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54 Clinical Rounds





April 2007

Myth Persists on Seafood Allergy/Contrast Link


San Francisco Bureau

S A N D IEGO — An old medical myth— that patients who are allergic to seafood are at risk of adverse reactions to radio- logic contrast media—persists even among cardiologists and interventional radiologists, despite having been thor- oughly debunked, Dr. Andrew D. Beaty re- ported at the annual meeting of the Amer- ican Academy of Allergy, Asthma, and Immunology. In a survey of 231 specialists at six aca- demic medical centers, 69% of physicians admitted asking patients about seafood al- lergy before radiologic procedures using contrast media. Of those surveyed, 37% of physicians admitted withholding contrast media or premedicating seafood-allergic patients with corticosteroids or antihista- mines before the procedure. Many studies over the past 30 years have failed to find any special relationship be- tween seafood allergy and adverse reac- tions to radiologic contrast media (RCM). According to some small studies, atopic pa- tients in general may have a fourfold to fivefold increased risk of adverse events in response to RCM. However, the baseline rate of these events is so low that even if confirmed in larger populations, less than 1% of atopic patients would be affected.

About 10 million procedures using RCM are conducted every year in the

United States. Life-threatening reactions occur in about 0.2% of patients receiving high-osmolarity contrast media and 0.04% of patients receiving low-osmo- larity contrast media. The origin of the seafood-allergy myth is unknown. But Dr. Beaty, of St. Louis University, has traced it at least as far as a

1975 paper in the American Journal of Roentgenology that stated that 15% of patients who experi- enced adverse reac- tions to RCM report- ed having seafood

allergy (Am. J. Roentgenol. Radium Ther. Nucl. Med. 1975;124:145-52). The authors of that study hypothesized that the iodine in seafood cross-reacted with the iodine in RCM. They never verified those patient re- ports, however, and similar percentages of patients with adverse reactions in their study reported allergies to other common foods such as milk and eggs. Since then, it has been determined that seafood allergy is mediated by im- munoglobulin E (IgE) antibodies to pro- teins in meat, with iodine playing no role.

Furthermore, IgE does not mediate severe

RCM reactions. The combination of these two findings effectively discounts the hy- pothesis of iodine cross-reactivity. For his study, Dr. Beaty and his col- leagues mailed anonymous question- naires to 231 faculty members at six prominent academic medical centers in the Midwest. Of the individuals queried, 49% responded.

Many studies over the past 30 years have failed to find any special relationship between seafood allergy and adverse reactions to radiologic contrast media.

The survey consist- ed of eight brief questions, but only two of them related to seafood allergy and RCM. The other six were intended as distractors. The first seafood-

related question was, “Do you or someone on your behalf in- quire about a history of seafood or shell- fish allergy prior to administration of con- trast media?” Sixty-five percent of the radiologists and 89% of the cardiologists answered, “Yes.” The second question was, “Would you withhold RCM administration or recom- mend pretreatment with corticosteroids and/or antihistamines based on a history of seafood or shellfish allergy?” Thirty-five percent of the radiologists and 50% of the cardiologists answered, “Yes.”

While 69% of the total respondents said that they would ask patients about seafood allergy, only 37% said that they would change management based on that infor- mation. That suggests that about 32% would ask the question even if the answer would not affect patient management. Merely asking that question may serve to perpetuate the myth among patients, Dr. Beaty said. He pointed to a separate study indicating that 65% of patients with seafood allergy had either read or been told by their physician to avoid RCM, and 92% believed that iodine in seafood was re- sponsible for their allergy (Allergy Asthma Proc. 2005;26:468-9). One audience member described a ra- diologic technician who received an offi- cial reprimand for failing to ask a patient

about seafood allergy. Another said that at his institution no allergic patients were allowed to receive RCM unless they were premedicated. A third physician said that at his institution, the computer system automatically categorized every patient with a seafood allergy as being sensitive to RCM, and every patient who was sen- sitive to RCM as having a seafood aller- gy. That has now been changed, but pa- tients who were seen before the change will have that erroneous information per- sist in their records until someone

changes it manually.

