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• W2100068566 abstract "Confusion continues to surround the clinical diagnosis and nomenclature of IgE-mediated food allergies related to primary pollen sensitization. The term ‘Oral Allergy Syndrome’ (OAS) was first used by Amlot et al. in 1987 to refer to food-allergic reactions which initially present with oral symptoms, prior to progressing to other systemic manifestations of IgE-mediated reactivity including anaphylaxis 1. No reference was made to OAS being associated with pollen sensitization, although the observation that pollen cross-reactivity might be associated with oral symptoms to food had been suggested by Anderson in 1970 2. It was only in 1988 that ‘OAS’ was used to describe oral symptoms to fruit and vegetables in pollen-allergic patients 3. In an attempt to improve nomenclature, the term pollen food allergy syndromes (PFAS) – also referred to as pollen food syndrome (PFS) – was subsequently proposed to describe the latter entity 4, 5. However, over the past two decades, both PFAS and OAS have been used interchangeably, including in recent international guidelines 6, 7. The debate is not purely one of semantics. It is likely that for the majority of patients, an accurate diagnosis of a primary IgE-mediated food allergy or of PFAS (in which food reactions are thought to be due to pollen-related cross-sensitization to plant-derived food allergens) can assist with risk stratification and management advice. Patients with PFAS are generally considered to be at lower risk of systemic food-allergic reactions, due to inherent lability of the causative allergens that are susceptible to modification by the gastric environment, rendering them non-reactive 8. Many, if not most, individuals with primary IgE-mediated food allergy will exhibit oral symptoms to low doses of food allergen. These patients will often progress to systemic symptoms and anaphylaxis with further allergen exposure 9, as was the case with 50% of Amlot's original cohort 1. There are reports in the literature of patients with PFAS experiencing wheezing with allergic reactions to the causative food 10, and there is no consensus on whether adrenaline auto-injector devices (AAI) might be indicated in patients with PFAS 9. Where an allergic subject with a label of PFAS or OAS experiences systemic symptoms, this could be because they in fact have primary food allergy; this situation confounds the existing data on risk of systemic symptoms in true PFAS. Furthermore, PFAS can also be caused by the presence of IgE to lipid-transfer proteins (LTPs), a situation more common in Southern Europe where cross-reactivity between pollen-associated LTPs and related foods are associated with a higher risk of severe systemic reactions 11. There are several potential consequences of incorrectly labelling a patient with PFAS (or OAS) where primary IgE-mediated food allergy is the correct diagnosis. The severity of the food allergy may be underestimated, with advice for ongoing allergen ingestion and with it, the potential risk for subsequent anaphylaxis. Provision of an AAI will often depend on the clinician's ability to distinguish between these two syndromes. Significant regional variations in predominant pollen sensitization and primary plant food allergens makes this area even more confusing, with generalization of regional data across regions problematic 8. A survey of US allergists in 2003 found evidence that patients with primary food sensitization were frequently labelled as having OAS, which might result in patients with potentially severe allergies being managed inappropriately 5. A more recent survey in the UK of 193 health care professionals reported similar findings 12. Both surveys included a scenario of a patient with mild systemic reaction (oral pruritis, lip angioedema and urticarial rash over upper torso) due to fresh peach. Sixty-one percent of UK respondents and 20% of US respondents described this scenario as being consistent with PFAS/OAS; 24% and 77% respectively would have prescribed an AAI. Sixty-four percent of respondents in the UK survey reported that OAS and PFAS are interchangeable terms. In contrast to the US study, the vast majority of practitioners did not recommend AAI for PFAS/OAS, which raises the concern that some subjects with primary food allergy but misdiagnosed as PFAS/OAS would not be considered for AAI provision. What is clearly required is an improved understanding of these syndromes, their patterns of presentation and the development of better diagnostics to assist in distinguishing between: (A) relatively benign PFAS, where cross-reactivity is directed to labile allergens such as Bet v 1 homologues and profilins; (B) PFAS, where cross-sensitization is directed against stable food proteins associated with systemic allergic reactions, such as LTPs and seed storage proteins; and (C) primary IgE-mediated food allergy to plant allergens, where oral symptoms have been the predominant or only initial symptoms. Oral food challenges are the current standard tool used for food allergy diagnosis in the clinical setting. However, discrimination between primary plant food allergy and