Food-Induced Anaphylaxis: Role of Hidden Allergens and Cofactors

Abstract

Food anaphylaxis is on the increase, with those who have an allergy to peanuts, tree nuts, milk, and seafood at the highest risk of developing such a reaction. However, the diet in many societies is increasingly varied, much of the food consumed is prepared outside the home, and meals are often composed of many different ingredients. Anaphylaxis may occur to a composite food, and it may be unclear whether the reaction is due to contamination or to a culprit allergen present in an added ingredient. Composite foods can contain many allergic proteins present in small amounts, which do not always have to be labeled, unless they feature in European or US labeling regulations. These “hidden” allergens include mustard, celery, spices, lupine, pea, natural food colourings, and preservatives, but can occasionally include allergenic material from contaminants such as cereal mites. Hidden allergens can provoke severe reactions to seemingly unconnected foods which might then lead to a diagnosis of idiopathic anaphylaxis. The same problem can arise with two well-known types of food allergy; wheat-dependant exercise induced anaphylaxis and allergy to non-specific Lipid Transfer Protein allergens, both of which might only manifest when linked to a cofactor such as exercise. Many of these risk factors for food anaphylaxis have a common link; the public's engagement with popular concepts of health and fitness. This includes the development of a food and exercise culture involving the promotion and marketing of foods for their health-giving properties i.e., meat substitutes, wheat substitutes, supplements and alternative, or “natural” remedies for common ailments. Some of these foods have been reported as the cause of severe allergic reactions, but because they are often viewed as benign unlikely causes of severe allergic reactions, could be considered to be hidden allergens. The best resource to elicit the likelihood of a hidden allergen provoking an allergic reaction is to take a detailed history of the allergic reaction, presence of co-factors, foods suspected, type of food and where it was consumed. A good knowledge of commonly used ingredients, and list of potential hidden allergen suspects are essential tools for the food allergy detective.

A multicenter anaphylaxis registry in Korea: Clinical characteristics and acute treatment details from infants to older adults

“…Physical exercise was the most common cofactor of anaphylaxis in adults in this study, whereas drug intake or tiredness was a more common cofactor among adults in other studies. 29 , 30 To date, little is known about the cofactors affecting the induction and augmentation of severe allergic reactions. In future studies, cofactors related with anaphylaxis should be more thoroughly evaluated so that patients can be better informed about the risk factors amplifying severe allergic reactions.…”

Comorbidities and Cofactors of Anaphylaxis in Patients with Moderate to Severe Anaphylaxis. Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland

“…Skypala provides an overview of hidden allergens and the influence of cofactors in food-related anaphylaxis. An accurate clinical history with a high index of suspicion is paramount in making a correct diagnosis [ 29 ].…”

Soy Preparations Are Potentially Dangerous Factors in the Course of a Food Allergy

“…They were also observed in people with atopic diseases and those allergic to cow's milk [12]. An increase in allergic symptoms occurring after eating soy is also noted in people who are allergic to birch, especially during the pollination period [13][14][15].…”