Sunday, November 15, 2026

When a food-triggered reaction isn't a food allergy

Two studies shine a light on eosinophilic esophagitis, an allergic condition that is on the rise

American College of Allergy, Asthma, and Immunology

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PHOENIX (Nov. 12, 2026) – It can be scary to have a reaction to something you’ve eaten and believe the symptoms indicate a food allergy. But for some, the cause of symptoms may be a different condition that can go unnoticed for years. Two new studies being presented at the American College of Allergy, Asthma and Immunology (ACAAI) Annual Scientific Meeting look at how eosinophilic esophagitis (EoE) diagnoses are on the rise, and how EoE symptoms can be mistaken for a food allergy.

EoE is an allergic condition of the esophagus, the tube that carries food from your mouth to your stomach. In people with EoE, a type of white blood cell called an eosinophil builds up in the esophagus. This causes swelling and irritation. Over time, it can make it hard to swallow and can cause food to get stuck.

The first study looked at 29 adults who had been sent to an allergist because doctors thought they experienced anaphylaxis, a severe allergic reaction, after eating certain foods. On average, each patient had gone to the emergency room three times, and most had been given at least one dose of epinephrine.

Their symptoms included a tight throat, trouble swallowing, chest pain, drooling, and food getting stuck in their esophagus. But testing did not show a true food allergy. Instead, tissue samples taken from their esophagus showed that the patients had EoE. On average, it took more than five years for them to get the right diagnosis.

“Not every frightening reaction after eating is anaphylaxis” said allergist Talal Nsouli, MD, ACAAI member and lead author of the study. “Eosinophilic esophagitis can closely mimic food allergy and may lead to repeated emergency visits before the correct diagnosis is made. When throat tightness, difficulty swallowing or food impaction recur, especially with negative food allergy testing, we should think about EoE. Early recognition can prevent years of uncertainty and progressive esophageal damage.”

Getting a prompt and accurate diagnosis is important. Additional research shows that when EoE is not treated, scar tissue can build up and narrow the esophagus. The chance of this narrowing increases about 9% for every year the disease goes untreated.

The second study used health records from more than 300 million patients in the U.S., making it the largest study of EoE in the country to date. Researchers found more than 500,000 people with an EoE diagnosis.

Key findings include:

The number of people diagnosed with EoE has increased by about 7 times since 2009.
EoE was most often first diagnosed in two age groups: the teen years and people in their 40s.
Males were more likely to have EoE than females.
Rates were highest in northern states, with New Hampshire at the top.
People with several allergic conditions, such as asthma, hay fever, eczema, and food allergies, were much more likely to have EoE. Among food allergies, wheat allergy had the strongest link.

“We are seeing increased EoE over time,” said allergist Bushra Tbakhi, MD, lead study author and ACAAI member. “Associated allergic conditions may help identify patients at high risk for EoE.”

Abstract Title: When Anaphylaxis Is Not Anaphylaxis: Eosinophilic Esophagitis Mimicking Food Allergy

Presenter: Talal Nsouli, MD

Abstract Title: Epidemiology and Clinical Features of Eosinophilic Esophagitis: Analysis Using the COSMOS Database

Presenter: Bushra Tbakhi, MD

For more information on the diagnosis and treatment of EoE, or to find an allergist in your area, visit AllergyandAsthmaRelief.org. The ACAAI Annual Scientific Meeting is Nov. 12-16. For more news and research from the ACAAI Scientific Meeting, go to our newsroom and follow the conversation on X/Twitter #ACAAI26.

About ACAAI

The American College of Allergy, Asthma & Immunology (ACAAI) is a professional medical organization of more than 6,500 allergists-immunologists and allied health professionals, headquartered in Arlington Heights, Ill. Founded in 1942, the College fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy, and research. ACAAI allergists are board-certified physicians trained to diagnose allergies and asthma, administer immunotherapy, and provide patients with the best treatment outcomes. For more information and to find relief, visit AllergyandAsthmaRelief.org. Join us on Facebook, Instagram, Threads and X.

