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Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center

Colin W. Summers, MSc,a* Richard S. Pumphrey, FRCPath,a* Charlotte N. Woods, MSc,a,b Garry McDowell, MRCPath, PhD,b Philip W. Pemberton, MSc,b and Peter D. Arkwright, FRCPCH, DPhila Manchester, United Kingdom.

As healthcare providers, we strive for a definitive message to give to our severely food allergic patients and their families. They want to know, what are the risks? Most life-threatening anaphylactic reactions are unpredictable, making management and reassurance of patients with peanut and nut allergies difficult. I’ve watched my own son have a severe allergic reaction to cashew. I know, firthand, that the panic of the moment eventually yields to an ongoing anxiety for both the patient and family members. Salve for this worry would be so welcome.

This study from the March JACI offers the clinician a firmer basis for identifying patients at increased risk of peanut and nut-induced anaphylaxis. The aim of this study was to determine which clinical and laboratory parameters best predict the likelihood of severe allergic reactions tree nuts and peanuts. The study highlights the fact that it is not so much the presence or absence of coexisting chronic atopic diseases that is important in predicting the likelihood of life-threatening acute allergic reactions, but rather the severity of these atopic diseases. This stands in contrast to previous conventional wisdom which suggested that patients with any degree of asthma (mild to severe) may be at a higher risk of life-threatening allergic reactions.

The investigators also found that patients with the lowest serum concentrations of angiotensin converting enzyme (ACE) were more likely to develop life-threatening pharyngeal edema. This,suggests that this complication may be partially mediated by bradykinin as ACE is involved in its catabolism. In the future, administration of specific bradykinin antagonists might serve as an adjunct therapy to epinephrine treatment for anaphylaxis. For the present, this study bears directly on the counseling we can provide to our patients and families regarding anaphylaxis to peanuts and tree nuts.

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