Ten-year outcomes of Perioperative Anaphylaxis Workup Study in Hong Kong (PAWS-HK): Performance of diagnostic modalities.

BACKGROUND: Studies on perioperative anaphylaxis (PA) in Asia are lacking. Furthermore, allergy workup for PA has largely been limited to the "silver standard" of skin tests (ST). Using in vitro tests as an adjunct to ST may improve and overcome these diagnostic challenges. OBJECTIVE: To evaluate the clinical characteristics and diagnostic tests of patients with suspected PA through the Perioperative Anaphylaxis Workup Study in Hong Kong cohort. METHODS: Patients with a diagnosis of PA over a 10-year period were recruited into the Perioperative Anaphylaxis Workup Study in Hong Kong. We reviewed the medical records, tryptase elevation, and diagnostic tests including ST, specific immunoglobulin E, and basophil activation tests (BAT). RESULTS: In 151 patients with PA, diagnosis was reached in three-fourths of the cases (113/151, 74.8%). The most common culprits identified were neuromuscular blocking agents (25.8%), ß lactams (17.2%) and chlorhexidine (13.9%). Severe anaphylaxis was associated with female sex, older age, elevated acute tryptase levels, and more cardiovascular manifestations during induction. Skin tests remained the most sensitive diagnostic modality overall (66.2%). BAT showed better performance for chlorhexidine and gelofusine anaphylaxis, with sensitivity of 80.0% and 79.6%, respectively. Specific Immunoglobulin E indicated even higher sensitivity (95.2%) than did ST (85.0%) and BAT (80.0%) for chlorhexidine anaphylaxis but performed poorly for other drugs. CONCLUSION: Neuromuscular blocking agents remain the most common culprit in PA. There was a higher prevalence of gelofusine anaphylaxis in our cohort than was seen in the literature. Skin tests remain the most sensitive testing modality. In vitro tests for chlorhexidine and gelofusine showed promising results, but more studies to further elucidate its use are warranted.

High volume of polysorbate-containing (Tween® 80) solutions induces false-positive results in intradermal test.

BACKGROUND: Intradermal test is used to detect causative allergens in IgE-mediated hypersensitivity. The surfactant polysorbate 80 can be added to intradermal test solutions to more reliably dissolve the allergen and ensure a constant bioavailability of the injected allergen. Polysorbate 80 has, however, some histamine-releasing properties which could blur the difference to the histamine-induced wheal. Routinely serving as a control. OBJECTIVE: Allergen-free polysorbate 80 containing (0.005%) test solutions were therefore systematically tested at different injection volumes to see whether polysorbate can falsify skin reactions and if yes whether conditions can be identified to avoid this. METHODS: In a partly blinded study, 30 patients were tested intracutaneously at the back: each received at three separate sites 0.05 mL of polysorbate-containing solvent, 0.02 mL polysorbate-containing solvent as well as 0.02 mL polysorbate-free solvent. After 15 min, wheal and erythema were documented and planimetrically quantified. RESULTS: Unexpectedly 23 of 30 (77%) patients showed false-positive test reactions to the volume of 0.05 mL of the polysorbate-containing solvent whereas the polysorbate-containing solvent with 0.02 mL and the polysorbate-free solvent with 0.02 mL injection volume had no reinforcing effect on skin test reaction. CONCLUSIONS: Different volumes of polysorbate-containing solutions, all recommended by manufacturers for intradermal tests, may significantly influence test results. The study shows that a polysorbate 80 used at 0.005% in solvents for intradermal test to provide a better bioavailability of allergens produces false-positive reactivity in a surprising and a hitherto unknown 77% if the 0.05 mL volume is injected. It is, therefore, mandatory to strictly adhere to an intradermal test volume of 0.02 mL as only then falsifying effects of the polysorbate additive are avoided, and comparable test results are ensured.

New skin test for detection of bovine tuberculosis on the basis of antigen-displaying polyester inclusions produced by recombinant Escherichia coli.

