Leguminosas como causa infrecuente de alergia alimentaria en Colombia: reporte de dos casos y revisión de la literatura / Legumes as an infrequent cause of food allergy in Colombia: report of two cases and review of the literature

La alergia alimentaria se ha venido incrementando a nivel mundial, afectando alrededor del 1,5 % a 2,5 % de los adultos y 6 % de los niños, y tiene un gran impacto en la calidad de vida de los pacientes y sus cuidadores, debido a las dietas de restricción. Los alérgenos más prevalentes son la leche, el huevo, el trigo, la soja, los frutos secos, el maní, el pescado y los mariscos. Las leguminosas mejor estudiadas son el maní y la soja; otras leguminosas como las lentejas, garbanzos y arvejas representan la quinta causa de alergia alimentaria en el área mediterránea, en Turquía y en la India, siendo menos prevalentes en otras áreas geográficas. La alergia a las leguminosas es una entidad infrecuente en Colombia, se desconoce la prevalencia en el país. Describimos los primeros dos casos de anafilaxia por lentejas reportados en el país. Ambos pacientes menores de 18 años, con reacciones adversas tras la ingesta de leguminosas, en las cuales se demuestra alergia mediada por IgE a las lentejas y además sensibilización en el primer caso a las arvejas y garbanzos, y en el segundo caso a los frijoles. Diferentes datos sobre la prevalencia se han descrito en varias áreas geográficas, siendo mayor en países con dietas mediterráneas. Las reacciones mediadas por IgE suelen aparecer incluso con el alimento altamente cocido, debido a la termo-estabilidad de las proteínas. La reactividad cruzada más frecuente se relaciona con los garbanzos y las arvejas

Food allergy has been increasing worldwide. Affects around 1.5% to 2.5% of adults and 6% of children, and has a great impact on the quality of life of patients and their caregivers, due to restricted diets. The most prevalent allergens are milk, egg, wheat, soy, tree nuts, peanuts, fish and shellfish. The best studied legumes are peanuts and soybeans; other legumes such as lentils, chickpeas and peas represent the fifth cause of food allergy in the Mediterranean area, Turkey and India, being less prevalent in other geographical areas. Allergy to legumes is not common in Colombia, the prevalence in the country is unknown. We describe the first two cases of legumes anaphylaxis reported in the country. Both patients were under 18 years of age, with adverse reactions after ingesting legumes, in which IgE-mediated allergy was demonstrated; in the first case to lentils, peas and chickpeas, and in the second case, to lentils and beans. Different data on prevalence have been described in various geographical areas, being higher in countries with Mediterranean diets. IgE-mediated reactions usually appear even with highly cooked food, due to the thermo-stability of proteins. The most frequent cross-reactivity is related to chickpeas and peas

Special topic: The association between pulse ingredients and canine dilated cardiomyopathy: addressing the knowledge gaps before establishing causation.

In July 2018, the Food and Drug Administration warned about a possible relationship between dilated cardiomyopathy (DCM) in dogs and the consumption of dog food formulated with potatoes and pulse ingredients. This issue may impede utilization of pulse ingredients in dog food or consideration of alternative proteins. Pulse ingredients have been used in the pet food industry for over 2 decades and represent a valuable source of protein to compliment animal-based ingredients. Moreover, individual ingredients used in commercial foods do not represent the final nutrient concentration of the complete diet. Thus, nutritionists formulating dog food must balance complementary ingredients to fulfill the animal's nutrient needs in the final diet. There are multiple factors that should be considered, including differences in nutrient digestibility and overall bioavailability, the fermentability and quantity of fiber, and interactions among food constituents that can increase the risk of DCM development. Taurine is a dispensable amino acid that has been linked to DCM in dogs. As such, adequate supply of taurine and/or precursors for taurine synthesis plays an important role in preventing DCM. However, requirements of amino acids in dogs are not well investigated and are presented in total dietary content basis which does not account for bioavailability or digestibility. Similarly, any nutrient (e.g., soluble and fermentable fiber) or physiological condition (e.g., size of the dog, sex, and age) that increases the requirement for taurine will also augment the possibility for DCM development. Dog food formulators should have a deep knowledge of processing methodologies and nutrient interactions beyond meeting the Association of American Feed Control Officials nutrient profiles and should not carelessly follow unsubstantiated market trends. Vegetable ingredients, including pulses, are nutritious and can be used in combination with complementary ingredients to meet the nutritional needs of the dog.

