Episode transcript
Time stamps:
0:30 - What to expect from Allergy After Dark episodes.
1:05 - Key takeaways from today’s conversation for primary care audience.
3:04 - Allergic reactions after kissing.
5:50 - Allergy reactions after oral sex.
9:40 - Allergy induced vaginitis after intercourse.
12:50 - Brazil nut allergen transferred through seminal fluid.
18:00 - Where listeners can read the case studies mentioned.
Announcer:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of Specific IgE testing and Phadia Laboratory Systems.
Gary Falcetano:
I'm Gary Falcetano, a licensed PA with over 11 years experience in allergy and immunology.
Luke Lemons:
And I'm Luke Lemons, with over five years of experience writing for healthcare providers and educating on allergies. You're listening to ImmunoCAST, your source for medically and scientifically backed allergy insights.
Hi, welcome to ImmunoCAST and our first Allergy After Dark episode. These episodes are going to be 18 and older. We're going to be talking about allergies in a more adult setting, so when it comes to let's say alcohol allergy, cannabis allergy. And in this episode's case intimacy related exposures. So, if you're listening to ImmunoCAST on speaker, you might want to take it off speaker. Also don't listen to podcasts in public on speaker, it's not cool to everyone else around you. But just a warning that we are going to be talking about some adult content here.
Gary Falcetano:
Yeah. So, today's conversation, I think, is important for a lot of reasons. This is our Valentine's Day issue. We've got Valentine's Day coming up, so we decided to really focus the content around intimate partner exposures. And I think there'll be some very important take homes for our primary care audience around anticipatory guidance for their patients with food allergy and the importance of including a sexual history when we're assessing patients in general.
Luke Lemons:
Yeah. And in these cases that we're going to be talking about today, they're rare. We don't want to make this sound like every patient who has a severe allergy may also have these sorts of reactions. But I still think that they're worth mentioning, to speak to what you had mentioned Gary, educating patients who are sexually active and do have allergies. Because oftentimes when we do think of allergies and intimate related exposures, it's usually latex because of condoms, and also human seminal plasma hypersensitivity, which is an allergy to human semen. But that still is very rare with only about 40,000 women in the US who are affected by that.
Gary Falcetano:
I mean that's exactly right. We do think these numbers though are somewhat under-reported, given the sensitive nature involved and also the potential for some of these reactions to occur and people not to be able to exactly relate why they're experiencing their symptoms. So both from an unawareness standpoint and also from a sensitivity standpoint, they are under-reported, but it's still relatively rare.
Luke Lemons:
And we keep mentioning the phrase intimacy related exposures, and this could be intercourse, oral intercourse, and kissing even too. So, Gary, I think you have a case here about actually somebody who did have a reaction due to just kissing.
Gary Falcetano:
That's exactly right. So let's start with our first case. This is entitled The Kiss of Death. It was published in 2003 in Mayo Clinic proceedings. It details a young woman who had a history of urticaria reactions after touching shrimp and lobster. She was seen in the emergency department after kissing her boyfriend.
Luke Lemons:
So she had gone to the ER after kissing her boyfriend who also worked with her. And this is actually important, the relationship, because where she was employed was a seafood restaurant. She was around a lot of the allergens that could cause a reaction in her. And she actually would wear gloves when she was serving out food. Sometimes she'd have rashes because of that, just by skin contact alone. And after work when she had met up with her boyfriend, who works with her as well, and who had eaten shrimp earlier in the night, they had kissed and we saw this reaction turn, I would say severe. Gary, did she go into anaphylaxis?
Gary Falcetano:
That's absolutely correct. So she had quite a number of symptoms including angioedema, throat swelling, diffuse flushing or urticaria, abdominal cramps, nausea, severe shortness of breath, and hypotension. So pretty dramatic symptoms. She went to the emergency department and was treated successfully with multiple interventions and subsequently discharged.
Luke Lemons:
And one of the other important, well I think that the biggest takeaways of this study, and they say this at the very end, they really want to call to action carefully counseling all patients who are allergic to food. And they say, quote "That they must avoid exposure to offending proteins via all potential routes of contact, including kissing and touching". So again, just nailing home that patient management conversation with people who do have allergies and letting them know that you don't have to just eat a food in order to react right.
Gary Falcetano:
No, that's exactly right. You can have various types of exposures and it's really not all that rare. In a letter published in the New England Journal of Medicine is entitled Food Allergies and Kissing. They talk about a study that was done at University of California Davis where they looked at 379 cases of IgE mediated food allergy, and they surveyed those patients to see if any of them had reactions after kissing. And actually a little over 5% of those patients actually reported symptoms of allergy after kissing.
Luke Lemons:
And it's not just kissing, to go into our next study-and this is a tragic case study as well-but these reactions can come out of even oral sex.
