D2.329 - Profilin-mediated anaphylaxis with cofactor

Profilin is a highly conserved panallergen that is widely present in pollens and plant-derived foods. Although it is typically associated with mild oral allergy syndrome, there is increasing evidence that sensitisation to profilin may cause severe reactions when combined with cofactors such as exercise, menstruation, or non-steroidal anti-inflammatory drugs (NSAIDs).

A 45-year-old woman with a long-standing pollen allergy and intermittent oral reactions to various fruits experienced an anaphylactic episode three hours after eating a hamburger, with menstruation and exercise acting as cofactors. The clinical evaluation included extensive skin testing, specific IgE and ALEX³ method. Oral food challenges involving pistachios, lentils and bananas were also performed. 

Skin prick testing revealed sensitisation to pollens and various plant foods, with a significant reaction to profilin (18×14 mm). Previous specific IgE testing revealed high levels of sensitisation to grass pollens (Phleum pratense: 61.8 kU/L; Lolium perenne: 83.4 kU/L), Olea (4.82 kU/L) and Platanus (6.46 kU/L), and profilin (rPhl p 12: 0.58 kU/L). Food-specific IgE values were low or borderline (e.g., peanut 0.59 kU/L, chickpea 0.32 kU/L, lentil 0.25 kU/L). Latex sensitisation was also confirmed (Hev b 8: 0.46 kU/L). The ALEX³ test showed a dominant profile of grass pollen reactivity, with high values for Phl p 1 (7.36 kU/L), Phl p 2 (6.26 kU/L) and Zea m 1 (7.59 kU/L). There was also sensitisation to profilins from multiple sources, with Phl p 12 showing a value of 0.37 kU/L and Cuc m 2 showing a value of 0.56 kU/L. Oral challenges confirmed tolerance to banana and pistachio, while lentils induced delayed gastrointestinal symptoms. 

Our findings indicated that the anaphylaxis episode was unrelated to the ingredients in the hamburger (which were tolerated later) and was instead consistent with a profilin-mediated food reaction exacerbated by cofactors. This case demonstrates that profilin sensitisation can lead to severe systemic reactions when cofactors are present.