Pitaya Allergy: A Case Report of Anaphylaxis in a Patient Without Cross-Reactive Allergens

doi:10.21203/rs.3.rs-5391094/v1

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Case Report

Pitaya Allergy: A Case Report of Anaphylaxis in a Patient Without Cross-Reactive Allergens

https://doi.org/10.21203/rs.3.rs-5391094/v1

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published 05 May, 2025

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Background: Pitaya, commonly known as dragon fruit, is increasingly available and has allergenic potential. While pollens have been found to have cross-reactivity and thus induce allergies to several fruits, the case report detailed herein to our knowledge is the first reported of pitaya anaphylaxis in a patient without co-sensitization to other fruit or environmental allergens.

Case presentation: A 26-year-old male presented to the emergency department with anaphylaxis after consumption of pitaya (dragon fruit). He had no prior history of atopy. Epicutaneous skin testing demonstrated positive skin testing to pitaya with negative testing to all environmental allergens, indicating his pitaya allergy did not derive from pollen allergy cross-sensitization.

Conclusions: Our case is unique in demonstrating the potential for pitaya allergy to occur independent of other allergies and cross-sensitization. Future research into suspected allergenic proteins in pitaya, quantifying their structural similarity to other allergens and identifying their likelihood of causing allergies independent of pollen sensitization, is warranted.

Pollen food allergy syndrome

Anaphylaxis

Pitaya

Cross-sensitization

Dragon fruit

Increasing globalization of food supply brings greater accessibility of unfamiliar food products and potential allergens. One such food, known as dragon fruit or pitaya, is a member of the Cactaceae family, native to Guatemala, Costa Rica, El Salvador and Mexico (1). Pitaya consumption can prompt allergic reactions and anaphylaxis, the suspected allergenic proteins being cupin_1, HSP sti1-like and HSP70 in red-fleshed pitaya seeds and cupin_1 and HSP70 in white-fleshed pitaya seeds (2). Hao et al. identified these possible allergens, and attempted to identify those allergenic proteins most similar to the aforementioned pitaya allergenic proteins and the likely sources of these similar proteins (2). These findings are summarized in Table 1 at the end of the Background section below. Pitaya flesh may also contain an allergenic protein, with the lipid transfer protein being identified as a potential culprit (3).

There is limited published data on reported allergic reactions to pitaya. One prior report describes an episode of urticaria and angioedema prompted by the ingestion of red pitaya fruit (4). This patient experienced no systemic symptoms, and there was no discussion regarding possible co-sensitization to other food or environmental allergens. A second case report described a patient who experienced tongue swelling, dermal erythema, urticaria and vomiting following their first ingestion of pitaya, which was later confirmed to be the culprit allergen (3). The authors postulated that the anaphylactic reaction occurred due to cross-sensitization to pollen-related lipid transfer proteins as the patient possessed established birch pollen allergy (3). A skin prick test demonstrated positive results for alder and hazel pollen as well as the birch pollen, mite and pitaya (3). There exists other research similarly investigating the cross-reactivity connection between pollen and various fruits; the suspected allergenic proteins in pitaya are similar in structure to those of pollen and various dust mites (2,5). Our report describes pitaya-induced anaphylaxis in a patient lacking pollen cross-sensitization.

Table 1. The predicted similar allergenic proteins to the pitaya allergenic proteins and their likely sources, adapted from Hao et al. (2022)

Allergenic protein in pitaya	Predicted similar allergenic protein	Predicted source of similar allergenic protein
Cupin_1	Coc n1	Coconut
HSP sti1-like	Hev b5	Latex
HSP70	Tyr p28	Storage mites

A healthy 26-year-old male presented to the emergency department with a history of sudden onset nausea, diarrhea, abdominal cramping, urticaria, periorbital angioedema, dysphagia and dyspnea. His symptoms began 15 minutes after he consumed a homemade smoothie containing cream of coconut, mango, banana, passion fruit and red pitaya. He was diagnosed with anaphylaxis and treated with oral diphenhydramine, intramuscular epinephrine, oral loratadine and oral prednisone. Symptoms resolved within 20 minutes of epinephrine administration.

He had no prior history of food allergy, asthma or atopic dermatitis. He was subsequently evaluated as an outpatient and at the time of initial consultation, he had been avoiding all components of the smoothie. Epicutaneous skin testing was performed for possible culprit foods. He tested negative for coconut extract, fresh coconut, fresh kiwi and fresh mango. The epicutaneous skin test for fresh pitaya was positive at 6mm. Histamine and saline controls were appropriate.

Given the possibility of pollen food allergy syndrome, he underwent environmental testing. Epicutaneous skin testing was negative for dust mite (D. farinae, D. pteronyssinus), cat, dog, grass pollens (including timothy, orchard and rye), various tree pollens (including alder and birch), weed pollens (including ragweed) and various molds. Histamine and saline controls were appropriate. These findings suggested that the pitaya caused his index reaction. The patient was counselled to strictly avoid pitaya and at the time of publication, he had developed no further allergic reactions.