WHEN ANAPHYLAXIS IS NOT ANAPHYLAXIS: EOSINOPHILIC ESOPHAGITIS MIMICKING FOOD ALLERGY
R033
T. Nsouli*, N. Diliberto, E. Abou-Jaoude, S. Nsouli, J. Bellanti, Washington, DC. Introduction:
Eosinophilic esophagitis (EoE) may present with acute food-triggered symptoms that
closely resemble IgE-mediated anaphylaxis. We reviewed patients referred for recurrent
presumed food-induced anaphylaxis who were ultimately diagnosed with EoE.
Methods:
A retrospective review was performed of clinical history, allergy evaluation, treatment
response, and endoscopic/histopathologic findings in 29 consecutive patients
subsequently diagnosed with EoE.
Results:
The cohort included 20 males (69%) and 9 females (31%), with a mean age of 38.5 ± 9.1
years. Patients reported recurrent episodes following ingestion of common food allergens
and experienced a mean of 3.24 ± 1.30 emergency department visits (median 3, range
1–6) and 0.97 ± 0.84 epinephrine administrations (median 1, range 0–3). The mean time
to diagnosis was 5.55 ± 2.20 years (median 6, range 2–10). Predominant symptoms
included throat tightening, dysphagia, chest pain, hypersalivation, food impaction, and
inability to swallow. Allergy evaluation failed to support IgE-mediated anaphylaxis.
Esophageal biopsies demonstrated ≥15 eosinophils per high-power field in all patients,
confirming EoE. This prolonged diagnostic delay is clinically important, as the risk of
fibrostenotic stricture increases by approximately 9% for each year of untreated disease.
Fibrostenosis is driven by chronic type 2 inflammation, with IL-4, IL-13, and TGF-β1
serving as key profibrotic mediators.
Conclusion:
EoE should be considered in patients with recurrent food-associated dysphagia, throat
tightening, or food impaction, particularly when allergy testing is negative or response to
epinephrine is incomplete. Early recognition and prompt endoscopic biopsy are essential
to prevent misdiagnosis, unnecessary treatment for presumed anaphylaxis, and
progressive fibrostenotic esophageal remodeling.

EPIDEMIOLOGY AND CLINICAL FEATURES OF EOSINOPHILIC ESOPHAGITIS: ANALYSIS USING THE COSMOS DATABASE
R304
B. Tbakhi*, R. Lee, M. Rothenberg, S. Andorf, S. Zhang, Cincinnati, OH.

Background: Eosinophilic esophagitis (EoE) is a chronic allergic disease of the esophagus with increasing prevalence. We aimed to characterize EoE epidemiology and clinical features in the largest U.S. cohort to date.

Methods: We retrospectively analyzed the Epic Cosmos database (1990–2024), comprising over 300 million deidentified patients, for prevalence, incidence, geographic distribution, comorbidities, and treatment patterns. EoE was identified by diagnostic code alone (diagnostic code) or in combination with endoscopy and histology (combined criteria).

Results: Of 300,278,878 patients, 508,739 had EoE by diagnostic code and 159,279 by combined criteria. Among patients with EoE identified by diagnostic code alone, there was a bimodal distribution of peak incidence in the second followed by the fifth decade of life. There was an overall higher proportion of males to females (59%), but this predominance decreased with increasing age. Since 2009, prevalence and incidence increased by 7.1 fold and 1.3 fold, respectively. Rates were highest in northern states (i.e. New Hampshire 0.31%). EoE is strongly associated with the presence of multiple allergic comorbidities (OR 23.7), food allergy (OR 6.3) and gastrointestinal diseases (i.e. celiac disease; OR 11.1). Amongst specific IgE mediated food allergies, wheat showed the strongest association (OR 37.1). Proton pump inhibitors were the most common treatment (83.4%); however, dupilumab use rose 4.4 fold since FDA approval in 2022, without increased risk of eosinophilia or malignancy.

