Management and prognosis of oral allergy syndrome (pollen-food allergy syndrome)
- Anna Nowak-Węgrzyn, MD
Anna Nowak-Węgrzyn, MD
- Associate Professor of Pediatrics
- Icahn School of Medicine at Mount Sinai
The oral allergy syndrome (OAS) (pollen-food allergy syndrome [PFAS or PFS]) describes allergic reactions that typically occur upon ingestion of certain uncooked fruits, nuts, vegetables, or spices in pollen-sensitized individuals [1,2]. The causative allergens in these plant foods are homologous to pollen allergens. The symptoms result from contact urticaria of the mucosal surface that touches the food, and symptoms are usually limited to the mouth and throat. Symptoms appear quickly after eating raw forms of the food because the responsible allergens are rapidly inactivated by cooking and digestion, although this is not always true. Systemic reactions are observed in 2 to 10 percent of patients, and reactions to cooked plant foods (including roasted nuts) are possible.
This topic review presents the management and prognosis of patients with PFS. The clinical manifestations, diagnosis, and pathogenesis of PFS are reviewed separately. (See "Clinical manifestations and diagnosis of oral allergy syndrome (pollen-food allergy syndrome)" and "Pathogenesis of oral allergy syndrome (pollen-food allergy syndrome)".)
In this topic review, the term "oral allergy syndrome" (OAS) is used to describe reactions limited to the oropharynx that are caused by food proteins that are homologous to pollen proteins. "Pollen-food allergy syndrome," "pollen-food syndrome," and "pollen-associated food allergy syndrome" (abbreviated PFAS or PFS) are broader terms that encompass both oropharyngeal and systemic symptoms. In this review, PFS is the preferred term for the spectrum of reactions caused by allergens in plant foods that are homologous to pollen allergens.
OVERVIEW OF MANAGEMENT
The approach presented in this topic review is based upon the author's experience because there are limited guidelines for the management of PFS, and clinicians vary considerably in their practices [1,3-6]. A questionnaire mailed to 226 randomly selected allergy specialists across the United States illustrated the variability in approach to this disorder . Of the 122 allergists who responded, 53 percent recommended complete avoidance of causal foods to all patients, whereas 9 percent did not advocate any restrictions. Sixty-six percent of allergists prescribed epinephrine for PFS on a case-by-case basis, 30 percent never prescribed it, and 3 percent always did. (See 'Indications for epinephrine' below.)
Avoidance — Dietary avoidance of the offending plant food(s) in the form in which it causes symptoms is the most common approach to management. However, strict avoidance may not be uniformly necessary if symptoms are mild. Additionally, patients may continue to eat forms of the foods that do not cause symptoms. Cooked, processed, and sometimes frozen forms of the foods typically do not cause symptoms of PFS. The purpose of avoidance is the prevention of future reactions. However, there are no studies reporting the impact of avoidance on the natural history of the condition. (See 'Prognosis' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126:1105.
- Muraro A, Werfel T, Hoffmann-Sommergruber K, et al. EAACI food allergy and anaphylaxis guidelines: diagnosis and management of food allergy. Allergy 2014; 69:1008.
- Ma S, Sicherer SH, Nowak-Wegrzyn A. A survey on the management of pollen-food allergy syndrome in allergy practices. J Allergy Clin Immunol 2003; 112:784.
- Blein JP, Coutos-Thévenot P, Marion D, Ponchet M. From elicitins to lipid-transfer proteins: a new insight in cell signalling involved in plant defence mechanisms. Trends Plant Sci 2002; 7:293.
- Mari A, Ballmer-Weber BK, Vieths S. The oral allergy syndrome: improved diagnostic and treatment methods. Curr Opin Allergy Clin Immunol 2005; 5:267.
- Sampson HA, Aceves S, Bock SA, et al. Food allergy: a practice parameter update-2014. J Allergy Clin Immunol 2014; 134:1016.
- Kosma P, Sjölander S, Landgren E, et al. Severe reactions after the intake of soy drink in birch pollen-allergic children sensitized to Gly m 4. Acta Paediatr 2011; 100:305.
- Ballmer-Weber BK, Hoffmann A, Wüthrich B, et al. Influence of food processing on the allergenicity of celery: DBPCFC with celery spice and cooked celery in patients with celery allergy. Allergy 2002; 57:228.
- Figueroa J, Blanco C, Dumpiérrez AG, et al. Mustard allergy confirmed by double-blind placebo-controlled food challenges: clinical features and cross-reactivity with mugwort pollen and plant-derived foods. Allergy 2005; 60:48.
- Bindslev-Jensen C, Vibits A, Stahl Skov P, Weeke B. Oral allergy syndrome: the effect of astemizole. Allergy 1991; 46:610.
- Bolhaar ST, Tiemessen MM, Zuidmeer L, et al. Efficacy of birch-pollen immunotherapy on cross-reactive food allergy confirmed by skin tests and double-blind food challenges. Clin Exp Allergy 2004; 34:761.
