422 A Rare Case of Food-induced Anaphylaxis to Pink Peppercorns

BACKGROUND: The incidence and prevalence of food allergies appear to be on the rise over the past 20 years. The most common foods to produce an IgE mediated hypersensitivity reaction in adults include peanut, tree nuts, and seafood. The increased use of spices in the U.S. has resulted in a growing number of patients presenting with hypersensitivity reactions. METHODS: We report a case of a 26 year-old-female who developed anaphylaxis after ingesting pink peppercorn seasoning. The patient was diagnosed with a tree nut allergy at 18 years of age when she developed hives, vomiting and throat closure after ingesting cashews. More recently, she had 3 similar anaphylactic episodes requiring epinephrine and emergency room care when she unknowingly consumed tree nuts contained in foods while dining out (veggie burger, pesto sauce, almonds in Indian food). She again had similar symptoms while eating a home prepared meal in which tree nuts were not included. Intramuscular epinephrine was administered and she was subsequently treated with oral steroids and antihistamines. It was later determined that a new peppercorn medley with pink peppercorns was used for seasoning. The reaction did not occur when she ate the same meal without pink peppercorn seasoning. Food specific IgE testing revealed an elevated IgE for cashews (2.52 kUA/L) and pistachios (2.85 kUA/L). RESULTS: Pink peppercorn is not a true pepper, but dried roasted berries derived from Schinus terebinthifolius, a flowering plant in the family Anacardiaceae, native to South America. Common names include Brazilian Pepper, Rose Pepper and Christmasberry. Pink peppercorns are used as a spice to add a mild pepper-like taste to foods. It may potentially cause an irritating skin effect and has been associated with atopic dermatitis in canines. Interestingly, S. terebinthifolius is a member of the family Anacardiaceae, which include plants in the genus Anacardium (cashew nut) and Pistacia (pistachio). No allergens from this plant have been characterized but there is potential for cross-reactivity among different members of the Anacardiaceae family. CONCLUSIONS: This is the first reported case of a patient developing anaphylaxis after pink peppercorn ingestion. Patients with tree nut allergies may need to be educated regarding this potential allergen.