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You can have fish allergy and eat it too!

2004; Elsevier BV; Volume: 114; Issue: 1 Linguagem: Inglês

10.1016/j.jaci.2004.04.026

1097-6825

Sami L. Bahna,

Contact Dermatitis and Allergies

Seafood (finfish and shellfish) is one of the most potent common food allergens. It can cause severe reactions, even after trivial exposures, such as hidden contamination of another food, indirect exposure, skin contact, or inhalation.1.Bahna S.L Exquisite food allergy without eating.Allergy. 1994; 49: 129-130Crossref PubMed Scopus (36) Google Scholar, 2.Crespo J.F Pascual C Dominguez C Ojeda I Munoz F.M Martin-Esteban M Allergic reactions associated with airborne fish particles in IgE-mediated fish hypersensitive patients.Allergy. 1995; 50: 257-261Crossref PubMed Scopus (124) Google Scholar, 3.Dominguez C Ojeda I Crespo J.F Pascual C Ojeda A Martin-Esteban M Allergic reactions following skin contact with fish.Allergy Asthma Proc. 1996; 17: 83-87Crossref PubMed Scopus (32) Google Scholar, 4.Bahna S.L Unusual presentations of food allergy.Ann Allergy Asthma Immunol. 2001; 86: 414-420Abstract Full Text PDF PubMed Scopus (26) Google Scholar, 5.Tan B.M Sher M.R Good R.A Bahna S.L Severe food allergies by skin contact.Ann Allergy Asthma Immunol. 2001; 86: 583-586Abstract Full Text PDF PubMed Scopus (74) Google Scholar Because of its popular palatability and increasing demonstration of its nutritional values, seafood consumption has been on the rise. As a consequence, an increase in the prevalence of seafood allergy would not be surprising. In this issue of the Journal, Sicherer et al6.Sicherer S.H Munoz-Furlong A Sampson H.A Prevalence of seafood allergy in the United States determined by a random telephone survey.J Allergy Clin Immunol. 2004; 114: 159-165Abstract Full Text Full Text PDF PubMed Scopus (466) Google Scholar present the first epidemiologic data on seafood allergy in the United States. The data are based on a well-designed, nationwide, cross-sectional, random telephone survey. As the authors admit, telephone questionnaires and self-reported allergies have some limitations. Nevertheless, the study revealed several worthwhile findings. I chose to comment on 4 issues in particular, namely prevalence, cross-reactivity, tolerance, and the effect of processing. First is the prevalence of seafood allergy. A strong history of allergy to seafood (fish or shellfish) was reported by 2.3% of individuals, to fish in 0.4%, to shellfish in 2%, and to both in 0.2%. Because the subjects were neither evaluated for IgE sensitization nor verified by means of challenge testing, the reported figures can be overestimates, particularly for the claimed allergy to shellfish (2%). Perhaps shellfish is more allergenic than fish, although the latter is more consumed. However, the reported figures might not be too far from the true prevalence considering the increasing trends of seafood popularity and of the prevalence of food allergy, as has been reported for peanut allergy.7.Grundy J Matthews S Bateman B Dean T Arshad S.H Rising prevalence of allergy to peanut in children: data from 2 sequential cohorts.J Allergy Clin Immunol. 2002; 110: 784-789Abstract Full Text Full Text PDF PubMed Scopus (493) Google Scholar, 8.Sicherer S.H Munoz-Furlong A Sampson H.A Prevalance of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a five year follow-up study.J Allergy Clin Immunol. 2003; 112: 1203-1207Abstract Full Text Full Text PDF PubMed Scopus (671) Google Scholar Modification of the gastrointestinal function might be one of the contributory factors. A recent experimental study demonstrated that the concomitant administration of antacids enhanced the IgE sensitization of mice to the major fish allergen parvalbumin.9.Untersmayr E Scholl I Swoboda I Beil W.J Forster-Waldl E Walter F et al.Antacid medication inhibits digestion of dietary proteins and causes food allergy: a fish allergy model in BALB/c mice.J Allergy Clin Immunol. 