- Asero R. Effects of birch pollen-specific immunotherapy on apple allergy in birch pollen-hypersensitive patients. Clin Exp Allergy 1998; 28:1368.
- Bucher X, Pichler WJ, Dahinden CA, Helbling A. Effect of tree pollen specific, subcutaneous immunotherapy on the oral allergy syndrome to apple and hazelnut. Allergy 2004; 59:1272.
- Hansen KS, Khinchi MS, Skov PS, et al. Food allergy to apple and specific immunotherapy with birch pollen. Mol Nutr Food Res 2004; 48:441.
- Asero R. How long does the effect of birch pollen injection SIT on apple allergy last? Allergy 2003; 58:435.
- Asero R. Effects of birch pollen SIT on apple allergy: a matter of dosage? Allergy 2004; 59:1269.
- Möller C. Effect of pollen immunotherapy on food hypersensitivity in children with birch pollinosis. Ann Allergy 1989; 62:343.
- Modrzyński M, Zawisza E. Possible induction of oral allergy syndrome during specific immunotherapy in patients sensitive to tree pollen. Med Sci Monit 2005; 11:CR351.
- Ciprandi G. Onset of oral allergic syndrome during birch sublingual immunotherapy. Eur Ann Allergy Clin Immunol 2012; 44:170.
- Kinaciyan T, Jahn-Schmid B, Radakovics A, et al. Successful sublingual immunotherapy with birch pollen has limited effects on concomitant food allergy to apple and the immune response to the Bet v 1 homolog Mal d 1. J Allergy Clin Immunol 2007; 119:937.
- Mauro M, Russello M, Incorvaia C, et al. Birch-apple syndrome treated with birch pollen immunotherapy. Int Arch Allergy Immunol 2011; 156:416.
- Kopac P, Rudin M, Gentinetta T, et al. Continuous apple consumption induces oral tolerance in birch-pollen-associated apple allergy. Allergy 2012; 67:280.
- Geroldinger-Simic M, Kinaciyan T, Nagl B, et al. Oral exposure to Mal d 1 affects the immune response in patients with birch pollen allergy. J Allergy Clin Immunol 2013; 131:94.
- Gilissen LJ, Bolhaar ST, Matos CI, et al. Silencing the major apple allergen Mal d 1 by using the RNA interference approach. J Allergy Clin Immunol 2005; 115:364.
- Dubois AE, Pagliarani G, Brouwer RM, et al. First successful reduction of clinical allergenicity of food by genetic modification: Mal d 1-silenced apples cause fewer allergy symptoms than the wild-type cultivar. Allergy 2015; 70:1406.
- Flinterman AE, Akkerdaas JH, Knulst AC, et al. Hazelnut allergy: from pollen-associated mild allergy to severe anaphylactic reactions. Curr Opin Allergy Clin Immunol 2008; 8:261.
- Ortolani C, Pastorello EA, Farioli L, et al. IgE-mediated allergy from vegetable allergens. Ann Allergy 1993; 71:470.
- Untersmayr E, Jensen-Jarolim E. The role of protein digestibility and antacids on food allergy outcomes. J Allergy Clin Immunol 2008; 121:1301.
- Untersmayr E, Schöll I, Swoboda I, 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.
- Schöll I, Untersmayr E, Bakos N, et al. Antiulcer drugs promote oral sensitization and hypersensitivity to hazelnut allergens in BALB/c mice and humans. Am J Clin Nutr 2005; 81:154.
- Untersmayr E, Bakos N, Schöll I, et al. Anti-ulcer drugs promote IgE formation toward dietary antigens in adult patients. FASEB J 2005; 19:656.
- Glaumann S, Nopp A, Johansson SG, et al. Anaphylaxis to peanuts in a 16-year-old girl with birch pollen allergy and with monosensitization to Ara h 8. J Allergy Clin Immunol Pract 2013; 1:698.
- Hoflehner E, Hufnagl K, Schabussova I, et al. Prevention of birch pollen-related food allergy by mucosal treatment with multi-allergen-chimers in mice. PLoS One 2012; 7:e39409.
- OVERVIEW OF MANAGEMENT
- Indications for epinephrine
- Specific clinical scenarios
- - Patients with past systemic symptoms
- - Patients with oral symptoms to high-risk foods
- - Patients with oral symptoms to low-risk foods
- OTHER MANAGEMENT ISSUES
- - Injection immunotherapy with pollen extracts
- - Other forms of immunotherapy
- Sublingual pollen immunotherapy
- Oral immunotherapy with food
- Sublingual immunotherapy with recombinant food allergens
- Anti-IgE therapy
- Genetically modified foods
- PATIENT EDUCATION
- The risk of systemic reactions
- Caution with antiulcer treatments
- Caution with large amounts of cross-reactive foods
- Other augmenting cofactors
- PRIMARY PREVENTION
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS