What is in your pantry? Entomologic anaphylaxis

Background: The booklouse, Liposcelis bostrychophila, is a potent environmental allergen clinically associated with rhinoconjunctivitis and asthma. Despite its known infestation of grain products, anaphylaxis from ingestion of this organism has, to our knowledge, not been previously reported. We present the case of a 44-year-old woman who developed anaphylaxis to ingested oats and rice shown to be contaminated with L. bostrychophila. Objective: The objective was to isolate a distinct antigen from L. bostrychophila implicated in a case of unexplained anaphylaxis. Methods: In vitro studies were obtained for relevant ingested materials and aeroallergens. Skin-prick testing (SPT) was performed with standard extracts, contaminated oats, fresh oats, and crushed L. bostrychophila. Western blots were conducted using subject and control serum to detect specific immunoglobulin E (IgE) against the grains and L. bostrychophila extract. Competitive inhibition immunoblotting was used to assess specificity of IgE binding. Results: In vitro studies and SPT were notable for positive responses to dust mite and flour contaminated by L. bostrychophila, along with contaminated oats. Testing results for fresh oat and rice were negative. Immunoblots that used the subject's serum revealed a strongly positive band in the contaminated oat and rice extracts at 24 kD, whereas dust-mite extract yielded a single 14-kD band. Isolated L. bostrychophila extract also yielded a 24-kD band. Competitive inhibition experiments demonstrated that the 24-kD band in the contaminated oat extract was immunologically distinct from the 14-kD dust-mite band. Conclusion: Our case highlights the importance of considering L. bostrychophila as a potential culprit for unexplained anaphylaxis due to ingested grain products. Given the ubiquitous presence of this insect, we suspect that this may be a more common problem than previously recognized.