2003; 112: 616-623Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar Several antacid preparations are being widely promoted to the public and are available without a prescription. It is of interest that almost 10% of the subjects with seafood allergy reported more severe reactions caused by inhalation or skin contact than by ingestion. Such an observation, if validated, should underscore the role of the respiratory tract mucosa and of the skin as routes of exposure in certain subjects. It is not known whether those particular patients were initially sensitized or primed through inhalation or epicutaneous contact. This phenomenon could be analogous to the oral allergy syndrome, in which patients typically ingest the offending food with impunity. Also, in baker's asthma patients wheeze on inhalation of wheat flour but tolerate ingested wheat well. Second, seafood allergy is not universal. In this survey individuals who reported reactions to multiple species of the family were two thirds for fish, one half for mollusks, and one third for crustacea. This suggests that not all IgE-binding epitopes are shared by all members of the seafood family. Using IgE-binding cluster analysis of 10 allergens, Tanaka et al10.Tanaka R Ichikawa K Hamano K Clinical characteristics of seafood allergy and classification of 10 seafood allergens by cluster analysis.Arerugi. 2000; 49: 479-486PubMed Google Scholar could classify seafoods into 4 groups: (1) salmon, sardine, and mackerel; (2) cod and tuna; (3) octopus and squid; and (4) crab and shrimp. The incomplete cross-reactivity among fish species has been previously reported.11.Bernhisel-Broadbent J Scanlon S.M Sampson H.A Fish hypersensitivity I. In vitro and oral challenge results in fish-allergic patients.J Allergy Clin Immunol. 1992; 89: 730-737Abstract Full Text PDF PubMed Scopus (221) Google Scholar, 12.Helbling A Haydel R McCants M.L Musmand J.J El Dahr J Lehrer S.B Fish allergy: is cross-reactivity among fish species relevant? Double-blind placebo-controlled food challenge studies of fish allergic adults.Ann Allergy Asthma Immunol. 1999; 83: 517-523Abstract Full Text PDF PubMed Scopus (115) Google Scholar Actually, some individuals' allergy might be limited to one particular type of fish13.Kelso J.M Jones R.T Yunginger J.W Monospecific allergy to swordfish.Ann Allergy Asthma Immunol. 1996; 77: 227-228Abstract Full Text PDF PubMed Scopus (59) Google Scholar or shrimp.14.Morgan J.E O'Neil C.E Daul C.B Lehrer S.B Species-specific shrimp allergens: RAST and RAST-inhibition studies.J Allergy Clin Immunol. 1989; 83: 1112-1117Abstract Full Text PDF PubMed Scopus (29) Google Scholar For many years, crustacea was thought to have no or minimal cross-reactivity with mollusks. In this survey, however, 14% of crustacean-intolerant individuals were intolerant to mollusks as well. Laboratory studies have demonstrated that certain allergens are shared between these 2 shellfish families.15.Waring N.P Daul C.B deShazo R.D McCants M.L Lehrer S.B Hypersensitivity reactions to ingested crustacean: clinical evaluation and diagnostic studies in shrimp-sensitive individuals.J Allergy Clin Immunol. 1985; 76: 440-445Abstract Full Text PDF PubMed Scopus (68) Google Scholar, 16.Goetz D.W Whisman B.A Occupational asthma in a seafood restaurant worker: cross-reactivity of shrimp and scallops.Ann Allergy Asthma Immunol. 2000; 85: 461-466Abstract Full Text PDF PubMed Scopus (65) Google Scholar These findings should encourage expanding the evaluation of subjects with seafood allergy to include testing for multiple species. Negative results of skin testing or in vitro testing must be cautiously verified with appropriately designed, titrated, blind challenge testing. Such an approach would allow many individuals to enjoy eating certain kinds of fish or shellfish. Self-injectable epinephrine should be constantly available, particularly when the food is prepared in commercial facilities, to guard against possible errors or contamination. This survey revealed that self-injectable epinephrine was prescribed to only 1 of every 12 patients. Reviewing a sample of charts of patients who presented with food allergy at 21 emergency departments in different regions of the United States revealed that self-injectable epinephrine was prescribed to only 16%, with a range of 0% to 39%.17.Clark S Bock S.A Gaeta T.J Brenner B.E Cydulka R.K Camargo C.A Multicenter study of emergency department visits for food allergies.J Allergy Clin Immunol. 2004; 113: 347-352Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Although there is a wide spectrum of food allergy manifestations, the constant availability of self-injectable epinephrine can be life-saving for patients who had experienced severe reactions. Third, seafood allergy is not forever. In the surveyed sample 3.5% of the subjects with fish allergy and 4% of the subjects with shellfish allergy reported loss of that allergy. This is in line with allergies to other foods, including peanut.18.Hourihane JO'B Roberts S Warner J.O Resolution of peanut allergy: case-control study.BMJ. 1998; 316: 1271-1275Crossref PubMed Google Scholar, 19.Vander Leek T.K Liu A.H Stefanski K et al.The natural history of peanut allergy in young children and its association with serum peanut-specific IgE.J Pediatr. 