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Clinical Management Review Clinical Management of Seafood Allergy Carla M. Davis, MDa, Ruchi S. Gupta, MD, MPHb, Ozge N. Aktas, MDc, Veronica Diaz, MDa, Sandip D. Kamath, PhDd, and Andreas L. Lopata, PhDd Houston, Texas; Chicago, Ill; and Townsville, QLD, Australia INFORMATION FOR CATEGORY 1 CME CREDIT Kamath, PhD, and Andreas L. Lopata, PhD (authors); Scott H. Sicherer, MD (editor) Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions. Learning objectives: Method of Physician Participation in Learning Process: The core 1. To distinguish characteristics of shellfish allergy, fish allergy, and material for these activities can be read in this issue of the Journal or seafood poisoning online at the JACI: In Practice Web site: www.jaci-inpractice.org/. The accompanying tests may only be submitted online at www.jaci- 2. To recognize aspects of cross-reactivity regarding seafood inpractice.org/. Fax or other copies will not be accepted. 3. To order appropriate laboratory tests to distinguish shellfish from fi Date of Original Release: January 1, 2020. Credit may be obtained for sh allergy these courses until December 31, 2020. Recognition of Commercial Support: This CME has not received Copyright Statement: Copyright Ó 2020-2022. All rights reserved. external commercial support. Disclosure of Relevant Financial Relationships with Commercial In- Overall Purpose/Goal: To provide excellent reviews on key aspects terests: of allergic disease to those who research, treat, or manage allergic C. M. Davis has grants/contracts from the National Institutes of Health Rare Disease Network, National Institute of Allergy and Infectious disease. Diseases, Regeneron Pharmaceuticals, Allakos, DBV Technologies, Inc, Target Audience: Physicians and researchers within the field of Aimmune Therapeutics, Inc, and FARE; and is a consultant for Moonlight allergic disease. Therapeutics, Inc. R. S. Gupta has received grants from the National Institute of Health (grant nos. R21 ID #AI135705, R01 ID#AI130348, and Accreditation/Provider Statements and Credit Designation: The U01 ID #AI138907), Rho, Inc, Stanford Sean N. Parker Center for Allergy American Academy of Allergy, Asthma & Immunology (AAAAI) is Research, Aimmune Therapeutics, United Health Group, Thermo Fisher accredited by the Accreditation Council for Continuing Medical Ed- Scientific, Genentech, and the National Confectioners Association; and ucation (ACCME) to provide continuing medical education for phy- serves as a medical consultant/advisor for Before Brands, Kaléo, Inc, sicians. The AAAAI designates this journal-based CME activity for Genentech, ICER, DOTS Technology, FARE, and DBV Technologies. 1.00 AMA PRA Category 1 CreditÔ. Physicians should claim only the The rest of the authors declare that they have no relevant conflicts of in- credit commensurate with the extent of their participation in the terest. S. H. Sicherer reports grants from NIAID; and personal fees from activity. American Academy of Allergy, Asthma and Immunology, UpToDate, and List of Design Committee Members: Carla M. Davis, MD, Ruchi S. Johns Hopkins University Press, outside of the submitted work. Gupta, MD, MPH, Ozge N. Aktas, MD, Veronica Diaz, MD, Sandip D. Seafood plays an important role in human nutrition and health. A contaminating ingested seafood. The 2 most important seafood good patient workup and sensitive diagnostic analysis of IgE groupings include the fish and shellfish. Shellfish, in the context of antibody reactivity can distinguish between a true seafood allergy seafood consumption, constitutes a diverse group of species and other adverse reactions generated by toxins or parasites subdivided into crustaceans and mollusks. The prevalence of aTexas Children’s Hospital Food Allergy Program, Baylor College of Medicine, United Health Group, Thermo Fisher Scientific, Genentech, and the National Texas Children’s Hospital, Houston, Texas Confectioners Association; and serves as a medical consultant/advisor for Before bCenter for Food Allergy and Asthma Research, Northwestern University Feinberg Brands, Kaléo, Inc, Genentech, ICER, DOTS Technology, FARE, and DBV School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Technologies. The rest of the authors declare that they have no relevant conflicts Chicago, Ill of interest. cDepartment of Pediatrics, University of Illinois College of Medicine at Chicago, Received for publication August 31, 2019; revised manuscript received and accepted Chicago, Ill for publication October 23, 2019. dCollege of Public Health, Medical and Veterinary Sciences, Australian Institute of Corresponding author: Carla M. Davis, MD, 1102 Bates Ave, MC 330.01, Houston Tropical Health and Medicine, Molecular