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.

Study of Glucose-6-Phosphate Dehydrogenase Deficiency: 5 Years Retrospective Egyptian Study.

BACKGROUND: Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency worldwide that causes a spectrum of diseases including neonatal hyperbilirubinemia, acute and chronic hemolysis after exposure to oxidative stress. AIM OF THE WORK: This five years retrospective study was carried out to study the demographic, clinical and laboratory data of 1000 patients with G6PD deficiency anemia registered in Hematology Unit, Pediatric Department, Tanta University Hospital. PATIENTS AND METHODS: Data were collected from patient's files, from November 2011 to November 2016, using the pre-designed questionnaires to obtain the complete history, clinical presentation and laboratory investigations including the complete blood count, red blood cells morphology, liver and renal functions and quantitative assay of G6PD enzyme activity by spectrophotometric method. RESULTS: Males were more commonly affected than females (932 males versus 68 females). The highest prevalence of hemolytic crisis in G6PD deficiency patients was found within the age group of 1-3 years (920 patients; 92%) with mean age of the first presentation of 22.8±15.54 months. Patients presented mainly with pallor (1000 patients; 100%), dark red urine (896 patients; 89.6%) and jaundice (878 patients; 87.8%) after 24-72 hours of exposure to the precipitating factors (mean: 36±17.73 hours). Diets were the most common precipitating factor of hemolysis in patients with G6PD deficiency (834 patients; 83.4% of studied cases) especially fava beans (326 patients; 32.6%) and falafel (194 patients; 19.4%) which were the most common precipitating food products causing hemolysis followed by chick pea (108 patients; 10.8%), broad bean (76 patients; 7.6%), green pea (44 patients; 4.4%), pea nuts (38 patients; 3.8%), lentil (28 patients; 2.8%), and lastly black eyed peas (20 patients; 2 %). Infections were the 2nd most common cause of hemolysis (124 patients; 12.4%) including pneumonia (34 patients; 3.4%), tonsillitis (32 patients; 3.2%), typhoid fever (28 patients; 2.8%), hepatitis A (18 patients; 1.8%) and urinary tract infection (12 patients; 1.2%). Drugs were the least common cause of hemolysis (42 patients; 4.2%) including diclofenac sodium (24 patients; 2.4%), ibuprofen (8 patients; 0.8%), acetylsalicylic acid (4 patients; 0.4%), co-trimoxazole (4 patients; 0.4%) and nitrofurantion (2 patients; 0.2%). There was normocytic normochromic anemia with reticulocytosis and Heinz bodies in pre-transfusion complete blood picture in all studied cases. G6PD assay show marked decrease in enzyme level at time of presentation in all cases with the commonest G6PD enzyme level of 3-4 U/gm Hb (592 patients; 59.2%). CONCLUSION AND RECOMMENDATIONS: G6PD deficiency anemia presented mainly with pallor, dark red urine and jaundice after exposure to certain diets, drugs and diseases and therefore patients with G6PD deficiency should avoid exposure to these precipitating factors of hemolysis. We can also recommend large neonatal screening programs to detect cases of G6PD deficiency before the occurrence of acute hemolysis and molecular studies to detect G6PD enzyme variant in Egypt.

Health Risks and Benefits of Chickpea (Cicer arietinum) Consumption.

Chickpeas (CPs) are one of the most commonly consumed legumes, especially in the Mediterranean area as well as in the Western world. Being one of the most nutritional elements of the human diet, CP toxicity and allergy have raised health concerns. CPs may contain various antinutritional compounds, including protease inhibitors, phytic acid, lectins, oligosaccharides, and some phenolic compounds that may impair the utilization of the nutrients by people. Also, high consumption rates of CPs have enhanced the allergic problems in sensitive individuals as they contain many allergens. On the other hand, beneficial health aspects of CP consumption have received attention from researchers recently. Phytic acid, lectins, sterols, saponins, dietary fibers, resistant starch, oligosaccharides, unsaturated fatty acids, amylase inhibitors, and certain bioactive compounds such as carotenoids and isoflavones have shown the capability of lowering the clinical complications associated with various human diseases. The aim of this paper is to unravel the health risks as well as health-promoting aspects of CP consumption and to try to fill the gaps that currently exist. The present review also focuses on various prevention strategies to avoid health risks of CP consumption using simple but promising ways.

Food-dependent exercise-induced anaphylaxis to chickpea in a 17-year-old female: a case report.

