D3.282 - A Case of Nonsteroidal Anti-Inflammatory Drug-Exacerbated Food Allergy

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are deemed significant cofactors in allergic reactions. Following the ingestion of certain foods, they can contribute to the development of NSAID-induced or NSAID-exacerbated food allergy (NIFA/NEFA). Lipid transfer proteins (LTPs) are prolamins found in plants that are resistant to heat and digestion and play a critical role in allergic reactions. Here, we present a case who experienced angioedema after ingesting peanut and flurbiprofen.

Case Report: A 40-year-old female was admitted to our clinic for hypersensitivity reaction to flurbiprofen. Her initial reaction occurred in 2020 following pea ingestion and administration of 100 mg flurbiprofen for menstrual pain. Four hours after flurbiprofen intake, she developed swelling of the lips, accompanied by urticaria. Following intravenous administration of pheniramine and dexamethasone in the emergency department (ED), her symptoms were relieved. She reported that she had frequently used flurbiprofen without any problems both before and after initial reaction. In 2024, she ingested peanuts and subsequently administered a 100-mg oral flurbiprofen tablet approximately 10 minutes later. Three hours after taking flurbiprofen, generalized urticaria, lip swelling, hoarseness, and dysphagia developed (Figure 1). Vital signs were stable. Her symptoms resolved within 30 minutes following antihistamine and corticosteroid administration in the ED. She reported developing cough and difficulty swallowing within five minutes after peanut ingestion, which resolved within 30 minutes following administration of antihistamine. While she tolerated the pulp of peaches, contact with or ingestion of the peel triggered lip angioedema. Skin prick testing revealed a positive histamine control (3x3 mm), with wheal sizes of 6 × 6 mm for both peanut and pea. Using the ALEX test, component-resolved diagnosis confirmed LTP sensitization (Table 1). An adrenaline autoinjector was prescribed. An oral provocation test with flurbiprofen was performed after 4 hours of fasting, followed by an additional 4-hour fasting period. Oral intake was then resumed with an LTP-free diet, and flurbiprofen was tolerated. NEFA diagnosis was confirmed.

Conclusion: As NSAIDs may serve as cofactors in allergic reactions, LTP sensitization and underlying food allergy should be evaluated before diagnosing NSAID allergy. NSAIDs that previously triggered reactions may be tolerated when administered with an LTP-free diet.