Based on our research, this is the first case report on a patient who experienced an anaphylactic reaction to pitaya in the absence of cross-sensitization to birch pollen. Birch pollen is heavily implicated in pollen food allergy syndrome (PFAS) and prompts cross-sensitization to various vegetables, nuts, and fruits in up to 70% of patients with a birch pollen allergy (6,7). Birch pollen and its associated PFAS typically involves fruits from the Rosaceae family, of which pitaya is not a member (6). The lack of a demonstrated connection between pitaya and birch pollen may be due to the relatively few instances of pitaya allergy observed thus far. As noted above, Kleinheinz et al. did postulate that birch pollen could have prompted their noted cross-sensitization with pitaya (3).

The primary culprit allergen in birch pollen is called Bet v 1 and tends to exist in greatest concentration within the raw peel and pulp of the Rosaceae fruits (6). This protein also degrades with heat exposure or digestion by gastric juices (8). This means that allergic reactions to birch pollen-sensitized fruits tend to occur when the fruit in question is consumed in its raw form with both the peel and pulp (6). The allergic reactions, however, tend to be confined to the oropharynx and are not commonly generalized unless there is impairment of gastric digestion (9).

This again highlights our unique case, wherein the patient consumed raw pitaya and his anaphylactic reaction was generalized rather than confined to the oropharynx, involving his gastrointestinal system, respiratory system and mucous membranes. While Hao et al. predicted some potentially similar allergenic proteins to those of pitaya which could be found in coconut, latex and storage mites, our patient was not allergic to any of these (2). As of yet there are no publications confirming or quantifying the similarities between pitaya allergenic proteins and the similar allergens as predicted by Hao et al. This too may be due to pitaya allergy being relatively uncommon. Our case report establishes that it can develop independent of other allergies.

Additional research is warranted to determine which of the suspected allergenic proteins of pitaya (cupin_1, HSP sti1-like, HSP70) are more likely to lead to systemic reactions in patients who are mono-sensitized to pitaya.

PFAS: Pollen food allergy syndrome

Ethics approval and consent to participate: Not applicable.

Consent for publication: The written consent was obtained for publication from the patient.

Availability of data and materials: Patient records cannot be made publicly available in order to protect patient confidentiality.

Competing interests: The authors declare that they have no competing interests relevant to this report.

Funding: None.

Authors’ contributions: H.M. engaged in background research on the subject and was a major contributor in writing the manuscript. P.S. oversaw the care of the patient and reviewed the submitted manuscript. All authors read and approved the final manuscript.

Acknowledgements: The authors would like to acknowledge the generosity of the patient for consenting to have this case published.

Attar ŞH, Gündeşli MA, Urün I, Kafkas S, Kafkas NE, Ercisli S, et al. Nutritional Analysis of Red-Purple and White-Fleshed Pitaya (Hylocereus) Species. Molecules. 2022 Jan 26;27(3):808.
Hao M, Xijiri, Zhao Z, Che H. Identification of Allergens in White- and Red-Fleshed Pitaya (Selenicereus undatus and Selenicereus costaricensis) Seeds Using Bottom-Up Proteomics Coupled with Immunoinformatics. Nutrients. 2022 May 7;14(9):1962.
Kleinheinz A, Lepp U, Hausen BM, Petersen A, Becker WM. Anaphylactic reaction to (mixed) fruit juice containing dragon fruit. Journal of Allergy and Clinical Immunology. 2009 Oct;124(4):841–2.
Damiani E, Aloia AM, Priore MG, Delle Donne P, Nettis E, Ferrannini A. “Allergy to red pitaya.” Allergy. 2008 Sep;63(9):1252–3.
Gruehn S, Suphioglu C, O’Hehir RE, Volkmann D. Molecular Cloning and Characterization of Hazel Pollen Protein (70 kD) as a Luminal Binding Protein (BiP): A Novel Cross-Reactive Plant Allergen. Int Arch Allergy Immunol. 2003;131(2):91–100.
Faber MA, Van Gasse AL, Decuyper II, Sabato V, Hagendorens MM, Mertens C, et al. Cross-Reactive Aeroallergens: Which Need to Cross Our Mind in Food Allergy Diagnosis? The Journal of Allergy and Clinical Immunology: In Practice. 2018 Nov;6(6):1813–23.
Geroldinger-Simic M, Zelniker T, Aberer W, Ebner C, Egger C, Greiderer A, et al. Birch pollen–related food allergy: Clinical aspects and the role of allergen-specific IgE and IgG4 antibodies. Journal of Allergy and Clinical Immunology. 2011 Mar;127(3):616-622.e1.
Webber CM, England RW. Oral allergy syndrome: a clinical, diagnostic, and therapeutic challenge. Annals of Allergy, Asthma & Immunology. 2010 Feb;104(2):101–8.
Kleine-Tebbe J, Wangorsch A, Vogel L, Crowell DN, Haustein UF, Vieths S. Severe oral allergy syndrome and anaphylactic reactions caused by a Bet v 1– related PR-10 protein in soybean, SAM22. Journal of Allergy and Clinical Immunology. 2002 Nov;110(5):797–804.

No competing interests reported.

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You are reading this latest preprint version

Pitaya Allergy: A Case Report of Anaphylaxis in a Patient Without Cross-Reactive Allergens

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Abstract

Background

Case presentation

Discussion and Conclusions

List of abbreviations

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References

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