Conclusion: EoE prevalence is rising in the U.S. with regional variation and strong associations with atopic and gastrointestinal comorbidities. These findings provide updated epidemiologic and clinical insights and highlight evolving treatment trends.

Allergic comorbidities among patients with eosinophilic esophagitis (EoE)

A) Odds ratios (ORs) for the presence of EoE in patients with single or various combinations of atopic comorbidities, including asthma (n = 3,016), allergic rhinitis (n = 67,644), eczema (n = 5,301), and food allergy (n = 20,261).

B) ORs (middle marker) with 95% CI (left and right markers) for the presence of EoE in patients with specific food allergies, including milk (n = 4,946), egg (n = 2,313), wheat (n = 914), soy (n = 48), fish/shellfish (n = 4,306), peanut (n = 3,210), tree nut/sesame (n = 760), and patients with multiple food allergies (FA) (n = 23,424).

C) ORs for the presence of EoE in patients with gastrointestinal and food protein–induced disorders, including food protein–induced enterocolitis syndrome (FPIES) (n = 674), food protein–induced enteropathy (FPE) (n = 105), food protein–induced allergic proctocolitis (FPIAP) (n = 23), inflammatory bowel disease (IBD) (n = 22,782), and irritable bowel syndrome (IBS) (n = 48,230).

Journal

Annals of Allergy Asthma & Immunology

Method of Research

Literature review

Subject of Research

People

Article Title

WHEN ANAPHYLAXIS IS NOT ANAPHYLAXIS: EOSINOPHILIC ESOPHAGITIS MIMICKING FOOD ALLERGY

Article Publication Date

12-Nov-2026

School nurses find stock epinephrine improves safety of students with severe allergies

Study shows most schools still require families to supply their own

American College of Allergy, Asthma, and Immunology

PHOENIX (Nov. 12, 2026) – For school kids with severe food allergies, having epinephrine on hand at school can mean the difference between a scary moment and a life-threatening one. A new national survey of school nurses presented at the 2026 Annual Scientific Meeting of the American College of Allergy, Asthma and Immunology (ACAAI) looks at how schools stock and manage this life-saving medicine. The results showed that while keeping epinephrine on hand at school clearly helps, many families are still being asked to supply their own, even when it may not be necessary.

"Our findings show that having stock epinephrine available at school clearly improves student safety, since schools without it were far more likely to end up without a working device in an emergency," said Mahi Singh, MD, lead study author and ACAAI member. "At the same time, schools also often require students with a known food allergy to bring their own personal epinephrine device each year and leave it with the school nurse. That can be expensive for families and limit accessibility outside school hours compared to backpack storage."

Epinephrine is the only medicine that can stop anaphylaxis, a severe allergic reaction, from becoming deadly. Many schools now keep a supply of epinephrine available, sometimes called "stock" epinephrine, that any student can use in an emergency. Only 10 states require schools to stock epinephrine, but many schools in other states do so voluntarily. At the same time, schools also often require students with a known food allergy to bring their own personal epinephrine device each year. That can be expensive and hard to keep track of for families.

Researchers surveyed nearly 1,850 school nurses across the country between August and December 2025. Of those, 349 nurses, each representing one school, completed the survey.

87% of schools kept stock epinephrine on site, but 74% still required students to bring their own personal device as well.
Most nurses (74%) preferred a "dual coverage" approach, keeping both stock epinephrine and personal devices on hand, while about a quarter (27%) said stock epinephrine alone would be enough. Dr. Singh notes this key point requires further study.
72% of schools reported that no student needed epinephrine at all in the past year, and 97% had never needed to use more than two doses in a single day. This suggests many personal devices go unused and may expire.
Importantly, 10% of nurses said that epinephrine was not available when a student needed it during a real allergic emergency. Schools that did not keep stock epinephrine were more than four times more likely to report this problem.

