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Chronic spontaneous urticaria (CSU) is defined as the spontaneous appearance of wheals, angioedema, or both, for at least 6 weeks, due to known or unknown causes [1]. In some patients who present a CSU with daily or almost daily symptoms a type I allergy could be the underlying cause. We present one adult patient with chronic urticaria who was finally diagnosed as a non-occupational case of IgE-mediated wheat allergy manifested following exposure by 3 different routes: inhalation (rhinitis and bronchial asthma), dermal absorption (contact urticaria) and ingestion (systemic chronic urticaria). We were able to detect the culprit proteins by immunoblotting. Serum IgE binds mainly to alpha-amylase/trypsin inhibitors and, to a lesser extent, to other proteins associated with food allergy to grains (e.g. beta-glucanase, serpin, peroxidase). In our opinion, skin prick tests with a food standard battery could help in the etiological diagnosis of chronic urticaria. The identification of responsible allergens could be difficult because only a few complex in vitro techniques allow detecting the allergy to several proteins.

The seeds of Plantago ovata, called psyllium or ispaghula, have been used in the preparation of bulk laxatives. Nowadays, it is also used as an ingredient in bakery and breakfast cereals to increase dietary fiber and to give baking products fluffiness and viscosity. Mostly, there are described cases of occupational allergy that handle Plantago ovata seeds in powder laxatives and some cases of anaphylaxis after eating products containing psyllium. This case report is about a geriatric assistant who had an anaphylactic shock after eating a multigrain gluten-free piece of bread containing psyllium, who presented a positive skin test with psyllium in the allergy study. We recommended to the patient to avoid the ingestion and the inhalation at work of Plantago ovata seeds and to carry self-injectable adrenaline. With this case, we would like to highlight the growing uses of psyllium, especially in bakery products, and that it can behave like a hidden allergen.

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