Some Consumers Are Ignoring Cautionary Food Allergen Labels

One-Third of Egg-Allergic Children Are Tolerant by Age 5


lergen they noticed most often on ingredient lists was milk (61%), followed by peanuts (55%), tree nuts (38%), egg (31%), wheat (21%), soy (21%), and “other” (6%). More than one-fourth of respondents (28%) contacted manufacturers to ask about allergens added to ingredient lists. Yet in 46% of cases, manufacturers told them that the al- lergen was a newly added ingredient. At the same time, 83% of survey respon- dents reported noticing that new precaution- ary labels about allergens like “may contain milk or milk products” began to appear on products. The allergen they noticed most of- ten on labels was peanuts (84%), followed by tree nuts (67%), milk (59%), egg (45%), wheat (35%), soy (35%), and “other” (14%). Overall, 20% reported contacting food manufacturers to ask about precautionary la- bels, yet only 14% of manufacturers said that the addition of such labels were directly re- lated to product formula changes. Of respondents, 75% said they would nev- er purchase a product with a precautionary la- bel specific to their food allergy. However, wording appears to affect behavior. For ex- ample, about 91% would not buy products with the words “may contain” or “may con- tain traces of ” on the label. That response fell to 85% for statements like “manufactured with the same equipment as,” to 70% for labels with “manufactured in a facility that also processes,” and to 65% for statements such as “packaged in a facility that also packages.” He acknowledged a limitation of the study was its reliance on self-reported data.



greater for follow-up tests on chil- dren older than 2 years of age. Dr. Heine reported that of 218 chil- dren, 105 (48%) were diagnosed after a clinical reaction to egg, while the re- maining 113 (52%) were diagnosed af- ter a positive skin prick test. The most common clinical presen- tation was atopic dermatitis, which occurred in 179 of the children (82%). Common clinical symptoms on first known exposure included urticaria (26%), angioedema (12%), vomiting (11%), and nonurticarial rashes (7%). By the time children were 5 years of age, 33% developed tolerance to un- cooked egg while another 34% devel- oped egg tolerance by 10 years of age. The researchers observed that chil- dren in the persistent egg allergy group had a greater skin prick test wheal diameter, a higher level of egg- specific IgE, and a higher total serum IgE at diagnosis compared with their counterparts in the egg-tolerant group. They were also more likely to be male. Other factors associated with a high risk of developing persistent egg al- lergy were concomitant allergy to peanuts, tree nuts, and rye grass. The percentage of children with atopic dermatitis on follow-up was lower in the egg-tolerant group com-

San Diego Bureau

San Diego Bureau

S A N D IEGO — Since the Food Allergen La- beling and Consumer Protection Act of 2004 took effect last year, 64% of consumers who must avoid food allergens have noticed major allergens added to ingredient lists. Yet 25% are likely to buy products that contain precau- tionary allergen statements, such as “manu- factured in a facility that also processes milk” or “packaged in a facility that also packages peanuts or other nuts.” The finding is important because there has been no formal assessment of consumer response to the labeling act, which mandates that food manufacturers disclose major al- lergens on lists of ingredients but does not es- tablish standards for advisory statements like “may contain,” Dr. Scott H. Sicherer said at the annual meeting of the American Acade- my of Allergy, Asthma, and Immunology. In a study led by his associate, Dr. Heather Lemon-Mule, the researchers surveyed 645 parents of children with food allergies and others who attended 2006 Food Allergy and Anaphylaxis Network meetings in New York, Baltimore, and Chicago. The majority of re- spondents were parents of children with food allergies, said Dr. Sicherer, of the depart- ment of pediatrics at Mount Sinai School of Medicine, New York. More than half of respondents (64%) re- ported noticing that major food allergens have been added to ingredient lists, whereas 18% were unaware of such changes. The al-

S A N D IEGO — About one-third of

egg-allergic children develop toler-


by age 5 years and another one-

third develop tolerance by age 10, Dr.


G. Heine reported at the annual

meeting of the American Academy of Allergy, Asthma, and Immunology. The finding is important because while egg-allergic children are be-

lieved to develop tolerance by school


“there are few hard data on this,”


Dr. Heine, an allergist and gas-

troenterologist with Royal Children’s

Hospital in Melbourne. “We know


a small number of people will de-

velop persistent egg allergy. Due to

the lack of [research] effort in this area we have to define the clinical mani- festations and natural history of egg allergy presenting in children.” He and his associates reviewed the charts of 141 boys and 77 girls aged 2 years and younger who were evalu-


for egg allergy in 1996 and had a


prick test wheal diameter of 5


or greater. The researchers then

compared the clinical parameters of children who developed egg toler-


by 5 years of age to those who

had persistent egg allergy. The medi- an follow-up period was 37 months


the researchers used a skin prick

pared with the persistent egg allergy


wheal diameter of 7 mm or

group (76% vs. 89%, respectively).