Families of students with food allergies often pay for a costly new epinephrine device every year to bring to school, even if it's never used and eventually expires unopened. That adds up to expense and hassle for families, on top of the stress of managing a child's allergy. The researchers say their findings support wider adoption of stock epinephrine programs in schools, which could reduce the financial and administrative burden on families while helping ensure epinephrine is always available when a student needs it most.

Abstract Title: Epinephrine Utilization and Management in Schools: A National Survey of School Nurses

Presenter: Mahi Singh, MD

For more information about treating anaphylaxis, or to find an allergist in your area, visit AllergyandAsthmaRelief.org. The ACAAI Annual Scientific Meeting is Nov. 12-16 in Phoenix. For more news and research from the ACAAI Scientific Meeting, go to our newsroom and follow the conversation on X/Twitter #ACAAI26.

About ACAAI

EPINEPHRINE UTILIZATION AND MANAGEMENT IN SCHOOLS: A NATIONAL SURVEY OF SCHOOL NURSES

D025
M. Singh*, E. Carr, A. Volerman, S. Nyenhuis, C. Ciaccio, Chicago, IL.

Introduction: Many students with a documented food allergy are required to supply personal epinephrine administration devices to school each year, creating both financial and administrative burdens. Transitioning to exclusive stock epinephrine in schools is a more cost-effective alternative; however, the safety, feasibility, and preference for this practice is unclear.

Methods: A cross-sectional survey was distributed to a national database of 1,847 U.S. school nurses between August-December 2025 to assess the current requirements and usage of epinephrine in US schools. Survey analysis included descriptive statistics and chi-square tests.

Results: 349 (19%) school nurses completed the questionnaire, each representing one school. Most schools (87%) had stock epinephrine; 74% required students to bring personal epinephrine devices. Approximately one quarter (27%) of nurses preferred stock-only supply; 74% favored a dual coverage supply model.

Encouragingly, 72% reported that there were no epinephrine administrations in the previous year, and 97% had never used more than two epinephrine devices in a single day. However, ten percent of nurses reported that epinephrine was unavailable when required for an anaphylactic event. In particular, schools without stock supply were 4.42 times more likely to report epinephrine unavailability (p<0.001).

Conclusion: These findings show keeping stock epinephrine at school has clear utility, and its availability is widespread across schools; however, most schools still require personal epinephrine devices. The high rate of unused, expired devices suggests excess supply of personal epinephrine autoinjectors.

Journal

Annals of Allergy Asthma & Immunology

Method of Research

Survey

Subject of Research

People

Article Title

EPINEPHRINE UTILIZATION AND MANAGEMENT IN SCHOOLS: A NATIONAL SURVEY OF SCHOOL NURSES

Article Publication Date

12-Nov-2026

US Insurance delays and denials mean kids don’t get allergy and asthma medications

New study finds about 4 in 10 requests for children’s biologic medications were denied

American College of Allergy, Asthma, and Immunology

PHOENIX, Ariz. (Nov. 12, 2026) – When a child’s severe asthma, eczema, hives, or food allergy isn’t under control, an allergist may prescribe a newer type of medicine called a biologic. But a new study being presented at the American College of Allergy, Asthma and Immunology (ACAAI) 2026 Annual Scientific Meeting finds that getting insurance to pay for these medicines can take weeks, and many requests are turned down.

Biologics are medicines, usually given as shots, that target the part of the immune system that causes allergic disease. They can help children whose symptoms don’t get better with other treatments. Before insurance will pay for a biologic, a doctor’s office usually must get prior authorization – requesting permission from the insurance company to order the medication.

Researchers at a children’s hospital looked at 326 prescriptions for biologic medicines written by allergists from 2018 to 2026. The children were about 11 years old on average.

The study found:

Almost every prescription needed permission from insurance. More than 9 out of 10 required prior authorization.
About 4 in 10 requests were denied.
Denials happened for two main reasons. The insurance company said the child did not meet its rules, or it wanted the child to try a different medicine first. Each reason accounted for about 1 in 4 denials.
Approval took time. On average, it took more than a month to go from the doctor writing the prescription to insurance approving it. Some families waited much longer.