Role of specific IgE in predicting the clinical course of lentil allergy in children.

BACKGROUND: Legumes, and particularly lentils, are frequently consumed in Mediterranean, Middle Eastern, and some Asian countries. The aim of this study was to document the demographic features of children with lentil allergy and to determine the role of specific IgE (sIgE) in predicting the risk of clinical reactivity and disease persistence. METHODS: Thirty children were enrolled. The diagnosis of lentil allergy was based on convincing history of symptoms or anaphylaxis after the ingestion of lentils, with positive skin tests and/or sIgE to lentils. To determine the diagnosis and prognosis of lentil allergy, 24 children were evaluated with food challenges. RESULTS: The median age at the onset of symptoms was 1.5 yr (0.9-2.3) (inter-quartile range). The most frequent symptoms were immediate cutaneous (97%) and respiratory (30%) reactions, whereas eight patients (27%) reported anaphylactic reactions. The median level of lentil sIgE at the time of diagnosis was 3 kU/l (1.2-9.6). Of the 24 challenges, 12 were positive. Fifteen patients (50%) outgrew the lentil allergy by the age of 3.5 (2.5-11) years. Children with an initial lentil sIgE < 4.9 kU/l had a significantly higher likelihood (68.4% vs. 18.2%) of outgrowing the lentil allergy than children with an initial lentil sIgE ≥ 4.9 k/l (p = 0.008). CONCLUSIONS: Our results suggest that sIgE levels may be important for predicting clinical reactivity and persistence of lentil allergy.

Urticaria and anaphylaxis in a child after inhalation of lentil vapours: a case report and literature review.

BACKGROUND: Among legumes, lentils seem to be the most common legume implicated in pediatric allergic reactions in the Mediterranean area and India, and usually they start early in life, below 4 years of age. CASE REPORT: A 22 -month-old child was admitted to our Pediatric Department for anaphylaxis and urticaria. At the age of 9 months she presented a first episode of angioedema and laryngeal obstruction, due to a second assumption of lentils in her diet. At admission we performed routine analyses that were all in the normal range, except for the dosage of specific IgE, that revealed a positive result for lentils. Prick tests too were positive for lentils, while they were all negative for other main food allergens. The child also performed a prick by prick that gave the same positive result (with a wheal of 8 mm of diameter). The child had not previously eaten lentils and other legumes, but her pathological anamnesis highlighted that the allergic reaction appeared soon after the inhalation of cooking lentil vapours when the child entered the kitchen Therefore a diagnosis of lentils vapours allergy was made. CONCLUSIONS: Our case shows the peculiarity of a very early onset. In literature there are no data on episodes of anaphylaxis in so young children, considering that our child was already on lentils exclusion diet. Therefore a diet of exclusion does not absolutely preserve patients from allergic reactions, that can develop also after their cooking steams inhalation.

Anaphylaxis induced by lentil inhalation.

Anaphylaxis is a rapid onset serious allergic reaction which may be fatal. Foods are the most common allergens leading to anaphylaxis especially for childhood. Most of the food-induced anaphylactic reactions take place after ingestion of the allergic food and only a few cases exist with anaphylactic reactions induced by inhalation of foods such as peanut, soybean and lupine. The case we present is unusual in that an 8 1/2-year-old boy developed anaphylaxis with the inhalation of steam from boiling lentils.

Effect of instant controlled pressure drop on IgE antibody reactivity to peanut, lentil, chickpea and soybean proteins.

BACKGROUND: The use of legume seeds is being expanded in the food industry due to their excellent nutritional and technological properties. However, legumes have been considered causative agents of allergic reactions through ingestion. Previous studies indicated that processing methods combining heat and steam pressure, such as instant controlled pressure drop (DIC®), could decrease allergenicity. The aim of this study was to investigate the impact of DIC treatment on peanut, lentil, chickpea and soybean IgE antibody reactivity. METHODS: Peanut, lentil, chickpea and soybean seeds were subjected to DIC treatment at different pressure and time conditions (3 and 6 bar for 1 and 3 min). Control (raw) and DIC-treated extracts were analyzed by SDS-PAGE and immunoblotting using a serum pool from sensitized patients. RESULTS: DIC treatment did not affect the total protein content of legume seeds. Nevertheless, modifications of protein profiles after DIC showed a general decrease in IgE binding to legume proteins that was correlated to a higher steam pressure and longer treatment. The immunoreactivity of soybean proteins was almost abolished with treatment at 6 bar for 3 min. CONCLUSIONS: The results demonstrated that DIC treatment produces a reduction in the overall in vitro IgE binding of peanut, lentil and chickpea and a drastic reduction in soybean immunoreactivity.

