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Pediatr Allergy Immunol 2003: 14: 420–428 Printed in UK.

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Copyright Ó 2003 Blackwell Munksgaard

PEDIATRIC ALLERGY AND IMMUNOLOGY

Review Article

Kiwi fruit allergy: A review
Lucas JSA, Lewis SA, Hourihane JO’B. Kiwi fruit allergy: A review. PediatrAllergyImmunol2003:14:420–428.Ó2003BlackwellMunksgaard Allergy to kiwi fruit was first described in 1981, and there have since been reports of the allergy presenting with a wide range of symptoms from localized oral allergy syndrome (OAS) to life-threatening anaphylaxis. The article reviews the available information concerning the clinical features of kiwi fruit allergy and the role of clinical investigations for diagnosis. Work identifying the major allergens in kiwi fruit has resulted in conflicting results, the possible reasons for which are discussed. The clinical associations of kiwi fruit allergy with allergies to pollens or latex are reviewed. Jane SA Lucas, Stella A Lewis and Jonathan O'B Hourihane
Division of Infection, Inflammation and Repair, University of Southampton, Southampton, UK Key words: kiwi fruit; allergy; OAS; anaphylax; latex; Actinadia Dr Jane Lucas, University Child Health (MP 803), University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK Tel.: +44(0)23 80 796867 Fax: +44(0)23 80 796378 E-mail: jlucas1@soton.ac.uk Accepted 30 July 2003

Kiwi fruit (Actinidia) is a plant native to the Yangtze Valley of China. Seed was taken to New Zealand in 1904, and almost all kiwi cultivars outside China are descended from the two female and one male plant grown from this single introduction of seed (1). Commercial plantings began in New Zealand in the late 1930s, and exports to the USA started in 1962. Californian kiwi fruit found their way onto the US market in 1970, and for the past three decades kiwi fruit has been increasingly available worldwide, with producers now in New Zealand, USA, Japan, Italy, Greece, Spain, Australia and Chile. Acute allergy to kiwi fruit was first described in 1981 (2) and there have since been reports of the allergy presenting with a wide range of symptoms from localized oral allergy syndrome (OAS) to life-threatening anaphylaxis (3, 4–8). The association of kiwi fruit allergy with allergies to pollen and latex has been widely reported in recent years and cross-reactivity has been confirmed by inhibition studies with birch pollen (9–12), timothy pollen (11), avocado (13, 14), banana (14), latex (13, 14) rye (15) and hazelnuts (15). Three of the possible major allergens responsible for kiwi allergy have recently been isolated and characterized (10, 16, 17), but much remains unknown about this increasingly common allergy.

In the preparation of this review article, PubMed was used as a search engine using the terms kiwi fruit, Actinidia, latex allergy and oral allergy syndrome. The Allergen Data Collection: Kiwi Fruit by Matthias Besler, Internet Symposium on Food Allergens, 2000: 2 (Suppl. 2) was also referred to (http://www.food-allergens.de). All articles published in the English language associated with kiwi fruit allergy were included for review. References in other languages have been included when the authors could obtain the article, and accurate translation could be ensured. Published work involving other fruits and allergens was included if important and relevant, particularly if information specific to kiwi fruit was lacking. The article will review the available information concerning the clinical features of kiwi fruit allergy and the relevance of clinical investigations. It will detail the known allergens and discuss the relevance of crossreactivity of kiwi allergens with pollens and latex.
Clinical characteristics

Funding: Jane Lucas and Stella Lewis receive funding from The Food Standards Agency.

Clinical information about kiwi fruit allergy is mostly based on a handful of case reports and small case series, in addition to extraction of data from scientific papers primarily written to explore cross-reactivity. The first reported case of kiwi fruit allergy was on a 53-year-old atopic woman who developed urticaria, wheeze and laryngeal oedema on handling the fruit (2). Since

