We report on a patient with anaphylaxis from mandarin. Temporal relationship between consumption of the fruit, the presence of positive specific IgE, the positive skin test and the basophil activation test for mandarin strongly supported the diagnosis of an IgE-mediated allergy from mandarin. The lipid transfer protein allergen from mandarin fruit was isolated and characterized. Specific IgE levels and IgE immunodetection data indicated the patient’s sensitization to orange (Cit s 3) and mandarin (Cit r 3) lipid transfer protein allergens, as well as to germin-like (Cit s 1) allergen. These results were fully confirmed by skin prick test and basophil activation test (BAT) for lipid transfer proteins, and a BAT for Cit s 1. This case report has several particularities. First, in Central and Northern Europe, it is not widely appreciated that citrus fruits, particularly mandarin, can elicit anaphylaxis. Second, this case report re-emphasizes sensitization from lipid transfer proteins to predispose for severe allergic reactions. Finally, it provides an opportunity to summarize the applications of flow cytometry-assisted analysis and quantification of in vitro activated basophils in the diagnostic approach of anaphylaxis from food.

1.
Ebo DG, Hagendorens MM, Bridts CH, De Clerck LS, Stevens WJ: Sensitization to cross-reactive carbohydrate determinants and the ubiquitous protein profilin: mimickers of allergy. Clin Exp Allergy 2004;34:137–144.
2.
Ahrazem O, Ibanez MD, Lopez-Torrejon G, Sanchez-Monge R, Sastre J, Lombardero M, et al: Orange germin-like glycoprotein Cit s 1: an equivocal allergen. Int Arch Allergy Immunol 2006;139:96–103.
3.
Lopez-Torrejon G, Ibanez MD, Ahrazem O, Sanchez-Monge R, Sastre J, Lombardero M, et al: Isolation, cloning and allergenic reactivity of natural profilin Cit s 2, a major orange allergen. Allergy 2005;60:1424–1429.
4.
Ahrazem O, Ibanez MD, Lopez-Torrejon G, Sanchez-Monge R, Sastre J, Lombardero M, et al: Lipid transfer proteins and allergy to oranges. Int Arch Allergy Immunol 2005;137:201–210.
5.
Sanchez-Madrid F, Morago G, Corbi AL, Carreira J: Monoclonal antibodies to three distinct epitopes on human IgE: their use for determination of allergen-specific IgE. J Immunol Methods 1984;73:367–378.
6.
Diaz-Perales A, Sanz ML, Garcia-Casado G, Sanchez-Monge R, Garcia-Selles FJ, Lombardero M, et al: Recombinant Pru p 3 and natural Pru p 3, a major peach allergen, show equivalent immunologic reactivity: a new tool for the diagnosis of fruit allergy. J Allergy Clin Immunol 2003;111:628–633.
7.
Ebo DG, Hagendorens MM, Bridts CH, Schuerwegh AJ, De Clerck LS, Stevens WJ: Flow cytometric analysis of in vitro activated basophils, specific IgE and skin tests in the diagnosis of pollen-associated food allergy. Cytometry B Clin Cytom 2005;64:28–33.
8.
Saarinen UM, Kajosaari M: Does dietary elimination in infancy prevent or only postpone a food allergy? A study of fish and citrus allergy in 375 children. Lancet 1980;i:166–167.
9.
Zhu SL, Ye ST, Yu Y: Allergenicity of orange juice and orange seeds: a clinical study. Asian Pac J Allergy Immunol 1989;7:5–8.
10.
Asero R, Mistrello G, Roncarolo D, Amato S, Zanoni D, Barocci F, et al: Detection of clinical markers of sensitization to profilin in patients allergic to plant-derived foods. J Allergy Clin Immunol 2003;112:427–432.
11.
Ibanez MD, Sastre J, San Ireneo MM, Laso MT, Barber D, Lombardero M: Different patterns of allergen recognition in children allergic to orange. J Allergy Clin Immunol 2004;113:175–177.
12.
Crespo JF, Retzek M, Foetisch K, Sierra-Maestro E, Cid-Sanchez AB, Pascual CY, et al: Germin-like protein Cit s 1 and profilin Cit s 2 are major allergens in orange (Citrus sinensis) fruits. Mol Nutr Food Res 2006;50:282–290.
13.
van Ree R: Clinical importance of non-specific lipid transfer proteins as food allergens. Biochem Soc Trans 2002;30:910–913.
14.
Salcedo G, Sanchez-Monge R, Diaz-Perales A, Garcia-Casado G, Barber D: Plant non-specific lipid transfer proteins as food and pollen allergens. Clin Exp Allergy 2004;34:1336–1341.
15.
Crespo JF, Retzek M, Foetisch K, Sierra-Maestro E, Cid-Sanchez AB, Pascual CY, et al: Germin-like protein Cit s 1 and profilin Cit s 2 are major allergens in orange (Citrus sinensis) fruits. Mol Nutr Food Res 2006;50:282–290.
16.
Ortolani C, Ispano M, Pastorello EA, Ansaloni R, Magri GC: Comparison of results of skin prick tests (with fresh foods and commercial food extracts) and RAST in 100 patients with oral allergy syndrome. J Allergy Clin Immunol 1989;83:683–690.
17.
Deluze C, Dunoyer-Geindre S, Girard JP: Comparative analysis of lyophilized fresh fruits and vegetables with commercial extracts for skin testing of patients with food allergy. J Investig Allergol Clin Immunol 1991;1:53–57.
18.
Pucar F, Kagan R, Lim H, Clarke AE: Peanut challenge: a retrospective study of 140 patients. Clin Exp Allergy 2001;31:40–46.
19.
Perry TT, Matsui EC, Conover-Walker MK, Wood RA: Risk of oral food challenges. J Allergy Clin Immunol 2004;114:1164–1168.
20.
Skamstrup HK, Vestergaard H, Stahl SP, Sondergaard KM, Vieths S, Poulsen LK, et al: Double-blind, placebo-controlled food challenge with apple. Allergy 2001;56:109–117.
21.
Martelli A, Bouygue GR, Isoardi P, Marelli O, Sarratud T, Fiocchi A: Oral food challenges in children in Italy. Allergy 2005;60:907–911.
22.
Ebo DG, Hagendorens MM, Bridts CH, Schuerwegh AJ, De Clerck LS, Stevens WJ: In vitro allergy diagnosis: should we follow the flow? Clin Exp Allergy 2004;34:332–339.
23.
Buhring HJ, Streble A, Valent P: The basophil-specific ectoenzyme E-NPP3 (CD203c) as a marker for cell activation and allergy diagnosis. Int Arch Allergy Immunol 2004;133:317–329.
24.
Shreffler WG: Evaluation of basophil activation in food allergy: present and future applications. Curr Opin Allergy Clin Immunol 2006;6:226–233.
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