Apple and Birch Pollen: What's the connection?
Nina, 17 years old and Peter, 19 years old, both with a history of birch pollen allergy, visit their healthcare provider after experiencing oral symptoms when eating apples; Nina gets intense oral itching while Peter gets oral swelling and throat discomfort.
Both have experienced rhinitis during spring and early summer. It has become worse for Nina but remains stable for Peter.
Nina and Peter’s healthcare provider conducts a full clinical history and physical examination of both and decide to test using apple components.
Two teens with a birch pollen allergy experience oral symptoms when eating apples and rhinitis during spring.
Patient History
Family History
- None
Nina and Peter's Personal History
- Rhino-conjunctivitis during spring and early summer.
Test |
Type |
Nina's Results |
Peter's Results |
Birch |
Whole Allergen |
+4 |
+3 |
Both Nina and Peter's test results were negative for grass, mugwort, cat, dog, and mite.
Test |
Type |
Nina's Results |
Peter's Results |
Birch |
Whole Allergen |
16 |
12 |
Both Nina and Peter's previous healthcare providers diagnosed them as birch pollen allergic, and prescribed antihistamines and local steroids to use during birch pollen season.
Nina and Peter’s ImmunoCAP Test Results
These results together with this patient's case history and symptoms, help confirm the diagnosis.
Test |
Type |
Nina's Results |
Peter's Results |
Birch |
Whole Allergen |
22.4 |
15.8 |
Apple |
Whole Allergen |
16.2 |
12.7 |
Bet v 1 |
Allergen Component |
21.1 |
14.6 |
Bet v 2 |
Allergen Component |
<0.1 |
<0.1 |
Bet v 4 |
Allergen Component |
0.2 |
<0.1 |
Mal d 1 |
Allergen Component |
15.3 |
8.2 |
Mal d 3 |
Allergen Component |
<0.1 |
6.4 |
Differential Diagnosis
Nina
Nina's positive test results for the PR-10 protein Mal d 1 suggest that her oral symptoms from eating apple are a consequence of her birch pollen allergy.1 She may experience symptoms in the future to other PR-10 containing plant foods, such as hazelnuts, pears, carrots or celery.
REFINED DIAGNOSIS
- Birch-pollen-related apple allergy.
HEALTHCARE PROVIDER MANAGEMENT PLAN
Nina's healthcare provider advises her to:
- Avoid raw apples if unpleasant but that cooked apples may be tolerated.
- Continue to use antihistamines for the birch pollen symptoms, starting treatment two weeks before the season.
FOLLOW UP
- Nina has an appointment with her healthcare provider one year later—she has been avoiding raw apples and has since had no issues.
Peter
Peter has IgE antibodies to the apple lipid transfer protein (LTP) Mal d 3, which is associated with a higher risk of developing sever and systemic reactions.2
REFINED DIAGNOSIS
- Birch pollen allergy, lipid-transfer protein dependent apple allergy.
HEALTHCARE PROVIDER MANAGEMENT PLAN
Peter's healthcare provider advises him to:
- Strictly avoid apples and to be cautious with other fruits and nuts.
- Always carry an emergency adrenaline autoinjector.
- Continue to use antihistamines for the birch pollen symptoms, starting treatment two weeks before the season.
FOLLOW UP
- Peter has an appointment with his healthcare provider one year later. He has continued to avoid apple in all forms, is fit and well, and his healthcare provider checks his autoinjector technique and is satisfied.
The people, places, and events depicted in these case studies and photographs do not represent actual patients, nor are they affiliated in any way with Thermo Fisher Scientific.
- Ebo DG, et al. Sensitization profiles in birch pollen-allergic patients with and without oral allergy syndrome to apple: lessons from multiplexed component-resolved allergy diagnosis. Clin Exp Allergy. 2010;40:339–347. doi: 10.1111/j.1365-2222.2009.03345.x
- Gomez F, Aranda A, Campo P, et al. High Prevalence of Lipid Transfer Protein Sensitization in Apple Allergic Patients with Systemic Symptoms. Hogan SP, ed. PLoS ONE. 2014;9(9):e107304. doi:10.1371/journal.pone.0107304.