Allergy Research Laboratory, James TX, 77030. E-mail: [email protected]. Cook University, Townsville, QLD, Australia 2213-2198 Conflicts of interest: C. M. Davis has grants/contracts from Regeneron Pharma- Ó 2019 The Authors. Published by Elsevier Inc. on behalf of the American Academy ceuticals, Allakos, DBV Technologies, Inc, Aimmune Therapeutics, Inc, and Food of Allergy, Asthma & Immunology. This is an open access article under the CC Allergy Research and Education; and is a consultant for Moonlight Therapeutics, BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Inc. R. S. Gupta has received grants from the National Institute of Health (grant https://doi.org/10.1016/j.jaip.2019.10.019 nos. R21 ID #AI135705, R01 ID#AI130348, and U01 ID #AI138907), Rho,Inc, Stanford Sean N. Parker Center for Allergy Research, Aimmune Therapeutics, 37 Downloaded for Anonymous User (n/a) at James Cook University from ClinicalKey.com.au by Elsevier on June 23, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 38 DAVIS ET AL J ALLERGY CLIN IMMUNOL PRACT JANUARY 2020 The prevalence of shellfish allergy seems to be higher than that of Abbreviations used fish allergy, with an estimate of up to 3% in the adult population.2,12 OFC- oral food challenge Fin fish allergy occurs in approximately 1% of adults. Shellfish al- PPT- prick-to-prick testing lergy is of particular importance in the Asia-Pacific region, with self- SPT- skin prick test reported rates of shellfish allergy ranging from 0.9% to 1.19% in children younger than 7 years to 5.12% to 7.71% in adolescents and adults in Hong Kong, Philippines, and Singapore.14,15 Similarly, a cross-sectional study on doctor-diagnosed seafood allergy in Viet- fi fi shell sh allergy seems to be higher than that of sh allergy, nam confirmed the high prevalence among children up to age 6 with an estimate of up to 3% in the adult population and fin years. Crustacean was the predominant allergy-inducing food fish allergy prevalence of approximately 1%. Clinical evalu- (3.8%), followed by fin fish (1.2%) and mollusk (1.0%) in a study ation of the seafood-allergic patient involves obtaining a population of more than 8600 participants.16 Unlike most other detailed history and obtaining in vivo and/or in vitro testing food allergies, seafood allergy is thought to persist for life in up to with careful interpretation of results with consideration of 90% of patients, with a similar trend also observed in peanut cross-reactivity features of the major allergens. Oral food allergy.17 challenge is useful not only for the diagnosis but also for The 2 most important seafood groupings include the fish and avoiding unnecessary dietary restrictions. In this review, we shellfish (see Figure 1). Within the large group of fish, most highlight some of the recent reports to provide solid clinical reported allergies are to bony fish, whereas cartilaginous fish (rays fi 18 and laboratory tools for the differentiation of sh allergy and sharks) seem to be of lower allergenicity. Shellfish, in the from shellfish allergy, enabling best treatment and manage- context of seafood consumption, constitutes a diverse group of ment of these patients. Ó 2019 The Authors. Published by species subdivided into crustaceans and mollusks. Crustaceans, Elsevier Inc. on behalf of the American Academy of Allergy, including shrimp, crab, and lobster, are classified as arthropods Asthma & Immunology. This is an open access article under together with mites, spiders, and insects.19,20 This might provide the CC BY-NC-ND license (http://creativecommons.org/ an explanation of the observed molecular and clinical cross- licenses/by-nc-nd/4.0/). (J Allergy Clin Immunol Pract reactivity. The term “shrimp” and “prawn” are often used 2020;8:37-44) interchangeably in the commercial as well as scientific sector, Key words: fi with the latter term used more in the United Kingdom and Fish allergy; Shell sh allergy; Crustacean; Mollusk; 21 Diagnosis of fish allergy; Skin prick test; Oral food challenge Australia. However, there are anatomical differences between the 2 animals. In general, prawns are bigger in size than shrimp. The most prominent difference is in the carapace. In shrimp, the second segment of the shell overlays the first and the third, INTRODUCTION thereby giving them the typical bend in their body. However, in Seafood plays an important role in human nutrition and prawns, the segments of the shell overlap each other front to health. The growing international trade in seafood species and back, thereby imparting a lesser bend to the body. products has added to the popularity and frequency of con- Patients with seafood allergy may fail to identify the offending sumption
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