2000; 137: 749-755Abstract Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 20.Skolnick H.S Conover-Walker M.K Koerner C.B et al.The natural history of peanut allergy.J Allergy Clin Immunol. 2001; 107: 367-374Abstract Full Text Full Text PDF PubMed Scopus (476) Google Scholar The duration of seafood avoidance until the attainment of tolerance is unknown but probably varies widely.21.Kajossari M Food allergy in Finnish children aged 1 to 6 years.Acta Paediatrica Scand. 1982; 71: 815-819Crossref PubMed Scopus (135) Google Scholar, 22.Solensky R Resolution of fish allergy: a case report.Ann Allergy Asthma Immunol. 2003; 91: 411-412Abstract Full Text PDF PubMed Scopus (20) Google Scholar It probably depends on several factors, such as age of onset, degree of sensitization, type of symptoms, severity of reaction, multiplicity of causative foods, and degree of avoidance. It is worth noting, however, that recurrence of intolerance might occur,23.De Frutos C Zapatero L Rodriguez A Barranco R Alonso E Martinez M.I Re-sensitization to fish after a temporary tolerance.Allergy. 2003; 58: 1067-1068Crossref PubMed Scopus (8) Google Scholar just as in the case of peanut.24.Busse P.J Nowak-Wegrzyn A.H Noone S.A et al.Recurrent peanut allergy.N Engl J Med. 2002; 347: 1535-1536Crossref PubMed Scopus (83) Google Scholar Fourth is the effect of processing. This survey apparently did not inquire about the effect of various methods of processing on seafood allergenicity. Patients often report reactions to seafood when prepared in a certain way but not in another. This phenomenon is often attributed, perhaps erroneously, to possible contamination with another food allergen or additive. Any of boiling, frying, grilling, salting, drying, or freezing might reduce or increase allergenicity. Peanut is a classic example; its allergenicity is markedly increased by roasting but not by boiling or frying.25.Maleki S.J Chung S.Y Champagne E.T Raufman J.P The effects of processing on the allergenic properties of peanut proteins.J Allergy Clin Immunol. 2000; 106: 763-768Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar, 26.Beyer K Morrow E Li X Bardina L Bannon G.A Burks A.W Sampson H.A Effects of cooking methods on peanut allergenicity.J Allergy Clin Immunol. 2001; 107: 1077-1081Abstract Full Text Full Text PDF PubMed Scopus (408) Google Scholar, 27.Chung S.Y Butts C.L Maleki S.J Champagne E.T Linking peanut allergenicity to the processes of maturation, curing, and roasting.J Agric Food Chem. 2003; 51: 4273-4277Crossref PubMed Scopus (69) Google Scholar The allergenicity to certain fish proteins seem to be reduced by heat.28.Bernhisel-Broadbent J Strause D Sampson H.A Fish hypersensitivity II: Clinical relevance of altered fish allergenicity caused by various preparation methods.J Allergy Clin Immunol. 1992; 90: 622-629Abstract Full Text PDF PubMed Scopus (143) Google Scholar Additionally, the survey did not provide information about intolerance to fish oils. Investigation of these 2 issues is likely to reveal information that can have a substantial effect on the prevention and treatment of seafood allergy. Lastly, I would like to address adverse reactions to fish that mimic fish protein allergy. A negative skin test result or in vitro test result should alert the physician to possible reactions to substances in fish other than fish protein allergens. Bacterial spoiling of certain fish can produce histamine and cause scombroid fish poisoning.29.Attaran R.R Probst F Histamine fish poisoning: a common but frequently misdiagnosed condition.Emerg Med J. 2002; 19: 474-475Crossref PubMed Scopus (58) Google Scholar In rare cases the allergy might be to a roe protein rather than a fish muscle allergen.30.Makinen-Kiljunen S Kiistala R Varjonen E Severe reactions from roe without concomitant fish allergy.Ann Allergy Asthma Immunol. 2003; 91: 413-416Abstract Full Text PDF PubMed Scopus (26) Google Scholar Several studies have demonstrated that certain patients with fish-related allergic reactions were actually allergic to the fish parasite Anisakis simplex.31.Alonso A Moreno-Ancillo A Daschner A Lopez-Serrano M.C Dietary assessment in five cases of allergic reactions due to gastroallergic anisakiasis.Allergy. 1999; 54: 517-520Crossref PubMed Scopus (53) Google Scholar, 32.Lorenzo S Iglesias R Leiro J Ubeira F.M Ansotegui I Garcia M et al.Usefulness of currently available methods for the diagnosis of Anisakis simplex allergy.Allergy. 2000; 55: 627-633Crossref PubMed Scopus (62) Google Scholar The extent of this problem in the United States is unknown and is worth investigating.