The tuberculin skin test for diagnosing tuberculosis (TB) in cattle lacks specificity if animals are sensitized to environmental mycobacteria, as some antigens in purified protein derivative (PPD) prepared from Mycobacterium bovis are present in nonpathogenic mycobacteria. Three immunodominant TB antigens, ESAT6, CFP10, and Rv3615c, are present in members of the pathogenic Mycobacterium tuberculosis complex but absent from the majority of environmental mycobacteria. These TB antigens have the potential to enhance skin test specificity. To increase their immunogenicity, these antigens were displayed on polyester beads by translationally fusing them to a polyhydroxyalkanoate (PHA) synthase which mediated formation of antigen-displaying inclusions in recombinant Escherichia coli. The most common form of these inclusions is poly(3-hydroxybutyric acid) (PHB). The respective fusion proteins displayed on these PHB inclusions (beads) were identified using tryptic peptide fingerprinting analysis in combination with matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). The surface exposure and accessibility of antigens were assessed by enzyme-linked immunosorbent assay (ELISA). Polyester beads displaying all three TB antigens showed greater reactivity with TB antigen-specific antibody than did beads displaying only one TB antigen. This was neither due to cross-reactivity of antibodies with the other two antigens nor due to differences in protein expression levels between beads displaying single or three TB antigens. The triple-antigen-displaying polyester beads were used for skin testing of cattle and detected all cattle experimentally infected with M. bovis with no false-positive reactions observed in those sensitized to environmental mycobacteria. The results suggested applicability of TB antigen-displaying polyester inclusions as diagnostic reagents for distinguishing TB-infected from noninfected animals.

Risk Assessment of residual monomer migrating from acrylic polymers and causing Allergic Contact Dermatitis during normal handling and use.

Acrylic, Poly Methyl Methacrylate (PMMA) based polymers are found in many industrial, professional and consumer products and are of low toxicity, but do contain very low levels of residual monomers and process chemicals that can leach out during handling and use. Methyl Methacrylate, the principle monomer is of low toxicity, but is a recognized weak skin sensitizer. The risk of induction of contact allergy in consumers was determined using a method based upon the Exposure-based Quantitative Risk Assessment approach developed for fragrance ingredients. The No Expected Sensitization Induction Level (NESIL) was based on the threshold to induction of sensitization (EC3) in the Local Lymph Node Assay (LLNA) since no Human Repeat Insult Patch Test (HRIPT) data were available. Categorical estimation of Consumer Exposure Level was substituted with a worst case assumption based upon the quantitative determination of MMA monomer migration into simulants. Application of default and Chemical-Specific Adjustment Factors results in a Risk Characterization Ratio (RCR) of 10,000 and a high Margin of Safety for induction of Allergic Contact Dermatitis (ACD) in consumers handling polymers under conservative exposure conditions. Although there are no data available to derive a RCR for elicitation of ACD it is likely to be lower than that for induction.

[Development and substantiation of complex approach to determination of individual intolerance and hypersensitivity to dental materials].

The aim of research was to define the most simple, objective and affordable test for determination of individual compatibility for dental materials before placement of prostheses in the oral cavity. After series of provocative and laboratory tests it was found that the most convenient is the muco-gingival test. Also found that absolutely all materials, including ceramics, can cause individual intolerance with more or less severe clinical symptoms.

Novel instrumentation to determine peel force in vivo and preliminary studies with adhesive skin barriers.

BACKGROUND/PURPOSE: Adhesive barriers secure medical devices to skin. Laboratory adhesion models are not predictive of in vivo performance. The objectives of these studies were to validate a novel peel force device, and to investigate relationships between barrier formulations, barrier width, subjective discomfort during barrier removal, and substrates. METHODS: Three hydrocolloid barrier formulations in three widths were adhered to ethylene/methyl acrylate film (EMA), VITRO-SKIN(®) and human abdominal skin. Peel force was measured using a MTS Insight™ and a cyberDERM Inc. Mini Peel Tester (CMPT). Subjects reported their discomfort. RESULTS: Peel forces were highly correlated between devices and highly dependent on substrate. Data suggested a weak direct association between peel force in vivo and discomfort. The 0.5″-wide barriers had the most precise peel forces measurements in vivo. A weak negative relationship between normalized peel force and barrier width on human skin was found. There was a strong positive relationship between peel force in vivo and on EMA, whereas no correlation was observed with VITRO-SKIN(®). CONCLUSION: The CMPT correlates with a standard instrument and can advantageously investigate adhesion in vivo. Barrier width and substrate impact the reliability and predictability of peel force measurements.

Cucumber anaphylaxis in a latex-sensitized patient.