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only 40% of subjects had positive skin reactions to one commercial extract. There are therefore discrepancies in the literature concerning the specificity of kiwi fruit skin tests in atopic groups. There have not been any studies of adequate size to investigate further the differences between subjects with mono-allergy. 6. but only 11% suffer clinically relevant latex allergy (4). However. 7. It appears that subjects with allergy to Rosaceae fruit are more likely to have systemic symptoms and anaphylactic shock in the absence of pollinosis (21).Kiwi fruit allergy: A review then there have been a number of reports of kiwi allergy in adults. In a study of 43 subjects with kiwi allergy. most subjects with pollinosis having symptoms localized to the oral mucosa. but the major allergens responsible for kiwi fruit remains controversial. 8. 9). Some authors have produced an extract of kiwi pulp (2. a Danish study of eight subjects with allergies to birch pollen and kiwi fruit had oral allergy syndrome as an entry requirement (12). The use of purified fruit allergens in diagnostic tests could improve their specificity. recruited 29 subjects with allergy to plant derived foods. In the same year. A 57-year-old man who had suffered two anaphylactic reactions when eating kiwi. all of whom had positive skin test responses to fresh kiwi fruit. Beezhold described 47 latex allergic individuals. eight of whom had positive skin tests with fresh kiwi. but only one had symptoms to kiwi fruit (28).’s study (9). 421 . whilst four of five subjects with no pollen allergy had anaphylaxis or wheeze. Gall et al. including 12 individuals with symptoms to kiwi. pollinosis or latexassociated allergy. There have been a number of studies investigating cross-reactivity of kiwi fruit with pollens. had a severe systemic reaction on skin testing (6) performed at home by his daughter. other groups have found kiwi skin tests to be highly specific. 12. Case reports of children remain very limited. urticaria and dizziness having eaten the fruit (7). All case reports but one (4) involved atopic subjects. Although highly sensitive. In addition some of these individuals have had more generalized reactions including urticaria (4). Prick to prick with fresh kiwi or skin testing with home-made kiwi extract was positive in reports of all subjects in whom kiwi allergy was suspected. vomiting (4. Prick to prick testing with fresh kiwi is simple and sensitive. and 28% to another make of skin test solution. 7) respiratory compromise (6) and cardiovascular collapse (6). 9. 23). and others have used commercially available skin test solutions (22. 22. 4). the specificity of fresh kiwi fruit for skin testing appears poor in subjects allergic to cross-reacting pollens or latex. 7) or of fruit skin for skin testing (2). and investigated the subjects for pollen allergy (20).’s study (9) included seven controls allergic to birch pollen but not kiwi fruit. and there are no data about the natural history of the allergy. and continued follow-up of such subjects is required to clarify the significance. two latex allergic individuals with no symptoms on eating kiwi fruit have been reported to have positive skin reactions to fresh kiwi and a commercial skin test extract (27). all subjects had positive reactions when tested by prick to prick with fresh kiwi (22). DiezGomez et al. The converse also occurs: asymptomatic sensitization to latex may be as high as 86% in fruit allergic patients. 24). the main limitation being that skin testing with fresh fruit lacks standardization. mostly presenting with oral symptoms (3–8). The negative predictive value in non-atopic controls approaches 100% (2. with negative skin tests in all pollen allergic (2. and these publications may have over-emphasized the mild reactions to kiwi fruit. A German study of 25 subjects with birch pollen and kiwi allergies reported that 23 had localized oral symptoms and two had urticaria (19). skin prick testing with fresh apple in pollen allergic subjects has showed a good positive predictive value of over 90% (30). The relevance of asymptomatic sensitivity to cross-reacting allergens remains unclear. Similarly. A 12-year-old atopic boy in Japan developed localized oral symptoms. mite allergic (4) and ‘atopic’ (7) subjects. Commercial skin test extracts are significantly less sensitive. Clinical investigations Skin tests Skin testing with fresh kiwi is the most common clinical investigation reported (3. and a hypotensive response to kiwi has been described in a 3-year-old boy (18). Screening subjects with fruit allergy by skin test or measuring foodspecific immunoglobulin E (IgE) levels to other fruits that might share cross-reactive antigens results in an unacceptable number of false-positive reactions (29). The subjects with associated pollen allergy were likely to have oral allergy syndrome. 4. when combined with a detailed symptom history of oral allergy syndrome. but as with all skin test procedures there is a small risk of reaction. In conflict with Gall et al. We do not know if children respond differently to adults with kiwi allergy.