PFAS with subjective oral and gastrointestinal symptoms alone is problematic, even when using double-blind, placebo-controlled food challenge (DBPCFC) 8. Component resolved diagnostics (CRD) may prove of value in this area. Detection of IgE to Ara h 8 (a Bet v 1-homologous allergen) but not other peanut epitopes may be a useful predictor of PFAS with low risk of systemic reactions 13 while sensitization to the lipid-transfer protein Ara h 9 may indicate a higher risk of anaphylaxis 14, 15. However, we are aware of patients with ‘exclusive’ sensitization to Ara h 8 who have experienced systemic symptoms to peanut; presumably, such individuals have specific IgE to other peanut epitopes not currently measured with existing CRD techniques. Furthermore, there is a report of an individual with ‘exclusive’ sensitization to Ara h 8 who passed an oral food challenge to peanut but subsequently experienced anaphylaxis with hypotension and respiratory compromise after eating an unusually large amount of peanut on an empty stomach 16. Several non-pollen-related storage proteins, including Cor a 9 (a 11s globulin) and Cor a 14 (a 2S globulin), have been shown to be relatively specific for primary hazelnut allergy 17, and able to distinguish irrelevant cross-sensitization to hazelnut in areas of high endemic birch and allergic individuals 18. Within the Mediterranean region, Cor a 8 (a LTP) is associated with high rates of systemic allergy to hazelnut 19. In this issue of CEA, Masthoff et al. 20 provide data demonstrating how hazelnut allergy in adults is different from that occurring in children, with adults predominantly presenting with a birch pollen-associated-PFAS and children with a primary IgE-mediated hazelnut allergy. They performed DBPCFC to confirm hazelnut allergy in 95 adults, of whom 96% developed oral symptoms, 78% had subjective symptoms only and 22% progressed to experience objective symptoms with further allergen exposure. Most adults reported only mild symptoms on previous hazelnut exposure and had a physician-diagnosis of birch pollen allergy. In those adults with a diagnosis of birth pollinosis, almost one quarter experienced objective symptoms during challenge that were not consistent with OAS. This was in contrast to their previous study 21 of hazelnut allergic children – in whom primary food allergy might be expected to be more frequent, and aeroallergen sensitization less common – who experienced objective symptoms far more frequently using the same challenge protocol and had a lower incidence of birch pollinosis. Of note, the authors report systemic allergic reactions to hazelnut at DBPCFC in 22% of their adult cohort, despite the majority experiencing oral symptoms in the first instance. Clearly, just being an adult does not exclude either primary hazelnut allergy or a hazelnut allergy with systemic allergic potential beyond the gastrointestinal tract, with 10% of this cohort having respiratory symptoms on DBPCFC. Similarly, a diagnosis of birch pollinosis was as common in those with objective symptoms as those with only subjective symptoms consistent with PFAS to hazelnut. Use of adrenaline (ever) or during challenge was not reported. It is possible that had DBPCFC not been stopped after recurrent subjective oral symptoms were reported by patients, a higher rate of systemic reactions may have occurred. The authors highlight the need to take account of age, prior history of birch pollinosis and prior symptoms to assist with the diagnosis of hazelnut allergy. They report that ssIgE and skin prick test (SPT) to hazelnut were not reliable diagnostics tools for adult hazelnut allergy and that a history of previous reactions of only mild oral symptoms combined with birch pollinsois was the most useful parameter (AUC of ROC curve 0.83). In contrast, hazelnut SPT was the best preforming diagnostic tool for the paediatric cohort (AUC 0.89). Unfortunately the authors did not report CRD parameters for their population, which would have provided potentially useful data. Allergic disease related to pollen-associated cross-sensitization to plant-derived food allergens continues to be poorly defined and often confused with primary food allergy. In general, the incidence of true PFAS likely increases with age, but is subject to significant regional and individual variations, causing problems for allergic individuals and clinicians alike. International guidelines need to be updated to reflect the difference between PFAS, PFAS with sensitization to stable plants allergens (such as LTPs) and food allergy to plant-based food allergens presenting with predominantly oral symptoms. Further research is required to understand the differing patterns of allergen component sensitization between these syndromes, the frequency of potentially life-threatening symptoms in PFAS, and clinical and laboratory predictors of anaphylaxis. In summary, it is high time we wake up and see the pollen from the trees. The authors declare no conflict of interest." @default.
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• W2100068566 title "A food allergy syndrome by any other name?" @default.
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