“When a child’s asthma or allergies are out of control, every week counts,” said allergist Aarti Pandya, MD, co-author of the study and ACAAI member. “The doctor and the family have already decided this medication is the right choice. Then they wait, sometimes for more than a month, and many times the answer is still no. Delays like these can put children at risk of serious health problems.”

The researchers say the findings show the need for changes to the prior authorization process, so children can get the medicines their doctors prescribe without long waits.

“We hope this data helps start a conversation about making the approval process faster and simpler,” said Dr. Pandya. “Children shouldn’t have to wait weeks for care their allergist knows they need immediately.”

Abstract Title: Biologic Medication Denials in Pediatric Atopic Conditions

Presenter: Aarti Pandya, MD

If your child’s asthma or allergies are not well controlled, talk with a board-certified allergist about treatment options. To find an allergist near you, visit AllergyandAsthmaRelief.org. The ACAAI Annual Scientific Meeting is Nov. 12-16. For more news and research from the ACAAI Scientific Meeting, go to our newsroom and follow the conversation on X/Twitter #ACAAI26.

About ACAAI

BIOLOGIC MEDICATION DENIALS IN PEDIATRIC ATOPIC CONDITIONS
R301
M. Holland*, M. Jacobson, C. Reinert, E. Cramer, A. Pandya, Kansas City, MO.

Introduction: Medication denials by insurance companies represent a growing barrier to timely and effective care for patients with atopic and immunologic conditions. Optimal treatment for uncontrolled atopic conditions such as asthma, atopic dermatitis, chronic urticaria, and IgE-mediated food allergy can require biologic therapy which often require prior authorization (PA) by payors. This study was performed to evaluate the landscape PA denials of biologic therapies by payors.
Methods: We conducted a retrospective chart review from a tertiary care pediatric care center of patients who had been prescribed biologic medications for atopic conditions by allergists. Medications included were omalizumab, mepolizumab, benralizumab, dupilumab and Tezepelumab that were prescribed between 2018 to 2026.
Results: A total of 326 prescriptions for biologic therapy were identified. The median age of the patients was 11.4 years old and male patients were 50.3% and female patients were 49.7%. A total of 93.6% of prescriptions required a PA. Among the biologics prescribed, more than half were for omalizumab (182; 55.8%) and the second most frequently prescribed was dupilumab (85; 26%). Of those requiring a PA, 39.3% of prescriptions were denied. The most common reasons for denial included not meeting insurance criteria (24.4%), a trial of a pre-requisite (23.4%). The mean days from prescription of medication to approval was 32.65 days.
Conclusion: This study showed a significant time delay from prescription of biologic therapy to final approval of medication. Delays in therapy can put patients at risk for serious health outcomes. This study suggests the need for policy change for the PA process for medications.

Patients with Pediatric Atopic Diagnoses Prescribed Biologic Therapies (n=326) (Table)

Journal

Annals of Allergy Asthma & Immunology

Method of Research

Data/statistical analysis

Subject of Research

People

Article Title

BIOLOGIC MEDICATION DENIALS IN PEDIATRIC ATOPIC CONDITIONS

Article Publication Date

12-Nov-2026

It’s not just peanuts and bee stings: Anaphylaxis can present in unusual ways

Three medically challenging cases reveal surprising allergic reactions

American College of Allergy, Asthma, and Immunology

PHOENIX (Nov. 12, 2026) – When people think about anaphylaxis, peanuts, shellfish, or even bee sting often come to mind. Three medically challenging cases presented at the American College of Allergy, Asthma and Immunology (ACAAI) 2026 Annual Scientific Meeting show that severe allergic reactions can come from far less obvious places: a fish ingredient hidden in an energy drink, a natural hair oil and a popular children's sensory toy.