Gary Falcetano:
That's correct. I mean typically what's been reported mostly in the literature has been cases of reactions after vaginal heterosexual sex. This case actually, and as you said a really tragic case, was reported in actually a male-to-male intimate contact. So this is a case of two adolescents who met on a popular dating phone application. So again, kind of relatively new, it was published in Allergy, Asthma, and Clinical Immunology in 2021. So these adolescents met, the one individual had a longstanding history of asthma and peanut allergy. The other individual had eaten peanut, actually peanut butter, in the hours before he met the other person. They were very careful in pointing out that there was no kissing involved in their contact. But the male with the peanut allergy actually received fellatio, while the other male who had eaten peanut butter was the one performing the fellatio. And apparently during this contact, the peanut allergen was transferred from the male who had eaten the peanuts oral mucosa to the peanut allergic patient's urethral meatus and mucosa.
Luke Lemons:
And right when the reaction started to happen, and this is why it's so unfortunate, is this patient, like you had mentioned, had asthma and a peanut allergy. They had came prepared with the medication that their provider probably counseled them on. They had their inhaler and they also had an epinephrine auto-injector. And what happened next was when this reaction happened, they had assumed that they were having an asthma attack.
Gary Falcetano:
Yeah. The patient experience just shortness of breath and wheezing and no other symptoms during the encounter. So it's reported that he used his inhaled bronchodilator and then subsequently collapsed. The 911 system was activated. He was resuscitated in the field as well as in the hospital. He ended up succumbing actually the next day. So to your point, Luke, he was very prepared in that he had a bronchodilator for his asthma and he had an epinephrine auto-injector. However, I don't think he recognized that the symptoms he was experiencing were due to an allergic reaction. It appears, he assumed that they were related to an asthma exacerbation.
Luke Lemons:
And these asthma attacks and food allergy reactions are not uncommon. I mean the way in which this one happened is uncommon, but we see that asthma's relation to food allergy is very closely tied when it comes to severity of reaction. Is that right, Gary?
Gary Falcetano:
That's correct. The people that have the most severe food allergy reactions, and actually the highest correlation of fatal food allergy reactions, is in those patients who have a comorbidity of asthma, especially asthma that's not well controlled, but even asthma that is. So that's why I think it's so important to give that anticipatory guidance to our patients with food allergy and asthma that they really need to have a very low threshold of response and use of their epinephrine auto-injector if they at all think they may be experiencing allergy related symptoms.
Luke Lemons:
And while this is a tragic case, the other studies that we have related to food allergy and the transfer via intimate exposure aren't as severe. So there's another case we have here, it's called A Nutty Case, rare presentation of allergic vaginitis. And who published this study, Gary? It was...
Gary Falcetano:
Yeah. So this was published in Annals of Allergy and Asthma and Immunology in 2022 as part of their medically challenging case abstract series. And this was a 28-year-old woman who was experiencing vaginitis after intercourse with her partner. There wasn't any obvious allergy involved, but she was experiencing pain and burning after intercourse and she was worked up for vaginitis. So as we know vaginitis can have many causes. They were able to rule out infectious causes and that's when her food allergy history, she had a history of being allergic to both peanuts and tree nuts, her food allergy history caught their eye and they thought, well, maybe we should try a targeted elimination diet on the part of her partner to get peanuts and tree nuts out of his diet and see if that affects the situation.
Luke Lemons:
And did it work?
Gary Falcetano:
It did. It did. So she was subsequently able to have unprotected intercourse with him. They were trying to conceive, the case doesn't discuss whether they successfully conceived a baby or not, but the targeted elimination of those potential allergens from his diet resolved her symptoms.
Luke Lemons:
It's really interesting that in a differential diagnosis situation when it comes to a disease like this, like vaginitis, the allergies would even be a card in that game. Is that something that is considered most often, Gary, when a patient does have some sort of allergy? Is allergies considered when it comes to I guess STDs or instances like this?
Gary Falcetano:
Yeah. I think it's certainly not high on the differential diagnosis of a standard vaginitis presentation. But again, like we've talked about so many times on this podcast, we have to go back to the history and the history of symptoms and the relationship to two symptoms of different activities or ingestions. And so when we have an immediate type of vaginitis that occurs rapidly after sexual contact, that definitely raises your index of suspicion. But again, it's not high on the differential. We typically think of infectious causes to be first line.
Luke Lemons:
And with a study like this, and a lot of the other studies when a partner does have an allergy, it's important that their significant other also abstains from eating these allergens or being around them as well. The weight of an allergy doesn't just fall on the person who has it, especially when it comes to somebody that they love and care for. If you are in a relationship and you are with somebody with a food allergy, it's important to remember that you have just as much high stakes and responsibility in keeping your partner healthy as they do themselves. And we see that again in another study where there is some crash reactivity between the partner seminal fluid and his significant other.