Clinical features of legume allergy in children from a Mediterranean area.

BACKGROUND: Lentils, chickpeas, beans, and peas are the most common consumed legumes in the Mediterranean area. However, there is little information about allergy to these legumes. OBJECTIVES: To describe the clinical features of a Spanish pediatric population allergic to legumes (lentils, chickpeas, peas, white beans, and peanuts), to evaluate the clinical allergy to several legumes, and to determine which legume extract is most appropriate to use in the diagnosis of legume allergy by skin tests. METHODS: Fifty-four children with allergic reactions after exposure to legumes were studied. The diagnosis of legume allergy was confirmed by positive skin prick test results with legume extracts and food challenges or a recent convincing history of severe reactions. RESULTS: The onset of allergic reactions was at approximately the age of 2 years (median, 22 months). Skin prick test results were positive for at least 3 legumes in 38 children (70%). Positive results were more frequent to boiled extracts than to raw extracts in children with a positive oral challenge. Allergy to lentil was the most frequently diagnosed legume allergy (43 children [80%]), followed by allergy to chickpea (32 children [59%]). Oral challenges with more than 1 legume (median, 3 legumes) were positive in 37 children (69%). The most frequent induced symptoms on challenge were respiratory (rhinitis and/or asthma) and cutaneous. CONCLUSION: In this population, lentils and chickpeas are the legumes that cause most allergic reactions, clinical allergy to more than 1 legume is common, and boiled legume extracts are most appropriate to discriminate between allergic and tolerant sensitized children.

In vitro and in vivo cross-reactivity studies of legume allergy in a Mediterranean population.

BACKGROUND: Legume allergy, mainly to lentils and chickpeas, is the fifth most common cause of food allergy in Spanish children. Serological cross-reactivity among legumes is frequent, but its clinical relevance is controversial. The aim of this study was to investigate the cross-reactivity among lentils, chickpeas, peas, white beans and peanuts and its clinical relevance in pediatric patients. METHODS: Fifty-four children with clinical allergy to legumes were included. Cross-reactivity was evaluated by ELISA inhibition experiments and oral food challenges to legumes. SDS-PAGE immunoblots were conducted with raw and boiled legume extracts. RESULTS: ELISA inhibition experiments demonstrated more than 80% inhibition with lentil, chickpea and pea extracts. Immunoblots performed with raw legume extracts (lentil, chickpea and pea) and individual sera revealed that more than 50% of the sera identified an allergen with approximately 50 kDa in all three legume extracts. In all three boiled extracts an intense band at approximately 50 kDa was visualized using a serum pool. The oral legume challenges demonstrated that 37 children (69%) were allergic to 2 or more legumes (median 3 legumes). The most frequent associations were allergy to lentils and chickpeas (57%), allergy to lentils and peas (54%) and allergy to lentils, chickpeas and peas (43%). CONCLUSIONS: In vitro inhibition experiments demonstrated a high degree of cross-reactivity among lentils, chickpeas and peas. Food challenges confirmed that clinical allergy to all three legumes is frequent in our cohort of Spanish children.

Food-dependent exercise-induced anaphylaxis to lentil and anaphylaxis to chickpea in a 17-year-old boy.

We report the case of a 17-year-old boy who experienced 4 episodes of exercise-induced anaphylactic reaction after ingestion of lentil and 2 episodes of anaphylaxis following ingestion of chickpea. His medical history revealed that he had allergic rhinitis with positive results after skin prick tests (SPT) with mites. His SPTs and specific immunoglobulin E antibody testing with lentil and chickpea were positive. Oral challenge with chickpea was not performed due to patient refusal. Treadmill exercise challenge tests in the fasting state and 1 hour after a meal not containing lentil were negative. However, an exercise challenge test 1 hour after intake of lentil soup resulted in pruritus of the hands, forearms, shoulders, and back, urticarial lesions on the face and shoulders, mild angioedema of the lips, and mild hoarseness and cough. To our knowledge, this is the first case of food-dependent exercise-induced anaphylaxis due to lentil.