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Sea Food Allergy Elham Hossny, Zeinab Ebraheem, Ayman Rezk Pediatric Allergy and Immunology Unit, Children’S Hospital, Ain Shams University, Cairo

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Sea Food Allergy Elham Hossny, Zeinab Ebraheem, Ayman Rezk Pediatric Allergy and Immunology Unit, Children’S Hospital, Ain Shams University, Cairo Egypt J Pediatr Allergy Immunol 2010;8(2):49-54. Review Article Sea Food Allergy Elham Hossny, Zeinab Ebraheem, Ayman Rezk Pediatric Allergy and Immunology Unit, Children’s Hospital, Ain Shams University, Cairo Fish and shellfish play an important role in human Sensitization to sea food nutrition and in the world economy. Unfortunately, It is well accepted that the major route of they also can be important causes of severe acute sensitization to sea food is through the hypersensitivity reactions, including fatal gastrointestinal tract. This mechanism was anaphylaxis. Food-related anaphylaxis is a growing confirmed for codfish allergens in animal and problem worldwide and is now estimated to be the human studies. The use of antacid medication that most frequent cause of anaphylaxis treated in increased the stomach pH can result in incomplete emergency departments.1 Fish and shellfish are two digestion and thereby increase exposure to and of the most common causes of IgE-mediated food- uptake of allergenic fish proteins or protein allergic reactions in both children and adults. A fragments. Challenge experiments on patients number of major allergens and important potential without clinical sensitivity demonstrated absorption cross-reacting allergens have been identified within of biologically active fish allergens already 10 min the fish family, and between shellfish and major after ingestion.4,9-10 inhalant allergens in arachnids and insects.2 The There is little information on the establishment edible fish include more than 20000 species; of threshold values for elucidating allergic reactions however, the most commonly consumed belong to to seafood. For codfish, very small amounts of less only a few orders of the ray-finned fish than 3 mg protein could trigger allergic reactions,10 (Actinopterygii). Fish-sensitive patients are often which is less than that previously reported.11 allergic to multiple species of fish and are therefore Double-blind placebo-controlled studies with advised to avoid consuming fish in general.3 shrimp demonstrated allergic reactions after ingestion of at least two to four shrimps (4 g each, Epidemiology and prevalence 16 g total) equivalent to 32 mg of extracted shrimp Fish is a major source of dietary protein, especially proteins.12 in coastal areas. It is generally considered that Although most food-allergic individuals have crustaceans and fish are among the four food knowledge of their allergy and thus can make groups most commonly provoking severe food attempts at strict avoidance, many unknowingly anaphylaxis. The consumption of seafood has ingest or inhale the offending food as a hidden increased worldwide, and therefore, the imports of allergen.1 Fish and shellfish allergic individuals seafood from other countries often surpass the own may not be aware of the various forms of potential productions.4 A recent analysis of food-related exposure, because the seafood content of some reactions in emergency departments in the USA foods is not obvious.13 established that shellfish was the most frequently implicated food in persons aged 6 years or older.5 Allergens in fish and shellfish Fish allergy accounts for an estimated 0.1% and In the late 1960s, Aas14 published the most 0.4% of food allergies in US children and adults, extensive study about fish allergy and Elsayed15 respectively. Shellfish are responsible for 0.1% of characterized Gad c 1, as the major allergen in food allergies in children and are the number one codfish, to be considered as a fish pan-allergen. cause of IgE-mediated food allergy in US adults, During the past several years, many new allergens affecting an estimated 2% of the adult population.6 and important potential cross-reacting allergens Seafood allergy is common not only in western but have been identified within the fish family and also in Asian countries where allergic reactions to between shellfish, arachnids, and insects. Codfish seafood and particularly shellfish are significant and shrimp have been the models used to study among children and adults.7 A study from allergy to fish and shellfish, respectively.16 Singapore on 227 children with food The major allergens responsible for cross- hypersensitivity confirmed that crustaceans and fish reactivity among distinct species of fish and were significant sensitizers in about 40 and 13% of amphibians are Parvalbumins. These proteins children, respectively.8 control calcium flow in the muscular sarcoplasm of the white meat and have a molecular weight of 49 Hossny et al. approximately 12 kD. Parvalbumins are resistant to sensitization to