Although the three cases are unrelated, each involved a child or teen who experienced anaphylaxis—a severe, potentially life-threatening allergic reaction—and required epinephrine. Together, the cases underscore how an allergic trigger might be identified when the cause is unclear.

Something fishy in an energy drink

Within minutes of trying a new energy drink, a 15-year-old boy developed widespread hives, wheezing and difficulty breathing. In the emergency department, he received two doses of epinephrine, as well as albuterol, an antihistamine and IV fluids, before his symptoms resolved.

The culprit was an unexpected ingredient. A review of the label showed the drink contained 5 grams of collagen derived from cod. The teen, who has eczema, asthma and allergic rhinitis, had noticed mild throat itching and lip swelling when eating canned tuna, but had eaten salmon without a problem. Skin prick tests for tuna, cod and flounder were all negative.

"This case shows how tricky fish allergy can be," said allergist Annabelle Rowland, MD, study author and ACAAI member. "Collagen from fish is showing up in a growing number of products, from drinks to supplements. Standard fish allergy tests mostly look for a different fish protein and contain very little collagen, so a person can test negative and still react."

Abstract title: Anaphylaxis Following Energy Drink Consumption Reveals Something Fishy

Presenter: Annabelle Rowland, MD

How castor oil is made can matter when it comes to allergic reactions

Castor oil is a common ingredient in cosmetics, hair products and laxatives. Allergy to the castor bean, from which castor oil is made, is well known. It almost always appears as a workplace allergy from breathing in bean dust. Anaphylaxis is rare from castor oil and has usually only been reported in adults exposed to the seed.

This case describes the first reported anaphylaxis in a child from castor oil applied to the skin. A 10-year-old girl with eczema on her scalp, neck and elbows used heat-pressed castor oil on her hair for years without trouble. The first time cold-pressed castor oil was applied to her scalp, she developed hives on her face and neck, wheezing and shortness of breath. She was treated in the emergency room with epinephrine, albuterol and steroids. Skin prick testing with her own products was positive for the cold-pressed oil and negative for the heat-pressed oil.

"Cold pressing keeps certain castor bean proteins intact, while the heat used in refining breaks them down," said allergist Keyun Wang, DO, lead author of the study and ACAAI member. "We believe years of applying oil to eczema-damaged skin may have caused her to develop an allergy, and the protein-rich cold-pressed oil then triggered a reaction. When evaluating allergy risk from plant oils, we must consider how the oil is processed, not just the plant source."

Abstract Title: Pediatric Anaphylaxis Due to Topical Castor Oil Application

Presenter: Keyun Wang, DO

Two squishy toys and two trips to the ER

Squishy squeeze ball toys are popular with some kids for stress relief and sensory play. Known risks include choking and skin irritation, but anaphylaxis has not been reported until now.

An 11-year-old girl with allergic rhinitis and asthma developed hives, swelling and throat tightness after handling a squishy toy at home and touching her face. She received epinephrine in the ambulance, then had a rebound of breathing symptoms that needed further treatment in the emergency department. One week later, she felt her throat tighten within an hour of using a different squishy toy at school. She used her own epinephrine and was taken to the ER again. The girl had no prior history of anaphylaxis, food allergy or latex allergy, but blood testing showed she was sensitized to latex. No other trigger was found.

"These toys are often marketed as non-toxic rubber, but they can contain a long list of chemical additives, and their exact makeup usually isn't disclosed," said Megan Marte, MD, lead author of the case report and ACAAI member. "Toy-related anaphylaxis has been linked to latex in ball pit materials, which raises the question of latex contamination or cross-reactivity in squishy toys. If a child has an unexplained severe reaction after playing with a toy, it's worth looking at the toys they've been playing with and possibly see an allergist."

Abstract Title: Anaphylaxis Following Exposure to a Squishy Squeeze Ball Toy: A Case Report

Presenter: Megan Marte, MD

Anyone with symptoms of a severe allergic reaction should seek emergency care. To learn more about anaphylaxis, and find an allergist near you, visit AllergyandAsthmaRelief.org The ACAAI Annual Scientific Meeting is Nov. 12-16. For more news and research from the ACAAI Scientific Meeting, go to our newsroom and follow the conversation on X/Twitter #ACAAI26.

