Fruit-induced anaphylaxis: causes, severity, effect of season and management gaps

Published online: July 1, 2021

Anaphylaxis is a severe and life-threatening allergic condition. Anaphylaxis due to fruit can occur either with fruit alone, independent of pollen allergy, or due to pollen-food syndrome (PFS). PFS usually manifests as itching and swelling of the mouth, tongue and lips, however, it can progress to anaphylaxis in up to 10% of patients. There are limited data on fruit-induced anaphylaxis in North America, especially regarding clinical characteristics and management.

In this original article published in The Journal of Allergy and Clinical Immunology: In Practice, Gabrielli et al. assessed children and adult presenting with fruit-induced anaphylaxis to the Emergency Department (ED) in four Canadian provinces as well as cases treated by the Emergency Medical Services in Outaouais, Quebec over a 9-year period. Patients were recruited as part of the Cross-Canada Anaphylaxis Registry and a standardized questionnaire documenting patients’ symptoms, triggers, and management were collected. Multivariate logistic regression analyses were conducted to identify factors associated with severe reactions to fruit and with epinephrine treatment in the pre-hospital setting, prior to ED arrival.

From 2011 to 2020, among 3,512 children and adults with anaphylaxis, 250 (7.1%) report fruit as a triggering food. The majority of the reactions were classified as moderate (72.8%), with 16.4% as mild and 10.8% as severe. The most common fruit trigger causing anaphylaxis were kiwi (15.6%), banana (10.8%), and mango (9.2%). Epinephrine was administered to 28.4% of patients in the pre-hospital setting, 40.8% of patients in the ED, and 6.0% of patients in both setting. Overall, 36.8% of patients did not receive any epinephrine treatment in either setting. Severe anaphylactic reactions to fruit were more likely to occur during the spring and among those with known eczema [adjusted Odds Ratio (aOR) 1.12 (95%CI 1.03, 1.23) and 1.17 (95%CI 1.03, 1.34), respectively] while adjusting for age, sex, fruit trigger, presence of asthma, and pre-hospital treatment with epinephrine. Epinephrine treatment in the pre-hospital setting was associated with moderate and severe reactions and a history of known food allergies [aOR 1.23 (95%CI 1.07, 1.43) and 1.38 (95%CI 1.24, 1.54), respectively] while adjusting for age, sex, fruit trigger, presence of asthma, presence of eczema, and season. Our main findings indicate that fruit-induced anaphylaxis affects a substantial percentage of anaphylaxis cases, however epinephrine use remains low. More severe anaphylactic reactions to fruit were more likely to occur in the spring, indicating possible cross-reactivity to pollens.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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