We report the case of a 76-year-old woman who experienced dizziness, vomiting, dyspnea, thoracic erythema, and vaginal itching within 5 minutes of eating cucumber. She had been diagnosed 3 months earlier with papaya urticaria and latex sensitization. The results of skin prick tests were positive for cucumber, watermelon, papaya, and latex and negative for melon and profilin extracts. ImmunoCAP for latex-specific serum immunoglobulin (Ig) E was positive. Cucumber-specific serum IgE was negative. Immunoblot analysis using patient serum revealed a 30- to 32-kDa protein band in the cucumber (peel) and papaya extracts. Immunoblot inhibition with latex extract demonstrated inhibition of the band in both extracts. Immunoblot inhibition with cucumber-papaya and papaya-cucumber revealed inhibition of the same band in the cucumber and papaya extracts, respectively. We present a case of IgE-mediated allergy to cucumber and papaya. Our results strongly suggest that the allergen(s) implicated are associated with latex sensitization. To our knowledge, this is the first report of cucumber-latex and cucumber-papaya cross-reactivity.

Patch Testing With a New Composition of the Mercapto Mix-A Multicenter Study from the International Contact Dermatitis Research Group.

BACKGROUND: Mercaptobenzothiazole compounds are associated with allergic contact dermatitis caused by rubber products. Several screening substances have been used for patch testing. OBJECTIVE: To compare the frequency of positive test reactions to a mercapto mix containing a higher concentration of 2-mercaptobenzothiazole with reactions to the combination of 2-mercaptobenzothiazole 2.0% and mercapto mix 2.0%. METHODS: There were 7103 dermatitis patients in 12 International Contact Dermatitis Research Group dermatology departments who were patch tested with 2-mercaptobenzothiazole 2.0% petrolatum (pet.), mercapto mix 2.0% pet., and mercapto mix 3.5% pet. RESULTS: Contact allergy to the 3 test preparations varied among the 12 centers: 2-mercaptobenzothiazole 2.0% pet. (0-2.4%), mercapto mix 2.0% pet. (0-4.9%), and mercapto mix 3.5% pet. (0-1.4%). 2-Mercaptobenzothiazole 2.0% and mercapto mix 2.0% detected a few more positive patients compared with mercapto mix 3.5%, but the difference was statistically insignificant (mercapto mix 2.0% pet., P = 1.0; 2-mercapto-benzothiazole 2.0% pet., P = 0.66). CONCLUSIONS: Mercapto mix 3.5% pet. is not better than 2-mercaptobenzothiazole 2.0% and mercapto mix 2.0% by a difference that is significant. By using only 1 test preparation (mercapto mix 3.5%), an additional hapten could be tested. No cases of suspected/proven patch test sensitization were registered.

BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia.

Investigation of anaphylaxis during general anaesthesia requires an accurate record of events including information on timing of drug administration provided by the anaesthetist, as well as timed acute tryptase measurements. Referrals should be made to a centre with the experience and ability to investigate reactions to a range of drug classes/substances including neuromuscular blocking agents (NMBAs) intravenous (i.v.) anaesthetics, antibiotics, opioid analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), local anaesthetics, colloids, latex and other agents. About a third of cases are due to allergy to NMBAs. Therefore, investigation should be carried out in a dedicated drug allergy clinic to allow seamless investigation of all suspected drug classes as a single day-case. This will often require skin prick tests, intra-dermal testing and/or drug challenge. Investigation must cover the agents administered, but should also include most other commonly used NMBAs and i.v. anaesthetics. The outcome should be to identify the cause and a range of drugs/agents likely to be safe for future use. The allergist is responsible for a detailed report to the referring anaesthetist and to the patient's GP as well as the surgeon/obstetrician. A shorter report should be provided to the patient, adding an allergy alert to the case notes and providing an application form for an alert-bracelet indicating the wording to be inscribed. The MHRA should be notified. Investigation of anaphylaxis during general anaesthesia should be focussed in major allergy centres with a high throughput of cases and with experience and ability as described above. We suggest this focus since there is a distinct lack of validated data for testing, thus requiring experience in interpreting tests and because of the serious consequences of diagnostic error.

Suspected allergy to local anaesthetics: follow-up in 135 cases.

