ill with urticaria, dyspnea, and high fever on three separate occasions after eating celery. No other idiosyncrasies were known, with the exception of mild hay fever. After application of celery press juice to the skin damaged by rust paper or inoculation coating, a wheal with red yard appeared, while application of the same press juice to the undamaged skin after the type of eczema test (Impermeable, 24 h) did not cause any reaction. The antigen was “coctostable” because the effect was not reversed by boiling for 5 min. The precipitates formed during boiling and dialysis were as effective as the supernatant liquids. The transfer experiment according to Prausnitz-Küstner succeeded in 18 of 20 subjects, also with celery dialysate, while the serum lost its sensitizing properties after heating for half an hour at 56 °C. The authors postulated that “therefore, our antigen cannot be a protein body and not at all a very high molecular substance, and that the apiol contained in celery is not the urticariogenic substance; for this did not produce any reaction in Z.” [1].
Were initially the associations with a botanical relationship within the family of the rose family or of the umbelliferae, it soon became apparent that the different allergens, especially Bet v1 and Bet v2 (profilins), in birch pollen are responsible for these cross-reactivities (Figs. 1 and 2).
The thermostable allergen present in mugwort pollen and celeriac has not yet been identified; a lipid transfer protein (LTP) is suspected.
The derivative allergy
The triggering of a food allergy through the mediation of a second person (mother, partner) was described as a phenomenon of derivative allergies by Erich Fuchs in 1954. Following our initial reports of an oral allergy syndrome in a birch pollen allergic patient, triggered by by a kiss of the friend who had eaten an apple before, or about a more severe reaction in a highly peanut allergic person by kissing the friend who had eaten some peanuts two hours before the rendez-vous, other case reports have appeared. In one case, saliva from the partner who had previously eaten the fruit in question was able to elicit a positive prick test in the birch and grass pollen allergic patient, but only if the saliva was tested within 5 min of eating the kiwifruit, apparently because of the instability of the kiwifruit allergen cross-reacting with birch pollen. This phenomenon is not all that uncommon; for example, of 379 allergic patients with high-grade, life-threatening allergic reactions to peanuts or other nuts, 20 (5.3%, 4 men and 16 women) reported having suffered a reaction after kissing. Symptoms ranged from oral allergy syndrome, lip swelling, and massive angioedema with eye swelling to respiratory distress with expiratory whistling in four cases. Symptoms occurred within less than one minute to 30 minutes after kissing in most cases, but occasionally after a few hours (stability of peanut and nut allergens).
Recently, the media even reported a fatal case of anaphylaxis in a 15-year-old Canadian girl with a high-grade peanut allergy after a kiss from her boyfriend, who had eaten a peanut butter sandwich shortly before. For the first time, a food allergy transmitted via semen during sexual intercourse (so-called “connubial allergy”) was also reported. The triggering food was Brazil Nuts, which the boyfriend had consumed before having sexual intercourse with the girlfriend, who was highly allergic to nuts. The prick test with semen after Brazil nut consumption was positive, but negative before ingestion. What other people eat can thus affect the quality of life of the food allergy sufferer in specific cases.
Food-dependent, exercise-induced anaphylaxis (FDEIA).
In 1979, American authors observed in a marathon runner the phenomenon that only the simultaneous action of physical exertion and ingestion of the food to which there is allergic sensitization leads to acute clinical symptoms, while exertion alone or ingestion of the food alone are unreactive. In 1983, the term food-dependent, exercise-induced anaphylaxis (FDEIA) was proposed. FDEAI is nowadays increasingly observed especially after wheat consumption and must be distinguished from exercise-induced anaphylaxis (EIA) and so-called idiopathic anaphylaxis (IA).
Oral desensitization
Since the 1980s, we have reported several times, first in the German-speaking world and later in the international medical literature, on the possibility of oral desensitization (OD) treatment with food, especially raw milk. Some authors have also used it successfully. However, it was not accepted by EAACI because there were no placebo-controlled trials and thus no scientific evidence of its efficacy (!). It was even rejected by experts. Now this method has been rediscovered by pediatricians, and the initial descriptors are not even listed in the bibliography.
In the case of high-grade allergy, the greatest caution is required when performing OD with food in native form; it requires adequate dilution of the allergen and good monitoring. Failures in OD are most likely explained by the fact that tolerance thresholds are not reached or are exceeded too quickly in cases of high sensitization. After reaching the final dosage, it is important to continue taking the tolerated food daily, because a break could break the achieved tolerance again. This first phase thus corresponds to an induction of tolerance; however, if daily application of the maintenance dose is continued for months, even years, true desensitization occurs, as evidenced by the negativity of skin tests and specific IgE determinations for milk proteins and caseins, as we were able to document (Fig. 3) [3].
In a case series of 16 female patients with IgE-mediated cow’s milk allergy, complete tolerance to milk and cheese was induced in 50% of cases after a treatment period of three to five years. Partial tolerance was achieved in four patients (25%) in that these patients were able to drink at least 1 dl of cold milk daily and tolerate some soft cheese, but not hard cheese. In four patients (25%), oral hyposensitization had to be interrupted because of repeated allergic reactions, even with dose reduction and concomitant therapy with ketotifen.
Literature:
- Jadassohn W, Zaruski M: Idiosyncrasy to celery. Arch Derm Syph 1926; 151: 93-97.
- Wüthrich B, Ballmer-Weber BK: Clinic of food allergies, in: Jäger L, et al. (Eds.): Food allergies and intolerances. Immunology – Diagnostics – Therapy – Prophylaxis. Urban & Fischer: Munich 2008: 65.
- Wüthrich B: Oral desensitization with cow’s milk in cow’s milk allergy. Pro!, in: Wüthrich B, Ortolani C (eds.): Highlights of Food Allergy. Karger: Basel Monogr Allergy 1996; 32: 236-240.
The further bibliography of the first and second part of the article can be requested from the publisher.
DERMATOLOGIE PRAXIS 2013, no. 5; 14-16