shrimp tropomyosin in orthodox thermal and enzymatic degradation.17 Jews who are prohibited by religious dietary laws The major one of these, Gad c 1, is a from eating shellfish; however, as they were never Parvalbumins that was first identified in Baltic cod exposed to crustacean allergens, this sensitization to (Gadus callarias). Another parvalbumin, the major tropomyosin is probably due to a noncrustacean allergen in the white muscle of Atlantic salmon, source, such as house dust mites (HDM), was identified and named Salmo salar (Sal s l). In cockroaches or both. Clinically relevant cross- the Atlantic cod (G. morhua), an oligomeric reactivity between crustacean and HDM allergens parvalbumin encoded by a distinct gene was was described in the early 1990s by Witteman et identified as Gad m 1 and found to have greater al.29 The primary sensitization is believed mostly to homology with Sal s 1 than with Gad c 1. be ‘respiratory’ allergy to dust mites, which in some Interestingly, Gad m 1 shares 75% homology with individuals may cause food-allergic reactions to Sal s 1 and only 62.3% homology with Gad c 1.18 crustaceans or mollusks. This view is supported by Hamada et al19 identified the major allergens, recent observations during immunotherapy to HDM Sco j1, Sco a1, and Sco s1, from three species of in which some patients developed clinical mackerel (Scomber japonis, S. australasicus, and S. sensitization to shellfish tropomyosin, which did scombrus, respectively). Swoboda et al.20 identified not exist before therapy. In contrast, sensitization to The major allergen in carp (Cyprinus carpio) was HDM in Iceland, where exposure to mites is found to inhibit IgE binding to parvalbumins of extremely rare, is strongly correlated with specific several other fish species and, therefore, contains IgE to shrimp.30 most of the fish-specific IgE epitopes.20 Because In the group of arthropods, the crustaceans are carp Parvalbumins contains 70% of the IgE more phylogenetically related to the ‘insects’ than epitopes present in natural extracts of cod, tuna, and to the group of ‘mites’ (arachnids).4 Other possible salmon, recombinant carp parvalbumin may prove IgE reactivities to tropomyosin-containing allergen to be a very important tool in the diagnosis and sources have been documented, such as the cross- treatment of fish-allergic subjects.21 In addition to reactivity with the nematode parasite, Anisakis the well-known major fish-allergen parvalbumin, found in many seafood species.31 gelatin (type I collagen) was identified as an Clinical features important novel allergen in the muscle and skin of Hypersensitivity reactions to fish and shellfish can several species of fish.22 result from ingestion, contact, or even inhalational The major allergen of shellfish is the muscle exposures. Many reactions have been described in protein, tropomyosin, in crustaceans and mollusks. allergic consumers after the ingestion of or direct In addition to tropomyosin, other allergens have contact with the offending seafood. In a double- been identified and characterized in crustaceans blind, placebo-controlled oral fish challenge study, such as the 40 kDa arginine kinase which might be emesis was the most frequent objective sign in a new class of invertebrate pan-allergens.23 A recent patients with a positive challenge. Oropharyngeal study demonstrated IgE binding to a 20 kDa symptoms or generalized pruritus preceded emesis allergen in 55% of patients reacting to the white in all patients.16 In another study, the most pacific shrimp (Litopenaeus vannamei).24 frequently reported signs/symptoms were pruritus Importantly, tropomyosin is not only a and hives, wheezing and chest tightness, and crustacean allergen but has been confirmed in a angioedema. Although symptoms can develop up to number of mollusk species. It has become apparent 60 minutes after ingestion, most reactions (85%) that mollusks such as mussel, oyster, squid, limpet occur within 30 minutes of ingestion of the culprit and abalone are significant food allergens in food.32 exposed population. In addition to tropomyosin, In addition to allergy in the consumer, fish and mollusks contain allergens such as myosin heavy shellfish have also been recognized as important chain, hemocyanin and amylase.25,26 allergens in occupational environments. In the Cross-reactivity with other allergens occupational setting, reactions are most commonly Patients with seafood allergy are frequently associated with direct contact or inhalational reported to also have allergic reactions to mites and exposure rather than with ingestion. Often these insects.27 This cross-reactivity is probably due to workers are unable to handle raw food but are able the high amino acid homology of these invertebrate to ingest the food once it is cooked, suggesting a tropomyosins and may have significant clinical heat-labile allergen.33 implications. Fernandes et al28 demonstrated ٥٠ Sea food allergy
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