BACKGROUND: Local anaesthetics (LA) are generally considered safe with respect to allergy. However, various clinical reactions steadily occur. Even though most reactions are manifestations of reflexes to perceptive stimuli, uncertainty often remains regarding a possible allergic mechanism. This uncertainty later leads to an avoidance of local anaesthesia and unnecessarily painful interventions, resource-consuming general anaesthesia or even the risk of re-exposure to other yet unidentified allergens. In the present study, follow-up procedures at an allergy clinic were analysed to examine the frequency of identified causative agents and pathogenetic mechanisms and evaluate the strength of the diagnostic conclusions. METHOD: The medical records of 135 cases with alleged allergic reactions to LA were reviewed. Diagnoses were based on case histories, skin tests, subcutaneous challenge tests and in vitro IgE analyses. RESULTS: Two events (1.5%) were diagnosed as hypersensitivity to LA, articaine-adrenaline and tetracaine-adrenaline, respectively. Ten reactions (7%) were diagnosed as IgE-mediated allergy to other substances including chlorhexidine, latex, triamcinolone and possibly hexaminolevulinate. As challenge testing was not consistently performed with the culprit LA compound, follow-ups were short of definitely refuting hypersensitivity in 61% of the cases. The reported clinical manifestations were in general diagnostically unspecific, but itch and generalised urticaria were most frequent in test-positive cases. CONCLUSION: Reactions during local anaesthesia are rarely found to be an IgE-mediated LA allergy. Whenever the clinical picture is compatible with allergy, other allergens should also be tested.

Potential method to determine irritant potency in vitro - Comparison of two reconstructed epidermal culture models with different barrier competency.

Testing chemicals for their ability to cause skin irritation is required for all ingredients of products that come into contact with the skin. Here, we describe a potential method for determining the irritant potency of a chemical in vitro and apply the method to two different reconstructed epidermis models which exhibit different barrier properties. Two surfactants: sodium dodecyl sulphate, Triton X100 and two non-surfactants: 2-4-di-nitro-chloro-benzene, cinnamaldehyde were applied topically in a dose response for 24h. Biomarkers IL-1alpha, IL-1RA, IL-8 and MTT were assessed and EC(50) values determined. Variation in barrier properties between the epidermal models led to variation in the extent of penetration of surfactants, but not of non-surfactants which in turn influenced the EC(50) value obtained from surfactants. Furthermore, EC(50) values showed that no single biomarker could be classed as the most sensitive biomarker since biomarker sensitivity differed between the different chemicals studied. However, the ranking of the chemicals in order of strong to weak irritant was the same irrespective of the model used and also independent of the biomarker used (Triton X100>DNCB>SDS>CA). This study describes a method which not only distinguishes an irritant from a non-irritant but which may possibly also be used to determine irritant potency.

Lupin allergy in peanut-allergic children and teenagers.

BACKGROUND: Lupin has now been introduced into food production in the UK. There is a concern that, on account of cross-reactivity, peanut-allergic children are at high risk for lupin allergy. AIMS: To investigate the prevalence of lupin sensitization and allergy in children with peanut allergy compared with atopic controls. METHODS: Children (<18 years) were recruited. Peanut-allergic subjects either had a convincing history of peanut allergy with diagnostic peanut skin prick test (SPT) or specific-immunoglobulin E (IgE) results or a positive food challenge. Control subjects were atopic but not peanut-allergic. All subjects had SPT to peanut and lupin. Sensitized subjects were offered a randomized, double-blind, placebo-controlled lupin challenge. Lupin allergy was defined as objective immediate hypersensitivity reaction at food challenge. RESULTS: Forty-seven peanut-allergic children and 46 atopic controls were recruited. Sixteen peanut-allergic children were sensitized to lupin [34%, 95% confidence interval (CI): 21-49%]. Nine were challenged to lupin. Two reacted (itchy mouth and urticaria; itchy mouth and 20% drop in peak expiratory flow rate) giving a minimum prevalence of lupin allergy in peanut-allergic children of 4.0% (95% CI: 1-15%). Atopic controls were significantly (P = 0.001) less likely to be sensitized to lupin (4%, 95% CI: 1-15%) and had smaller wheals and serum-specific IgE results. None of the atopic controls reacted on lupin challenge, giving a rate of allergy in the atopic controls of 0% (95% CI: 0-8%). CONCLUSIONS: A small but significant number of children with peanut allergy are allergic to lupin. Sensitization to lupin is much rarer in nonpeanut-allergic atopic subjects.

