Nut allergy presents a growing public health burden and is the most common cause of fatal anaphylaxis in the UK.1 Adults and children commonly present to primary care with suspected reactions to nuts. The UK has a nut allergy prevalence of 0.7–2.5%.2 The British Society for Allergy and Clinical Immunology (BSACI) released their Guideline for the Diagnosis and Management of Peanut and Tree Nut Allergy 2 in July 2017 and the National Institute for Health and Care Excellence (NICE) Quality Standard Food Allerg y (QS118)3 reinforces expectations in food allergy management.Life-threatening primary nut allergy most often arises in early childhood, and is caused by the production of specific IgE (sIgE) antibodies, which recognise heat-resistant nut proteins. Signs of a reaction usually develop within a few minutes of ingestion, and include vomiting, oral tingling, itching, urticaria, and lip and eyelid angioedema. Symptoms such as airway swelling, hoarse voice, breathing impairment, and drowsiness are often not correctly recognised as indicating anaphylaxis.Not all patients who report oral symptoms, facial swelling, and urticaria shortly after eating nuts have life-threatening primary nut allergy. Patients with seasonal allergic rhinitis may develop cross-sensitisation between pollen allergens and structurally similar heat-labile proteins within nuts, which can present as pollen food syndrome (PFS). In these cases, the majority of IgE-mediated symptoms are oral-gastric because the labile nut proteins are broken down by gastric acid. Therefore, PFS rarely induces systemic symptoms and the prescription …
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