D1.419 - Setbacks in the management of multiple nuts allergy in atopic children

Primary nut allergy typically manifests during the first five years of life, often following the first recognized ingestion and it is accompanied by the usual rapid onset IgE-mediated symptoms. As it is a chronic condition with a persistent risk of anaphylaxis, obtaining tolerance, even for low doses through oral immunotherapy, can be a challenging option, especially in children with food allergies to multiple nuts. 

We report a 6-year-old boy, with a history of atopic dermatitis and mild urticaria that lead to avoidance of cow’s milk since infancy, who also developed nuts sensitization once the diversification stage started. He regularly consumed few pieces of almonds, walnuts and pistachio. Additionally, he suffered from recurrent episodes of wheezing.

The patient was evaluated with periodical ImmunoCAP specific IgE food panels. Oral provocation tests (OPT) were performed with almond, walnut, pistachio and  cashew.

Through the first 4 years of life, the sIgE food panels revealed slightly increasing values of the sIgE to extracts of peanut (3.79kU/L), hazelnut (7.83kU/l), almond (0.54 kU/L), cashew (4.48 kU/L), pistachio (6.65 kU/L) and walnut (2,26 kU/L). OPT with almond, walnut and pistachio resulted in no immediate reaction and permitted their regular consumption in small quantities. However, OPT with cashew led to anaphylactic shock (generalized hives, cough, oropharyngeal pruritus, wheezing, hypoxemia). After 2 months, reevaluation of sIgE showed increased values for cashew and pistachio (both >100 kU/L), walnut (78.6 kU/L), peanut (36.7 kU/L), hazelnut (37.7 kU/l). Except for almond, the patient ceased the ingestion of other nuts, due to the parents’ anxiety regarding possibility of having lost tolerance.

Our results indicate that multiple food allergies, particularly to nuts and in an atopic patient, present a profile difficult to manage that requires numerous OPT and repeated training of the patients and the caretakers to recognize and use  life-saving medication. Furthermore, patients with a history of atopic disease have a higher likelihood to a more significant difference of sIgE before and after an anaphylaxis. This adds to the caretakers’ reluctance to retry introduction of the tested food into diet, even if OPT proved negative.