Food-dependent exercise-induced anaphylaxis to pistachio

We report the case of a 16-year-old male who, 30 minutes after beginning to play football with previous ingestion of pistachio nuts, experienced an anaphylactic reaction. Prick-by-prick test with roasted pistachios was negative. Specific IgE antibodies to pistachio, cashew nuts and mango were negative. An open oral challenge test with pistachio in resting conditions was negative. Treadmill ergonometric stress in a fasting state and 60 minutes after a meal without pistachio gave negative results. A specific food exercise challenge 60 minutes after ingestion of 50 g pistachio nuts was positive, showing mild diffuse erythema and small wheals in face and thorax. To the best of our knowledge, this is the first described case of specific food dependent exercise-induced anaphylaxis to pistachio. Negative allergologic tests is an unusual condition, since most cases appear to be IgE-mediated. In this case, a positive specific food exercise challenge test provided a definite diagnosis.