Gall et al. despite having positive skin tests with fresh kiwi fruit. (16) Mancuso and Berdondini (5) Möller et al.35 18/25. (31) found relatively high specificity (83%). 12. (24) Gavrovic-Jankulovic et al. (9) Garcia et al. (4) Gastraminza et al. (19) Specific IgE to kiwi-method CAP (Pharmacia. Food challenges Double-blind food challenges (DBFC) are the ‘gold standard’ for confirming food allergy (36. DBFC confirmed only 68% of 25 positive open challenges.35 kU/l (1/1) 4/6 positive `positive' Sp IgE < 0. Reports of sensitivity of measuring IgE vary between 13% (31) to over 70% (19). 16). Sp IgE > 0. (6) Shimizu and Morikawa (7) Voitenko et al. However. Sweden) Specific IgE kiwi result 45% (18/40) positive 48% positive Positive in 100% with severe symptoms. but symptoms of birch pollen allergy. and the different techniques used to measure specific IgE. (9) found no specific IgE to kiwi fruit in non-kiwi allergic controls with birch pollen allergy. and further work is required to evaluate their role. DBFC confirmed allergy to kiwi in only 66%. It is possible that his subjects with oral allergy syndrome had IgE confined to the oral mucosa with no detectable circulating specific IgE. All subjects with negative blind food challenges were again given an open provocation. Variation in sensitivity may reflect the different kiwi allergic populations being studied. Breler et al. with some groups using the CAP system (22.Lucas et al. or were allergic to a labile allergen not present in the specific IgE kit. There is also evidence that such subjects may only have reactions to the cross-reacting fruit during the pollen season (38). Sweden) Maxisorp RAST CAP system (Pharmacia. other studies have found that at least some subjects with oral allergy syndrome have detectable circulating IgE to kiwi fruit (11. who had detectable IgE to kiwi fruit (19) 422 and a case report of two subjects with latex allergy who had positive RAST to kiwi despite being asymptomatic (27). Phadebas RAST (Pharmacia Diagnostics AB. all of which were negative. Most of their subjects had oral allergy syndrome. This is in contrast to reports of four of four subjects with no symptoms to kiwi. Gall found that although he was able to detect specific IgE in all subjects with severe symptoms. The present information about the role of clinical investigations in kiwi allergy is therefore confusing and requires further evaluation.37 AEU/ml) Negative <0. In his study of 22 subjects with kiwi fruit allergy (9). In vitro investigatons to confirm kiwi allergy Author (reference) Aleman and Quirce (22) Gall et al. Although positive in some case reports of patients with kiwi allergy (5–7. Table 1. 19). Sweden) CAP system FEIA (Pharmacia Diagnostics) RAST Home-made allergen discs. Sweden) Kallestad CAP (Pharmacia. IgE was generally higher to BP and apple than to kiwi Positive 5. 23).35 7/25. Uppsala. and the results may reflect the difficulty of performing challenges in a group who by definition have predominantly subjective symptoms. Sweden) ELISA Home-made allergen discs.9 PRU/ml 4/9 positive 5/9 were positive by the CAP system-the subjects positive with CAP and Maxisorp did not correlate Specific IgE in controls Negative 100% Positive in 100% of birch pollen allergic controls Novembre et al. despite all subjects reporting symptoms and all having positive skin tests. other authors have found it unhelpful (4. The specificity of in vitro tests is also unclear. 14. the results were negative in subjects with mild local symptoms. 24. 24). In their study of 33 subjects. Likewise. It has been suggested that each individual has a threshold for antibirch pollen titres to cause oral allergy intolerance with apple (32) and indeed several studies have demonstrated higher specific birch pollenspecific IgE or larger skin test reactions in subjects with oral allergy syndrome (33–35). Only one group has published (in abstract) DBFC data concerning kiwi fruit (22). but blinded food challenges have rarely been used in the context of oral allergy syndrome. In a case series of patients reporting mostly oral allergy symptoms to melon (39). 19). negative in 100% with mild local symptoms Negative (0. (12) 6/7 negative 6/7 negative Specific IgE The role of measuring specific IgE to confirm kiwi fruit allergy is less clear (Table 1).37). EAST (Allergopharma) RAST Pharmacia CAP system RAST (Pharmacia. Using the CAP method to detect specific IgE to kiwi in 136 latex allergic patients. Some research groups .7 kU/l Positive 0. but others using home-made allergen discs (9.

