Anaphylaxis Caused by Artisanal Honey in a Child

A Case Report

Margherita Di Costanzo; Nicoletta De Paulis; Silvia Peveri; Marcello Montagni; Roberto Berni Canani; Giacomo Biasucci


J Med Case Reports. 2021;15(235) 

In This Article

Case Presentation

The patient was a 5-year-old Slavic boy affected by allergic rhinitis from the age of 4 years (sensitization for dust mite and Plantago lanceolata). His past medical history was unremarkable; in particular he had no personal previous history of food allergy or anaphylaxis. He attended nursery school. Familial history revealed that his father had seasonal allergic rhinitis.

The patient was referred to our hospital emergency department by the territorial emergency unit for generalized urticaria and breathing impairment (peripheral oxygen saturation was 93% on ambient air). All the symptoms occurred suddenly 30 minutes after the ingestion of a meal containing salmon and artisanal honey. The intake of other foods/juices, alcohol, or medications was not reported. Salbutamol with inhaler (four inhalations, equivalent to 400 μg) was administered in the ambulance. On admission, the physical examination revealed generalized urticaria and wheeze–bronchospasm in apyrexia. Peripheral oxygen saturation was 97% on ambient air, blood pressure was 100/65 mmHg, heart rate was 120 beats/minute, and respiratory rate was 28 breaths/minute. He was afraid but alert and responsive (Glasgow Coma Scale: 15). Intravenous methylprednisolone (20 mg, equivalent to 1 mg/kg/dose) and chlorpheniramine (5 mg, equivalent to 0.25 mg/kg/dose) were administered, and salbutamol with inhaler (four inhalations, equivalent to 400 μg) was repeated, with progressive and rapid resolution of cutaneous and respiratory symptoms.

The results of routine laboratory analyses on admission were within the normal range (see Table 1). Tryptase serum levels and specific food IgE tests were performed for egg (0.31 kUA/L), milk (0.67 kUA/L), shrimp (0.08 kUA/L), cod (0.11 kUA/L), gluten (0.27 kUA/L), lipid transfer protein (LTP) Pru p 3 (0.12 kUA/L), soy (0.72 kUA/L), grass pollen (16.5 kUA/L), Dermatophagoides pteronyssinus (3.67 kUA/L), ragweed (7.93 kUA/L), and mugwort (35.3 kUA/L), using the ImmunoCAP (Thermo Fisher Scientific, Sweden). Levels ≥ 0.35 kUA/L were considered positive.

The reaction tryptase level was 6.63 μg/L (normal values <11 μg/L), whereas the post-reaction level, detected 24 hours after the allergic event, was 2.04 μg/L. In the pediatric age group, tryptase reaction levels exceeding a threshold level of 2 ng/mL + 1.2 × (post-reaction tryptase level) may be very useful in establishing a diagnosis of anaphylaxis.[9] In our patient, the reaction tryptase level exceeded the threshold level of 4.18 μg/L.

The test for serum IgE antibodies to bee venom yielded a weak positive result (0.65 kUA/L). However, his personal history was negative for bee stings, and sensitization to hymenoptera venom is frequently found in atopic and non-atopic subjects. In particular, in atopic patients, a high sensitization rate has been observed and could partially be explained by cross-sensitization between pollen and hymenoptera venom due to specific IgE to cross-reactive carbohydrate determinants.[10]

The patient was discharged after 24 hours of clinical observation in good condition and without drug therapy. At the time of hospital discharge, an allergology follow-up was scheduled for 2 weeks later. Skin prick tests with ragweed (Ambrosia artemisiifolia) and mugwort (Artemisia vulgaris) were positive, while prick-by-prick tests with salmon and peanut were negative. As for honey, prick-by-prick test with the mixture of flower artisanal honey that the patient consumed before allergic reaction was positive. On the contrary, prick-by-prick test with a commercial flower honey mixture, Millefiori (a kind of honey frequently consumed in our country, obtained from foraging on Compositae), was negative. Positive (histamine) and negative (saline solution) controls were included. The reactions were read after 15 minutes and were positive if there was a wheal 3 mm or greater. Based on the patient's clinical history and allergy test results, we made a diagnosis of anaphylaxis induced by honey. An oral provocation test was not performed because of the personal recent history of anaphylaxis. The patient was informed of the honey allergy and the importance of honey avoidance. An adrenaline auto-injection kit (0.15 mg) was prescribed and the patient was instructed on its usage. After a year of follow-up, he had been able to avoid honey and remained asymptomatic.