D3.82 - Could Lipid Transfer Protein Induced Anaphylaxis Be a Surprising Outcome of Sleeve Gastrectomy?

Non-specific lipid transfer proteins (nsLTPs) are small, highly structurally stable proteins found in various plant foods and pollen. Their structure contains four disulfide bonds that are responsible for their resistance to thermal processing as well as gastrointestinal digestion. nsLTPs are mostly present in the peel of fruits, rather than the pulp. Interestingly, symptoms after the consumption of LTP-containing foods can differ. Incidence of anaphylactic attacks in LTP-sensitized patients is much lower than that observed in patients allergic to other food plant allergens such as seed storage proteins. Clinical presentation of LTP-hypersensitive patients can range from asymptomatic to severe anaphylaxis.We herein report an unusual case of a man who developed an anaphylactic reaction several times including a variety of different foods ranging from walnut, peach, apple and tomato, 1 year after sleeve gastrectomy.

A 29-year-old man presented with several anaphylactic reactions  with a meal including a variety of different foods. His past medical history included sleeve gastrectomy and allergic rhinitis (AR) with a positive skin prick test to grass and tree pollens. His first reaction was minutes after consuming mixed fruit juice. Anaphylactic reactions occur after eating apples, peaches, tomatoes, walnuts and maize, too. Symptoms of an anaphylactic shock after an itchy rash on his neck, swelling of his lips and syncope occured after the consumption of many taxonomically unrelated plant foods.Skin prick testing revealed sensitization to 5 grasses mix (Phleum, Dactylis, Lolium, Festuca and Alopecurus) (12 mm) and Strawberry (4.2 mm). The positive control (histamine) reaction was 8.5 mm. The concentration of specific IgE-antibodies to different allergen extracts and single allergens was determined by Macroarray Allergy Explorer® (ALEX®2) technique (Macroarray Diagnostic, Vienna, Austria). Total serum IgE was normal (38 kU/L; normal <100 kU/L). Specific IgE to single allergens was positive in descending concentration for the nsLTPs of peach (rPru p 3), Arizona cypress pollen (rCup a 1), timothy (rPhl p 1), apple (rMal d 3), kiwifruit (rAct d 10), strawberry (rFra a 1+3), grape (rVit v 1), walnut (rJug r 3) and hazelnut (rCor a 8). These results are shown in Table 1. The ability to manage and counsel patients allergic to nsLTP is essential for Allergy&Immunology specialists, due to a large number of anaphylactic reactions with a variety of taxonomically unrelated plant foods. Sleeve gastrectomy seems to accelerate the absorption of the protein from the gut, as well as reducing chemical degradation, thus, inducing more severe clinical symptoms. Food reactions emerging after obesity surgery should raise suspicion for nsLTP syndrome.