64 10–12. a 30 kDa protein. 43. proteins Table 2. work has resulted in conflicting and confusing results (Table 2). 17.Kiwi fruit allergy: A review have used open oral challenges to confirm OAS (11. with rescue therapy determined by the severity of reactions. 27. 30. (42) ´ Gavrovic-Jankulovic et al. melon and apple by pollen-specific injection immunotherapy has been described (40. 14. had a band at 30 kDa and one at 18 kDa. This stance needs to be balanced against the lack of information about the long-term outcome of subjects with asymptomatic sensitization in the absence of clinical allergy. avoidance of kiwi fruit is the mainstay of treatment. and 73% to birch pollen.41). cucumber. 27(100%). (12) Denmark 10–12 (56%) 20–25 (56%) Möller et al. one of which. so advice varies from just avoiding the fruit. 30. 15–18. 30 (100%) 423 . none of the other subjects’ sera recognized the 30 kDa protein. (16) Germany Yugoslavia 23. a positive skin test. 20. 22.19) found that proteins of ¨ molecular weight 43 and 67 kDa were recognized by over 50% of 22 German subjects with birch pollen allergy. SPT and measurement of specific IgE to known cross-reacting fruits will result in excessive positive tests results in the absence of clinical symptoms (29). 25. In subjects with a diagnosis of IgE mediated fruit allergy. Evidence based data on the management of fruit allergy are lacking. differing eating habits). Management of kiwi fruit allergy As with other food allergies. 1 kiwi allergic only) 22 subjects with birch pollen allergy and sp IgE to kiwi > 0. 1 asymptomatic) 7 subjects with kiwi allergy. 43. 43. 20–25. 67. 24 and 12 kDa appeared important either because of the large number of subjects reacting to them or for their part in the clinical crossreactivity of kiwi allergy with birch and timothy pollinosis. 80. 30. 22. avocado and/or latex (6 OAS. 38. indicating the low amount of these allergens in kiwi extract. 38–40 (30 kDa recognized by only 1 subject with mono-allergy) 13. 30. Their one subject with kiwi fruit allergy but no pollinosis. 32. Allergens With regard to identifying major allergens. and a positive open challenge.7 (1 urticaria. diagnosed by clinical history of OAS.g. 1 asymptomatic) 9 subjects with kiwi allergy. are only slightly detected by total protein staining of the blot with Indian ink or by silver staining of the gel. 5 also allergic to banana. (19) Germany 43 (68%) 67(55%) Möller et al. 20 OAS. (11) Subjects 30 subjects with OAS to kiwi (27 localized symptoms. Unnecessary food restriction may occur if incompletely validated allergy test systems are used as a basis for prescribing elimination diets. However. 28. 41. Instead. and one subject with isolated kiwi allergy had conflicting findings. avocado or banana allergy. >67 30 (89%) 23 (56%) 24 (100%). 67 Author (reference) Pastorello et al. (19) 43 (71%) 67 (57%) Fahlbusch et al. Moller’s studies (14. Different studies have reported different dominant allergens. Successful treatment of OAS to fennel. In addition they detected minor allergens of 13. (14) Germany See Möller et al. >80 24. On the other hand. 30. 25 (100%). five of whom also had latex. Pastorello (11) studied 27 Italian subjects with kiwi fruit allergy. 12. 43 and 67 kDa. A Danish study (12) using the sera of eight subjects with pollinosis associated kiwi allergy. Eighty-seven per cent of subjects also had IgE antibodies to timothy pollen. genetics. 3 systemic) 9 kiwi allergic subjects (8 kiwi allergic and birch pollen allergy. 5 also allergic to birch pollen 7 subjects with kiwi fruit allergy Dominant allergens 30 (100%) Voitenko et al. Kiwi allergens Country where the study was based Italy Molecular weights of IgE binding proteins (kDa) 12. they showed proteins in the 10–12 and 22–24 kDa regions to be the most common allergens in kiwi extract. This could be due to different experimental procedures and/or differences in the study population used (e. 22 and 30 kDa. They identified 12 IgE-binding proteins. The major allergens. 30). was recognized by all of the subjects. 24. to restrictive diets of an entire food group. Other allergens with molecular weights of 28.

