Diagnosis of Sesame Allergy: Analysis of Current Practice and Exploration of Sesame Component Ses i 1.

BACKGROUND: Sesame is an allergen of increasing importance. OBJECTIVE: We sought to characterize the outcomes of oral food challenges (OFCs) to sesame and evaluate the diagnostic accuracy of skin prick testing (SPT), sesame, and Ses i 1-specific IgE (sIgE). METHODS: We reviewed sesame OFCs performed at the Mount Sinai pediatric allergy clinic between January 2010 and April 2018. We assessed the accuracy of diagnostic tests by calculating the area under the curve (AUC) of the receiver operating characteristic curves. The association between OFC outcome and sesame sensitization was analyzed using a logistic regression, which was then used to estimate the 95% positive predictive value (PPV) of these tests. RESULTS: We identified 341 patients (69% male, mean age 7.7 years) who underwent sesame OFC. Among 106 (31%) positive OFCs, the median cumulative eliciting dose was 500 mg sesame protein (1/2 teaspoon tahini). Sesame SPT wheal ≥6 mm had sensitivity 54.1% and specificity 87.8%; AUC 0.756 (95% confidence interval [CI], 0.699-0.814). SPT wheal size ≥14 mm had 95% PPV. Sesame-sIgE level did not correlate with OFC outcome. Ses i-sIgE levels were analyzed in 30 patients using the Immuno Solid-phase Allergen Chip (ISAC) microarray and were significantly associated with OFC outcome (AUC: 0.715 [95% CI, 0.541-0.890]). Ses i 1-sIgE ≥0.3 ISAC Standardized Units had sensitivity 58.3% and specificity 83.3%. CONCLUSIONS: This is the largest study of sesame allergy to date. Sesame SPT is a more accurate predictor of sesame allergy compared with sesame sIgE. Ses i 1-sIgE appears promising but requires further study regarding diagnostic accuracy.

Review of 400 consecutive oral food challenges to almond.

BACKGROUND: Diagnosis of almond allergy is complicated by a high rate of false-positive test results. Accurate diagnosis of almond allergy is critical because almond is a source of nutrition and milk products for children with other food allergies. OBJECTIVE: We reviewed the outpatient almond oral food challenges (OFCs) performed at our institution to analyze the pass rate and identify variables that predict OFC outcome. METHODS: We reviewed all almond OFCs performed at our pediatric, university-based outpatient practice between October 2015 and July 2017. Oral food challenge details, including dosing, reactions, and treatments, as well as demographic, clinical, and laboratory data, were compiled. Statistical analysis was performed using the Fisher's exact and Student's t tests. RESULTS: We identified 400 patients who underwent consecutive almond OFCs. Of these, 375 passed (93.8%, median sIgE 1.41 kUA/L, mean skin prick test [SPT] wheal 3.23 mm), 16 failed (4.0%, sIgE 2.54 kUA/L, SPT 5.0 mm), and 9 were indeterminate (2%, sIgE 3.33 kUA/L, SPT 5.0 mm). Among children who reacted, pruritus was the most common symptom. Only 2 children had reactions that required epinephrine. No difference was seen in demographics or allergic comorbidities between those who passed and failed. CONCLUSION: Among patients in our cohort, the probability of passing an almond OFC was 94%. Although increasing almond sIgE level and SPT wheal size correlated with OFC failure, the pass rate remained greater than 95% for patients with sIgE up to 10 kUA/L and SPT wheal size up to 5 mm. Among the patients who had a reaction to almond, anaphylaxis was uncommon. Our data support that performing outpatient OFCs to almond is safe for select patients.

Increased Tolerance to Less Extensively Heat-Denatured (Baked) Milk Products in Milk-Allergic Children.

BACKGROUND: Most milk-allergic children tolerate baked milk. OBJECTIVE: To investigate the effect of more frequent versus less frequent introduction of higher doses of more allergenic (less heat-denatured) forms of milk (MAFM) on progression to tolerance. METHODS: Milk-allergic children were challenged with increasing doses of MAFM; baked foods were incorporated into the diet; challenges were repeated at 6- or 12-month intervals over 36 months. RESULTS: A total of 136 children (70% males) were enrolled in the active group (median age, 7 years). At baseline, 41 (30%) reacted to muffin, 31 (23%) to pizza, 11 (8%) to rice pudding, 43 (32%) to non-baked milk; and 10 (7%) tolerated non-baked milk. Children who tolerated baked milk but reacted to non-baked liquid milk were randomized to MAFM challenges every 6 months (n = 41) or 12 months (n = 44). At month 36, 61% children in the 6-month and 73% in the 12-month escalation groups tolerated MAFM. Overall, 41 (48%) children who ingested baked-milk diet became tolerant to non-baked milk; no difference was seen between 6- and 12- month escalations. Among children who reacted to muffin at baseline and continued avoidance, 20% developed tolerance to baked milk and 0% tolerated non-baked milk. None of the 34 children who qualified for inclusion but chose not to take part in the active study became tolerant to any form of milk by history. CONCLUSIONS: Majority of children tolerated baked milk at baseline. Baked-milk diets were associated with progressive immunomodulation. Most children who incorporated baked milk into their diet progressed to tolerating MAFM, but there was no advantage to more frequent attempts to escalate to MAFM, per intention-to-treat analysis.