Occupational contact urticaria: Australian data.

BACKGROUND: Over the last 30 years there has been increasing recognition of the clinical entity contact urticaria (CU) and the related diagnosis, protein contact dermatitis. However, there are relatively few reports of the occupational relevance of this condition. OBJECTIVES: To describe relevant characteristics of patients diagnosed with occupational CU (OCU) in a tertiary level specialist occupational dermatology clinic in Australia. METHODS: We performed a retrospective analysis of all patients diagnosed with OCU at an occupational dermatology clinic in Melbourne between 1 January 1993 and 31 December 2004. We identified 151 cases of CU diagnosed over the 12-year period. RESULTS: OCU was diagnosed in 8.3% (143 of 1720) of the total number of patients with occupational skin disease. Natural rubber latex accounted for the majority of all cases of OCU. Other common causes were foodstuffs and ammonium persulphate utilized as hairdressing bleach. The most commonly affected sites were the hands, followed by the arms and face. The most frequently affected occupations were healthcare workers, food handlers and hairdressers. All cases of CU in patients with hand symptoms were assessed to be work related. Atopy was a significant risk factor for both latex-related and nonlatex-related OCU. CONCLUSIONS: Radioallergosorbent tests and skin prick testing, including to patients' own food samples, should be part of the routine assessment of patients in high-risk occupations for OCU, particularly if the hands are affected, there is a history of atopy and there is exposure to urticants. We emphasize the importance of both determining the role of occupation in the causation of CU and recognizing all contributory factors in complex cases of occupational contact dermatitis of the hands.

Sensitivity and specificity of different skin prick tests with latex extracts in pediatric patients with suspected natural rubber latex allergy--a cohort study.

Skin prick tests (SPT) with latex extracts are commonly used in the diagnostic approach of natural rubber latex (NRL) allergy. Non-ammoniated latex extracts are commonly utilized for this purpose. There is only one commercially available ammoniated latex extract for both diagnostic and therapeutic purposes. To our knowledge, no direct clinical comparisons have been made so far comparing sensitivity and specificity of different latex extracts in patients with clinically confirmed latex allergy. The objective of this study was to evaluate sensitivity and specificity of non-ammoniated or ammoniated SPT of latex extracts in children with a clinical history suggestive of NRL allergy. Forty-two subjects (age 4-15 yr), referred to our Allergy Clinic Center, with suspected clinical signs of NRL allergy were evaluated. Patients were selected according to the following inclusion criteria: pediatric patients of age above 4 yr with a suspected clinical history of urticaria, rhinoconjunctivitis and/or asthma due to sensitization to NRL. A definitive NRL allergy diagnosis was made on the identification of latex-specific IgE (>0.7 kU/l), positive glove use test and a highly indicative clinical history. NRL allergy was confirmed in 26 (62%) subjects. SPT for latex were performed with three different SPT solutions containing non-ammoniated NRL extracts (product A: Lofarma SpA, Milan, Italy and product B: Stallergenes, Milan, Italy) or an ammoniated extract (product C: ALK-Abellò, Madrid, Spain). A positive result was considered as the appearance of a wheal with a diameter >3 mm. In patients with confirmed NRL allergy, wheal mean (s.d.) diameters were 7.3 (2.1) with product C, and 5.7 (2.3) and 4.4 (1.8) with products B and A respectively (p = 0.004 C vs. B and A). Mean wheal diameters were significantly higher for product C in comparison with product B and A (p < 0.04). Sensitivity according to the different products tested was 65% (product A); 81% (product B) and 96% (product C) (p = 0.0084; C vs. A). No difference between the three products was observed regarding diagnostic specificity (94%, 88% and 94%, product A, B and C, respectively). Our study shows that diagnostic sensitivity of different latex extract for SPT could differ. In this particular clinical setting (i.e., children with NRL allergy) ammoniated latex extract shows a higher sensitivity in comparison with non-ammoniated products. This aspect should be considered in the diagnostic approach in subjects with suspected NRL allergy. In children with clinical confirmed latex allergy, sensitivity and specificity of different commercially available skin prick test could vary. Ammoniated latex extract has shown a higher sensibility in comparison with non-ammoniated products.