INTRODUCTION: Food-dependent exercise-induced anaphylaxis is a subtype of anaphylaxis and, although rare, it is an important condition to be familiar with as it can ultimately lead to death. CASE PRESENTATION: We present a case of food-dependent exercise-induced anaphylaxis in a 17-year-old white girl due to chickpea. She had a history of anaphylaxis after eating crackers and hummus before exercising. Skin prick testing and serum-specific immunoglobulin E level confirmed chickpea to be the causative allergen. CONCLUSIONS: This case demonstrates the challenge in identifying specific causative food allergens when foods are eaten in combination, when the food is processed, and when cross-reactivity is possible. These challenges add complexity to a condition that is already rare and unfamiliar to some health care providers. We hope that this case will serve as an important reminder that although rare, food-dependent exercise-induced anaphylaxis exists and making a diagnosis can lead to life-saving preventative strategies. As legumes are not a common food associated with food-dependent exercise-induced anaphylaxis, this will add to our current knowledge base in the field of allergy.

Gastrointestinal Tolerance to Daily Canned Chickpea Intake.

PURPOSE: Consumption of pulses is recommended to improve diet quality and decrease the risk of chronic disease. However, their constituent α-galactosides, including raffinose, are commonly thought to contribute to unpleasant gastrointestinal symptoms. METHODS: Using a random crossover design, healthy adults (n = 12) received control foods, control foods with 5 g raffinose, and foods with 200 g of canned chickpea (11 g fibre per day), each for three weeks following a 3-day diet rotation. Gastrointestinal symptoms (rating 0 = none to 3 = severe), compliance, and stool frequency were recorded daily. RESULTS: No change in daily stool frequency (mean ± SD) was found with chickpea (1.7 ± 0.3) or raffinose (1.7 ± 0.4) compared with control (1.5 ± 0.3). Reported flatulence (mean ± SD) was rated higher with chickpea (1.0 ± 0.2, P < 0.001) and raffinose (0.7 ± 0.2, P < 0.001) compared with control (0.4 ± 0.1). Although bloating was infrequent, ratings were higher with chickpea (0.2 ± 0.1, P < 0.001) and raffinose (0.3 ± 0.1, P < 0.001) compared with control (0.0). No differences were found for diarrhea or abdominal pain. CONCLUSIONS: As gastrointestinal symptoms were mild for most participants, canned chickpea may be a feasible way of increasing pulse intake and improving overall diet quality.

Chickpea (Cicer arietinum) proteins induce allergic responses in nasobronchial allergic patients and BALB/c mice.

Allergy to chickpea or Garbanzo bean (Cicer arietinum) has been reported in the Indian population. Little information is found regarding allergenic events involved in the chickpea allergy; therefore, chickpea allergenicity assessment was undertaken. In vivo and ex vivo studies were carried out using BALB/c mice. Chickpea skin prick test positive patients have been used to extend this study in humans. Identification of allergens was carried out by simulated gastric fluids assay for pepsin resistant polypeptides and validated by IgE western blotting using chickpea sensitive humans and sensitized mice sera. Our data have shown the occurrence of a systemic anaphylactic reaction resulting in reduced body temperature after challenge along with significantly increased levels of IgE, IgG1, MMCP-1, CCL-2 as well as histamine. Further, increased Th1/Th2 (mixed) cytokine response was observed in spleen cell culture supernatants. Jejunum, lungs and spleen showed prominent histopathological changes specific for allergic inflammation. Immunoblotting with pooled sera of either sensitized mice or human sera recognized seven similar IgE binding polypeptides that may be responsible for chickpea induced hypersensitivity reactions. This study has addressed the allergenic manifestations associated with chickpea consumption and identifies the proteins responsible for allergenicity which may prove useful in diagnosis and management of allergenicity of legumes especially chickpea.

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.

Latex and chickpea (Cicer arietinum) allergy: first description of a new association.

In this paper we describe the existence of cross-reactivity between allergens from latex and chickpea, a food from the Leguminosae family, which is common in the Mediterranean diet. We present the case report of a spina bifida boy with a clinical relevant food allergy to chickpea (oral syndrome + dysphonia), developing after the appearance of latex allergy symptoms (lip angioedema + intraoperative anaphylaxis). Specific IgE to latex and chickpea was demonstrated by skin prick tests, measurement of patient's serum specific IgE and IgE-immunoblotting. Cross-reactivity was studied by means of EAST-inhibition and western blotting-inhibition. A strong inhibition was observed in several IgE-binding bands when latex extract was used in solid phase and patient serum was preincubated with chickpea extract (chickpea extract as inhibitor phase). As far as we know, this is the first report of cross-reactivity between latex and chickpea, a food which should therefore be added to the extensive list of latex cross-reactive foods.