Gary Falcetano:
Yeah. And in this study or this case study, Luke, I think it's important to note that the partner actually did take quite a bit of responsibility in trying to prevent any issues. So this patient is a female with identified tree nut, specifically Brazil nut allergy. Her intimate partner was aware of this allergy, as obviously she was, and took pretty significant precautions in preventing transmission orally to the patient, so through kissing. He actually brushed his teeth, he made sure that it had been several hours after he'd eaten mixed nuts before they had intimate relations. It was being very careful about transmission of potential allergens. What he wasn't counting on was the potential of transmission of allergens through his semen. And that's exactly what happened in this case. She experienced pretty significant vaginal swelling of both the vagina and the vulva. She had some near syncopal type symptoms. In this case, she did not get treated. She took some antihistamines at home and the symptoms resolved after about 45 minutes. But they had taken precautions, just not the precautions of it being transmitted through the semen.
Luke Lemons:
And the way that it is transferred into the semen is not widely known or understood yet. But this study does make a suggestion and they mentioned that because Brazil nut, which is what she was allergic to, has certain storage proteins that are heat and digestion stable, it might have gone through his digestive process. The Brazil nut protein entered his circulatory system and made its way to his prostate and where his semen is produced. So this protein from a Brazil nut was able to go through his whole body and end up in his seminal fluid, which caused a reaction in her. And these proteins are found in a lot of different types of nuts. Peanuts have heat stable and digestion stable proteins, other sorts of tree nuts do as well.
Gary Falcetano:
Yeah, that's correct. And specifically in Brazil nuts, we have a heat stable protein called Ber e 1. It's a 2S albumin and it's a storage protein. And as you said, not unlike other storage proteins and we know they're very stable. The one other interesting thing about this case is they went on to try to prove that it was indeed the allergen in the patient's semen that caused her symptoms by actually designing a skin test. And they skin tested her with her partner semen both before he had eaten Brazil nuts and several hours after he had eaten Brazil nuts. And she had a significant skin reaction to the semen after he had eaten Brazil nuts and no reaction prior to eating the Brazil nuts. So they fairly conclusively demonstrated that there was allergen being transferred after consumption of the Brazil nuts.
Luke Lemons:
And this study doesn't speak to exactly which protein in Brazil nut may be responsible. But when reading it, I was really curious because there is Brazil nut component resolved diagnostic testing, and I'm curious if she had an allergy to one of those proteins found in Brazil nut. And for those who don't know what component resolved diagnostic allergen testing is, we will have an episode, actually the next episode of ImmunoCAST, which we'll speak to it. But it's just I'm always so curious when I read these papers and they haven't mentioned maybe what component may be responsible.
Gary Falcetano:
Yeah. And I think we'll talk certainly more in depth about allergen components and how they can really help to improve diagnosis and allow us to be more specific in our diagnosis. And then also design more personalized management plans based on that diagnosis.
Luke Lemons:
And nothing is more personal than intimate exposure through these different allergens. And again, we hope that these studies and these examples brought forth the importance of having conversations with patients after somebody gets tested and you're able to diagnose a clinical allergy looking at history as well, that you have a conversation around keeping food if they're allergic to let's say peanuts, keeping a safe distance away from people who are making stuff with peanuts, making sure that there's peanut free areas that you have access to. But there's also a warranted conversation around intimacy and kissing and having that partner or their partner involved in those conversations.
Gary Falcetano:
Absolutely. And we know that different patients have different thresholds. So especially for patients that have a very low threshold so that they experience reactions to even small amounts of allergen, these conversations are even that much more important to have. And also including obviously a sexual history and being comfortable with these conversations, I think is really important to keeping our patients safe.
Luke Lemons:
And if you want to read any of these case studies or papers that we had mentioned today, there'll be available on thermofisher.com/immunocast on this episode's page. Tune in next week for a component conversation and happy Valentine's Day to everybody.
Gary Falcetano:
Happy Valentine's Day and we'll see you next time.
Speaker 1:
ImmunoCAST is brought to you by Thermo Fisher Scientific, creators of ImmunoCAP Specific IgE testing and Phadia Laboratory Systems.For more information on allergies and specific IgE testing, please visit thermofisher.com/immunocast. Specific IgE testing is an aid to healthcare providers in the diagnosis of allergy and cannot alone diagnose a clinical allergy. Clinical history alongside specific IgE testing is needed to diagnose a clinical allergy. The content of this podcast is not intended to be and should not be interpreted as or substitute professional medical advice, diagnosis or treatment. Any medical questions pertaining to one's own health should be discussed with a healthcare provider.