Investigation and diagnosis of an immediate allergy to amide local anaesthetic in a paediatric dental patient.

Local anaesthetics remain the most common prescription medication utilized in dental practise. Adverse reactions following administration of local anaesthetic are somewhat common and are frequently reported as 'allergies'. However, of these events, it is estimated that only 1% are confirmed allergies to the local anaesthetic. This case report presents the process of referral for investigation and testing to confirm an amide local anaesthetic allergy in a paediatric patient. Testing for a safe alternative was also completed to identify local anaesthetic agents also of the amide variety that could be utilized safely on this individual. Following skin testing of alternative agents, intraoral challenges were completed. Finally, restorative dental treatment was provided safely for the patient with the use of an alternative amide local anaesthetic on a number of occasions with no further adverse outcomes.

Establishment and evaluation of immortalized human epidermal keratinocytes for an alternative skin irritation test.

Human skin is located at the outermost part of the body, and various cosmetics and chemicals that may come in contact with human skin need to be evaluated for their potential to cause irritation. Until recently, the Draize test was considered the standard method for skin irritation; however, this technique has disadvantages such as the need to sacrifice many rabbits and subjective scoring. Thus, to contribute to the development of an animal-free alternative skin irritation test, we investigated the cytotoxicity and inflammatory response to standard skin irritants in SV40 large T antigen-transformed human epidermal keratinocyte 2 cells (SV-HEK2 cells). In this study, we established an SV-HEK2 cell line immortalized by SV40 large T antigen (SV40 T) and characterized the inherent morphological and cytological properties. We next used 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) or neutral red uptake (NRU) assays of cell viability to investigate the optimal experimental conditions for determining SV-HEK2 cell viability after exposure to sodium dodecyl sulfate at 6.25×10-3% to 1×10-1% as a standard skin irritant. We then examined the viability of SV-HEK2 cells in response to five skin irritants (benzalkonium chloride, isopropanol, sodium dodecyl sulfate, Triton X-100 and Tween20) at 5×10-3% to 1×10-1% by MTT or NRU assay. Finally, we estimated the level of cytokines secretion in response to stimulation by skin irritants in SV-HEK2 cells. The results revealed that SV-HEK2 cells responded well to skin irritants in a concentration-dependent manner and that there was good correlation between irritant concentration and cytotoxicity (or cytokine secretion) when cells were exposed to skin irritants for 10min at room temperature (RT) using an MTT assay. Overall, these findings suggest that SV-HEK2 cells could be a good alternative in vitro model for skin irritation tests.

Sunflower seed allergy.

Sunflower seeds are a rare source of allergy, but several cases of occupational allergies to sunflowers have been described. Sunflower allergens on the whole, however, still await precise and systematic description. We present an interesting case of a 40-year-old male patient, admitted to hospital due to shortness of breath and urticaria, both of which appeared shortly after the patient ingested sunflower seeds. Our laryngological examination revealed swelling of the pharynx with retention of saliva and swelling of the mouth and tongue. During diagnostics, 2 months later, we found that skin prick tests were positive to mugwort pollen (12/9 mm), oranges (6/6 mm), egg protein (3/3 mm), and hazelnuts (3/3 mm). A native prick by prick test with sunflower seeds was strongly positive (8/5 mm). Elevated concentrations of specific IgE against weed mix (inc. lenscale, mugwort, ragweed) allergens (1.04 IU/mL), Artemisia vulgaris (1.36 IU/mL), and Artemisia absinthium (0.49 IU/mL) were found. An ImmunoCap ISAC test found an average level of specific IgE against mugwort pollen allergen component Art v 1 - 5,7 ISU-E, indicating an allergy to mugwort pollen and low to medium levels of specific IgE against lipid transfer proteins (LTP) found in walnuts, peanuts, mugwort pollen, and hazelnuts. Through the ISAC inhibition test we proved that sunflower seed allergen extracts contain proteins cross-reactive with patients' IgE specific to Art v 1, Art v 3, and Jug r 3. Based on our results and the clinical pattern of the disease we confirmed that the patient is allergic to mugwort pollen and that he had an anaphylactic reaction as a result of ingesting sunflower seeds. We suspected that hypersensitivity to sunflower LTP and defensin-like proteins, both cross-reactive with mugwort pollen allergens, were the main cause of the patient's anaphylactic reaction.