Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge

Objectives To provide a review of the literature and discuss the clinical, pathophysiologic, diagnostic, and therapeutic challenges of oral allergy syndrome (OAS). Data Sources English-language publications on OAS (and pollen-food allergy syndrome) were identified through MEDLINE and through the reference lists of each identified article and review. Study Selection Articles pertaining to OAS with respect to its varied clinical presentation, underlying pathophysiology, available and investigational diagnostic testing, and evidence-based treatment options were selected. Results OAS occurs in patients with a prior cross-reactive aeroallergen sensitization and clinically presents with initial oral-pharyngeal symptoms after ingestion of a triggering fruit or vegetable. Although controversial, these symptoms may progress to systemic symptoms outside the gastrointestinal tract in 8.7% of patients and anaphylactic shock in 1.7%. OAS's underlying pathophysiology may play a role in clinical presentation and outcome, depending on whether the cross-reactive protein is a heat-labile PR-10 protein, a partially labile profilin, or a relatively heat-stable lipid transfer protein. Diagnostic testing is variable based on the underlying food tested, but fresh food skin prick test typically has the highest sensitivity. Treatment centers on avoidance and the consideration of self-injectable epinephrine. Because of its relationship with a cross-reactive aeroallergen sensitization, subcutaneous immunotherapy and sublingual immunotherapy have also been therapeutically tried with mixed results. Conclusion OAS is a challenging diagnosis to the practicing allergist because of its many clinical, diagnostic, and therapeutic considerations. Understanding these challenges and their underlying mechanisms can facilitate a knowledgeable approach to treating an oral allergy patient.