About ACAAI

ANAPHYLAXIS FOLLOWING ENERGY DRINK CONSUMPTION REVEALS SOMETHING FISHY
M517
A. Rowland*, Atlanta, GA.

Introduction

A teenager presents with anaphylaxis after consuming energy drink containing fish collagen.

Case Description

This case describes a 15-year-old boy with history of eczema, asthma, allergic rhinitis, and idiopathic pulmonary hemosiderosis who presented to allergy clinic following anaphylaxis. He was trying a new energy drink, and within minutes, he developed diffuse hives, wheezing, and difficulty breathing. He was evaluated in the emergency department and treated with intramuscular epinephrine twice as well as albuterol, cetirizine, and isotonic fluids with resolution of symptoms. He was in his usual state of health earlier that day and denies exercise or NSAID use prior to reaction. He has noticed throat itching and mild lip swelling with ingestion of canned tuna fish. He tolerates salmon as well as the other top-9 allergens without concern. History is also notable for localized urticaria following exposure to chlorhexidine wash. Review of drink ingredients revealed 5 grams of fish collagen derived from cod. Skin prick testing (SPT) in clinic was negative for tuna, cod, and flounder but positive for environmental allergens. Family was asked to bring fresh cod for prick-to-prick testing, but working diagnosis for this patient is allergy to fish collagen as further testing is pending.

Discussion

This case demonstrates nuances of fish allergy which are important to consider as fish collagen is included in a growing number of products. A previous study demonstrated sensitization to fish collagen in patients without evidence of sensitization to parvalbumin1. Commercial fish extracts have minimal collagen and can lead to missed diagnoses2.

PEDIATRIC ANAPHYLAXIS DUE TO TOPICAL CASTOR OIL APPLICATION
M055
K. Wang*, M. Vastardi, Brooklyn, NY.

Introduction

Ricinus communis L. (castor bean) yields an oil that is commonly used in cosmetics, laxatives, and hair products. Castor sensitization is well described but almost always as an occupational inhalant allergy. Anaphylaxis is rare and previously reported only in adults exposed to the seed. We describe the first pediatric anaphylaxis attributed to topically applied castor oil, with reactivity dependent on the oil's processing method.

Case

A 10-year-old girl with atopic dermatitis of the scalp, nape, and antecubital fossae with previous use of heat-pressed castor oil for hair care, developed urticaria of the face and neck, wheeze, and dyspnea within minutes of the first topical application of cold-pressed castor oil to her scalp. In the emergency room, she responded to intramuscular epinephrine, nebulized albuterol, and systemic corticosteroids. Skin prick testing with her own products was positive to cold-pressed oil and negative to the heat-pressed oil. Laboratory results revealed total serum IgE of 573 kU/L with broad aeroallergen polysensitization including latex allergy. Castor specific IgE testing was unavailable.

Discussion

This is the first reported anaphylaxis case from topical castor oil and the first clinical demonstration of processing-dependent reactivity. Cold pressing preserves native, heat-labile storage proteins (2S albumins Ric c 1 and Ric c 3), whereas thermal refining denatures them. Years of heat-pressed oil use on barrier-impaired, eczematous skin possibly enabled epicutaneous sensitization, with the protein-rich cold-pressed oil later crossing the reaction elicitation threshold. Processing methods, not merely the source ingredient, should be considered when assessing the allergenic risk of plant-derived oils.

ANAPHYLAXIS FOLLOWING EXPOSURE TO A SQUISHY SQUEEZE BALL TOY: A CASE REPORT
M082
M. Marte*, A. Nowak-Wegrzyn, E. Putter, New York, NY.