The groups working on kiwi fruit allergens have reported using different gels. three kiwi allergens have been isolated and characterized (16): Act c 1 (30 kDa).5 (17). The allergens involved in patients allergic to fruits may differ between subjects with and without pollinosis (21). suggesting complete identity between the relevant kiwi and pollen allergens (11). Different extraction methods may account for some of the discrepancy between major allergens identified by different groups (Table 2). 43 and 80 kDa. Voitenko (12) used two different extraction procedures for kiwi fruit. Although amino acid composition. Fahlbusch (42). only a very weak cross-reactivity has been found between these thiol proteinases (46). do not represent potent allergens. Other kiwi aller- . and per oral sensitization is unlikely to these unstable allergens. 19) are considered responsible for the cross-reactivity between kiwi fruit and birch pollen. with similar modes of action. For example. N-terminal amino acid sequencing has shown that this protein corresponds to thaumatin-like protein. 22 and 14 kDa were completely inhibited by birch pollen. 23 and 26 kDa. So far. Act c 2 (43 kDa) and a thaumatin-like allergen (24 kDa). 38 and 22 kDa were completely inhibited by timothy grass extract grass pollen. Actinidin is secreted in an inactive form as actininidin. The quantity of Act c 2 as a percentage of the total protein in kiwi fruit is estimated to be as low as 0. an IgE response towards a 9 kDa protein specifically occurred in subjects with severe anaphylaxis (43). A recent study has suggested that a protein with a molecular weight of 24 kDa and isoelectric point of approximately 9. a need for standardization of techniques between groups working in the same field. where appropriate. very little is known about kiwi allergens in non-pollen allergic individuals. The same group also found protein patterns varied according to whether reducing or non-reducing running conditions were applied during electrophoresis. Many allergens in kiwi fruit are readily digested by simulated gastric fluid (48). the precise methodology is unclear in some reports. dilutions of sera and probing methods. banana and latex (14). Act c 2 has also been N-terminal sequenced and the isoelectric point determined to be 6.1%. They therefore used a mixture of both extracts in an attempt to provide a more complete allergen extract. Act c 1 is an unglycosylated thiol protease with a mean isoelectric point of 3. with molecular weights of 20. However. using sera from nine kiwi allergic subjects. The structure of actinidin has been described (44). blockers. there are many structural similarities. However. Kiwi allergens of 41. The protein has been partially sequenced and comparison with 424 the Swiss Protein bank showed that this was actinidin. The lability of the kiwi allergens may explain why allergic reactions are restricted to the oral cavity (OAS) in many patients with pollen allergy.4 is a major allergen (16). antigens in birch pollen and apples share allergenic epitopes leading to cross-reactivity that may cause clinical symptoms of OAS when a birch pollen allergic subject eats an apple (32). and a stronger 27 kDa band. Allergens with a wide range of molecular weights from 12–67 kDa (11. found in larger amounts in their extract. and kiwi allergens with mw 41. which has a molecular weight of 39 kDa. It has also been shown that the 43 and 67 kDa allergens in kiwi fruit cross-react with allergens from avocado. 38. producing similar protein profiles in SDS–PAGE but a different antigen profile by crossed immunoelectrophoresis. 24. In hazelnut allergic subjects. pre-sensitization by inhaling birch pollen allergens will predispose to allergic symptoms to kiwi fruit. IgE-binding proteins were also seen at 23. Bromelain (from pineapple) and papain (from papaya) are also thiol proteases. reported that eight subjects recognized a 30 kDa protein. as demonstrated for actinidin and papain in which polypeptide backbones are extremely similar (45). Kiwi allergens associated with pollen allergy The clinical association of pollinosis with allergy to fresh fruit including kiwi is well-recognized (47). However. Initial respiratory sensitization results in IgE antibodies to pollen proteins which are homologous to those found in some fruits or vegetables. five with birch pollen allergy. isoelectric points and molecular weights differ.Lucas et al. It has been suggested that actinidin might only express its allergenicity after cleavage of the pro-sequence (17). Although fruit allergens in patients allergic to pollens have attracted much attention.9 (10). When non-reducing conditions were used the 30-kDa band of the BBS kiwi extract split into two bands: a weak band corresponding to 30 kDa. The allergenic components of kiwi fruit that cross-react with allergens from timothy and birch pollen have been characterized. This emphasizes the need for very clear reporting of laboratory techniques by authors working in this field and. The IgE-binding pattern may reflect different symptom patterns.

