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. 2017 May;118(5):591-596.e3.
doi: 10.1016/j.anai.2017.02.010. Epub 2017 Mar 27.

Characteristics of tree nut challenges in tree nut allergic and tree nut sensitized individuals

Christopher Couch  1 , Tim Franxman  2 , Matthew Greenhawt  3
Affiliations

Characteristics of tree nut challenges in tree nut allergic and tree nut sensitized individuals

Christopher Couch et al. Ann Allergy Asthma Immunol. 2017 May.

Abstract

Background: Characteristics and outcomes of tree nut (TN) oral food challenges (OFCs) in patients with TN allergy or sensitization alone are poorly studied.

Objective: To determine the relation between TN sensitization levels and OFC outcomes.

Methods: Open TN OFCs performed from 2007 through 2015 at a referral center were analyzed to compare outcome based on skin prick test (SPT) wheal size, food-specific immunoglobulin E (sIgE), peanut co-allergy, and TN sensitization only vs TN allergy with sensitization to other TNs. Delayed OFC was defined as longer than 12 months from the time of an sIgE level lower than 2 kUA/L.

Results: Overall passage rate was 86% for 156 TN OFCs in 109 patients (54 almond, 28 cashew, 27 walnut, 18 hazelnut, 14 pecan, 13 pistachio, and 2 Brazil nut). Passage rates were 76% (n = 67) in patients with a history of TN allergy who were challenged to another TN to which they were sensitized and 91% (n = 65) in those with TN sensitization only (mean sIgE 1.53 kUA/L; range 0.35-9.14). Passage rates were 89% (n = 110 of 124) for a TN sIgE level lower than 2 kUA/L and 69% (11 of 16) for a TN sIgE level of at least 2 kUA/L. In 44 challenges in patients with peanut allergy and TN co-sensitization, the TN OFC passage rate was 96%. In 41 TN OFCs with a TN SPT wheal size of at least 3 mm, 61% passed, with a mean wheal size of 4.8 mm (range 3-11) in those passing vs 9 mm (range 3-20) in those failing.

Conclusion: TN challenges are frequently passed in patients with TN sensitization with or without a history of TN reactivity despite a TN SPT wheal of at least 3 mm or a TN sIgE level of at least 2 kUA/L. Nearly all patients with peanut allergy and TN co-sensitization passed the TN challenge, questioning the clinical relevance of "co-allergy."

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Conflict of interest statement

Conflicts of Interest: Dr. Greenhawt is an expert panel member of the NIAID-sponsored Guidelines for Peanut Allergy Prevention; has served as a consultant for the Canadian Transportation Agency and Aimmune Therapeutics; is a member of physician/medical advisory boards for Aimmune, Nutricia, Kaleo Pharmaceutical, Nestle, and Monsanto; is a member of the scientific advisory council for the National Peanut Board; has received honorarium for lectures from Thermo Fisher, ReachMD, and the Kentucky/Pennsylvania/Aspen/New York allergy societies, the ACAAI, the EAACI, and UCLA/Harbor Medical Center; and is a member of the Joint Taskforce on Allergy Practice Parameters. Dr. Couch and Dr. Franxman report no relevant conflicts of interest.

Figures

Figure 1
Figure 1. 50% Negative Predictive Values for OFC to Tree Nut Among Tree Nut Allergic and Sensitized Individuals
50% negative predictive values for the combined allergic and sensitized population, adjusted for patient age, eczema, asthma, gender, and peanut allergy. Left panel displays wheal size curve, and right panel tree nut sIgE curve.
Figure 2
Figure 2. 50% Negative Predictive Values for OFC to Tree Nut Among Tree Nut Sensitized Individuals
50% negative predictive values for the tree nut sensitized population, adjusted for patient age, eczema, and peanut allergy. Left panel displays wheal size curve, and right panel tree nut sIgE curve. Reflects relationship with sensitized tree nuts in individuals with no history of tree nut allergy.
Figure 3
Figure 3. 50% Negative Predictive Values for OFC to Tree Nut Among Tree Nut Allergic Individuals
50% negative predictive values for the tree nut sensitized population, adjusted for patient age, eczema, and peanut allergy. Left panel displays wheal size curve, and right panel tree nut sIgE curve. Reflects relationship with sensitized tree nuts other than the nut to which the patient has a primary allergy.
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