Introduction: Squishy Squeeze Ball Toys are popular sensory toys. Health risks include choking, chemical burns, skin irritation, or toxic fume inhalation, but anaphylaxis has not been reported to date. We report a case of anaphylaxis temporally associated with squishy toy exposure in an atopic child with latex sensitization.?
Case Description: An 11-year-old female with allergic rhinitis and asthma developed acute-onset urticaria, angioedema, and throat tightness after handling a squishy toy and touching her face at home. During ambulance transport, the patient received intramuscular epinephrine with initial improvement, followed by rebound respiratory symptoms treated with intravenous diphenhydramine, then observation in the ED. One week later, she experienced throat tightness within an hour of handling a different squishy toy at school, prompting self-administered epinephrine and another ED visit for oral prednisone. Serum latex-specific IgE was elevated (3.2 kUa/L), indicating latex sensitization. The presentation met clinical criteria for anaphylaxis, and no alternate trigger was identified. She had no history of anaphylaxis, food, or latex allergies.
Discussion: This case highlights squishy toys as a potential source of severe allergic reactions in children. Although marketed as non-toxic thermoplastic rubber (TPR), these toys may contain numerous chemical additives, including volatile solvents, vulcanization accelerators, diisocyanates, styrene monomers, and phthalate plasticizers. Toy-related anaphylaxis has been linked to latex-contaminated ball pit materials, raising concern for latex contamination or cross-reactivity within squishy toy products. The undisclosed composition of children’s toys makes allergen identification challenging, emphasizing the need for comprehensive allergy workup and evaluation of toy materials in unexplained anaphylaxis.

Journal

Annals of Allergy Asthma & Immunology

Method of Research

Case study

Article Title

ANAPHYLAXIS FOLLOWING ENERGY DRINK CONSUMPTION REVEALS SOMETHING FISHY

Delays in peanut introduction to infants found in families who don’t speak English

Language barriers may interfere with best tool for peanut allergy prevention

Ann & Robert H. Lurie Children's Hospital of Chicago

Research shows that introducing peanut foods to babies around 4 to 6 months of age can significantly lower their chances of developing a peanut allergy. In the U.S., doctors now recommend early peanut introduction as a standard part of infant care. However, families who don't speak English may be missing out on this protection, according to a new study presented at the 2026 Annual Scientific Meeting of the American College of Allergy, Asthma and Immunology (ACAAI).

"Early peanut introduction is one of the few tools we have to actually prevent a food allergy before it starts, so it matters that every family has equal access to this guidance," said lead author James Senter, MD, MPH, a fellow at Ann & Robert H. Lurie Children’s Hospital of Chicago. "Our findings suggest that language, on its own, is a barrier. This isn’t about families not caring about their child’s health — it’s about making sure our medical guidance actually reaches every family in a way they can understand and act on."

Dr. Senter and colleagues reviewed medical records for 3,170 children seen at two pediatric primary care clinics between 2021 and 2026. This included 240 children from families who spoke a language other than English at home, representing 25 different languages.

Overall, only about 28% of babies had peanut foods introduced by their 6-month checkup, and about 68% had it introduced by their 9-month checkup. Families who spoke a language other than English were far less likely to have started peanut foods by 6 months, and still less likely by 9 months, even after researchers accounted for other factors like income and neighborhood. This gap did not close over time. Non-English-speaking families were not "catching up" between the 6-month and 9-month visits any more than English-speaking families were.

“It will be important to have nutrition and allergy resources for families in multiple languages, something my group and I are also developing,” said Dr. Senter. “Recognizing this area as a key gap in protection for families who speak languages other than English may help providers emphasize this practice to more families, address any questions or uncertainties, and clarify any cultural or linguistic barriers to early peanut introduction.”

Ann & Robert H. Lurie Children’s Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children’s hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children’s resources are devoted to serving their needs. Research at Lurie Children’s is conducted through Stanley Manne Children’s Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children’s is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation’s top children’s hospitals by U.S. News & World Report.

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Sunday, November 15, 2026

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