the authors concluded that the pollen allergens are responsible for the elicitation and maintenance of OAS. Latex-associated allergy Most of the natural rubber in the world is manufactured using the sap of Hevea brasiliensis. It has been hypothesized that conserved defence proteins in higher plants are the cause of latex allergy with accompanying fruit crossreactivity (66). especially fruits such as avocado. It remains uncertain whether pollinosis precedes food allergy in oral allergy syndrome.62). Approximately 30–50% of individuals who are allergic to natural rubber latex show hypersensitivity to some plant derived food. food allergy preceded the development of latex reactions clinical sensitization to latex was associated with clinical anaphylaxis to kiwi fruits (65). however. Immunization of rhesus monkeys with recombinant birch pollen allergens rBet v 1 and rBet v 2 induced immediate-type skin reactions to food containing Bet v 1 and Bet v 2 related allergens (53). Recently. banana and kiwi fruit. banana and kiwi) are able to cause clinically relevant reactions by immunological cross-reactions. and cross-reactivity has been confirmed by inhibition techniques (14. Based on an assumption that the primary sensitizing molecule will carry most if not all the relevant IgE epitopes. avocado. giving support to the hypothesis that OAS is caused by a primary sensitization to pollen allergens (54). In a study of adults with OAS (55). In this population.Kiwi fruit allergy: A review gens. whereas IgE reactivity to pollen allergens was poorly inhibited by recombinant plant food allergens. rubber industry workers (57) and children with spina bifida (58). were only partially inhibited. The association between latex and these food allergens has been named ‘latex-fruit syndrome’ (62). Because of their evolutionary role in host defence mechanisms these proteins are widely distributed throughout the plant kingdom and may form the basis for cross-reactivity. Recombinant allergens from kiwi are not yet available.g. in individuals allergic to latex. could bind latex-specific IgE in vitro.31). In another study (12). Class I chitinases are panallergens in latex-fruit allergy. celery (Api g 1) (50) and carrot (Dau c 1) (51) were isolated and shown to share an average sequence identity of approximately 45% with Bet v 1. cross-reactivity between birch pollen and kiwi allergens was partly explained by a protein of 10–12 kDa. (63) were amongst the first to describe how fruit allergens. avocado and banana. Act c 1). Using immunoblot inhibition. and the major kiwi allergens of 43 and 67 kDa are involved in these cross-reactions (14). perhaps suggesting that only a minor allergen was involved in the cross-reactivity. It has been shown that T cells and T cell clones with specificity for Mal d 1 cross-react with the major birch pollen allergen Bet v 1 (52). whereas the secondary cross-reactive allergen will have less-reactive epitopes. are likely to be related to the defence responses of a rubber tree. Latex allergy is particularly prevalent in health care workers (56). children with spina bifida showing different IgE binding to health care workers (61). for example the 30 kDa allergen (actinidin. Hev b7 and chitinase/lysozyme. It is possible that Bet v 2 is a pan-allergen causing cross-reactions between latex. in this case banana. It has been suggested that sensitization to latex occurs by inhalation of allergen adsorbing powder and direct contact with latex products (48) followed 425 . Of the more than 150 polypeptides in natural latex. M’Raihi et al. chestnut. complementary DNA coding for the Betv1 homologous allergens from apple Mal d 1 (49). the inhibition was poorly expressed in only half the subjects. Most of the cross-reacting allergens are more abundant in the pollen than in fruits. Different groups of patients appear to be sensitized to different groups of latex proteins. a combination of recombinant and natural pollen extracts almost completely inhibited IgE binding to plant extracts. This protein had significant structural homology to a latex antigen. Latex allergens including Hev b2. fruits and pollens. Moller showed ¨ that allergens from kiwi fruit share common epitopes with allergens from latex. Kiwi fruit is recognized as part of the ‘latex– fruit syndrome’ (28. 35 or more can act as allergens and are recognized by IgE antibodies in the sera of latex allergic subjects (60). In a study of fruit allergic subjects (65) 86% had latex sensitization (SPT and/or CAP) although only 12% had a clear history of latex allergy. More recently it has been shown that an avocado protein (a class I chitinase) could bind specific IgE in the serum of latex allergic patients (64). supporting the hypothesis that foods (e. and its antifungal activity has been demonstrated. suggesting much weaker cross-reactivity. but has a very low prevalence in a general paediatric population (59). A study of fruit and vegetable allergic subjects from Spain found that subjects with pollinosis showed a high frequency of IgE reactivity to Bet v 2 (20) and all subjects with positive IgE to Bet v 2 also had reactivity to latex.

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