The Prevalence and Natural History of Food Allergy.

Numerous studies have demonstrated that the prevalence of food allergy is increasing. Not only are more children being diagnosed with food allergies, but studies suggest that when people outgrow their food allergies, it is taking longer than was previously thought. Studies in recent years have noted factors that may lead to a lower likelihood of developing a food allergy, including the early introduction of common food allergens, having a sufficient vitamin D level, or having a higher maternal intake of peanut early in pregnancy. Given a recent report that sensitization to common food allergens did not increase from the late 1980s/early 1990s to the mid-2000s, further studies will need to examine if the rise in food allergy prevalence is due to a change in the relationship between sensitization and clinical allergy or changes in the recognition and diagnosis of food allergy.

Allergen Component Testing in the Diagnosis of Food Allergy.

IgE-mediated food allergies are an important public health problem, affecting 5 % of adults and 8 % of children, with numerous studies indicating that the prevalence is increasing. Food allergic reactions can range in severity from mild to severe and life threatening. Accurate diagnosis of food allergy is necessary not only to provide appropriate and potentially life-saving preventive measures but also to prevent unwarranted dietary restrictions. The diagnosis of food allergy has traditionally been based on clinical history and food specific IgE (sIgE) testing, including skin prick testing (SPT), serum tests, or both. These tests tend to be extremely sensitive, but positive test results to foods that are tolerated are common. Studies of allergen component-resolved diagnostics (CRD) show that adjuvant use of this modality may provide a more accurate assessment in the diagnosis of food allergy, though the reported benefits are questionable for a number of major allergens. Furthermore, diagnostic cutoff values have been difficult to determine for allergens where component testing has been demonstrated to be beneficial.

Optimizing the diagnosis of food allergy.

Accurately diagnosing a patient with a possible food allergy is important to avoid unnecessary dietary restrictions and prevent life-threatening reactions. Routine testing modalities have limited accuracy, and an oral food challenge is often required to make a definitive diagnosis. Given that they are labor intensive and risk inducing an allergic reaction, several alternative diagnostic modalities have been investigated. Testing for IgE antibodies to particular protein components in foods has shown promise to improve diagnostics and has entered clinical practice. Additional modalities show potential, including epitope binding, T-cell studies, and basophil activation.

Phellinus tropicalis abscesses in a patient with chronic granulomatous disease.

Chronic Granulomatous Disease (CGD), caused by genetic defects in components of the phagocyte NADPH oxidase pathway, leads to recurrent life-threatening bacterial and invasive fungal infections. While a number of unique pathogens have been associated with this disease, the causative organisms may be difficult to identify. Here, we present a 24 year old male with known X-linked CGD who concurrently developed a cervical abscess and an abscess in the subcutaneous tissues of the right hip, both of which were surgically drained. Cultures failed to identify any organisms. He was treated empirically with ertapenem but the hip abscess recurred at the original site and in contiguous dependent areas in the posterior thigh and knee. A filamentous organism was observed microscopically, initially considered a contaminant, but on culture yielded a mold growth, identified as Phellinus tropicalis (synonym: Inonotus tropicalis) based on phenotypic and molecular methods. This is the third case report of human infection with P. tropicalis, all in subjects with CGD. The patient was treated with voriconazole with resolution of his symptoms.

Potential therapies for food allergy: a review.

Food allergy is a widespread problem that has been increasing in prevalence in recent years. Avoidance of food allergens is difficult. Food allergic reactions are common and can be severe. Unfortunately, there is little in the way of therapies for food allergy, and strict allergen avoidance remains the standard of care. Several therapeutic approaches are currently being investigated, including subcutaneous, oral, and sublingual immunotherapy, anti-immunoglobulin E therapy, and traditional Chinese medicine. Although results thus far show promise for several of these strategies, further studies are needed to evaluate the safety, efficacy, and long-term outcomes before any food allergy therapies currently under investigation are ready for widespread use in clinical practice.

Allergen component testing for food allergy: ready for prime time?

Food allergies can cause life-threatening reactions and greatly influence quality of life. Accurate diagnosis of food allergies is important to avoid serious allergic reactions and prevent unnecessary dietary restrictions, but can be difficult. Skin prick testing (SPT) and serum food-specific IgE (sIgE) levels are extremely sensitive testing options, but positive test results to tolerated foods are not uncommon. Allergen component-resolved diagnostics (CRD) have the potential to provide a more accurate assessment in diagnosing food allergies. Recently, a number of studies have demonstrated that CRD may improve the specificity of allergy testing to a variety of foods including peanut, milk, and egg. While it may be a helpful adjunct to current diagnostic testing, CRD is not ready to replace existing methods of allergy testing, as it not as sensitive, is not widely available, and evaluations of component testing for a number of major food allergens are lacking.