May 5, 2025 • 20 mins
Did you know the average person unknowingly consumes about 2 pounds of insects or insect parts annually? This startling fact underscores the ubiquitous presence of insects in our environment and diet, presenting unique challenges in allergy diagnosis and patient management. This episode of ImmunoCAST explores the multifaceted world of insect-related allergies, moving beyond common respiratory or stinging triggers to uncover lesser-known presentations. We explore the "Pancake Syndrome" and its link to dust mites, discuss the cross-reactivity between dust mites and shellfish, and examine the allergenic potential of insect-derived food additives. By understanding these complex interactions, clinicians can enhance their diagnostic acumen and provide more comprehensive care for patients with suspected insect allergies.
References and resources available at: https://www.thermofisher.com/phadia/us/en/resources/immunocast/hidden-insect-allergies-food-dust-mites.html?cid=0ct_3pc_05032024_9SGOV4
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
ImmunoCAST is brought to you byThermo Fisher Scientific, creators of
(00:03):
ImmunoCap specific IGE diagnosticsand FADIA Laboratory systems.
- I'm Gary Falcetano, a licensedand board certified PA with over
12 years experience in allergyand immunology.
- And I'm Luke lemons, with over6 years experience writing for
healthcare providers andeducating on allergies.
(00:25):
You're listening to ImmunoCAST,your source for medically and
scientifically backedallergy insights.
What do cockroaches, dust mitesand shrimp have to do with pancakes?
- Oh, it does not sound likea very good pancake mix.
- No, no, it doesn't. We're gonnago into that a little bit more later on.
But to give everyone listeninga hint, we're gonna be talking about
(00:46):
bug or insect allergies today.
But before we dive in to some ofthe lesser known ways pancakes that
insects may come in contact withpatients and cause reactions,
we'd be remiss to not some ofthe more conventional allergies
that insects may cause.
- Yeah, absolutely. So, you know,I think when we think about insects
(01:08):
and how they affect our healthand allergy, we typically think
of respiratory issues. Right.We think of rhinitis and asthma
and how exposure to cockroachand dust mites. Right. Are such
big drivers. Right. When you'resensitized to cockroaches and
dust mites, how much that actuallydrives our respiratory allergies.
But there's more to bug allergiesthan just that.
(01:30):
- Yeah. And I think that most ofthe providers listening, when they
think of insect allergies, theymight go straight towards bees
or vespids.
- Yeah, that's true.
- And that's common. But someproviders may not know actually
that a lot of those severereactions to bees and vespid
stings and their venom areactually underreported by patients.
And also that the venomimmunotherapy, in which you may
(01:51):
refer to an allergist, if you dohave a patient who had a severe
reaction, it's very successfulform of therapy.
- We've talked about this inprevious episodes. We had Dr. Golden
with us on our anaphylaxis andstinging insects episode back in
episode 27. I think we did oneourselves, episode 13 on stinging
insects. And it really is, it'svital that providers have that
index. Right. Of suspicion ofanytime we're seeing patients.
(02:14):
You know, part of that initialhistory should be, have you ever
had a systemic reaction to aninsect sting? Because people
don't report it.
- And I'm Glad you mentioned thepast episodes that we've done
because we've talked about insectsin the past and we've definitely
talked about em from a respiratorypoint of view with dust mites
and asthma. We've definitelytalked about them when it comes
(02:37):
to stinging insect venom. Andthen also Alpha Gal syndrome,
which isn't necessarily an allergyto an insect, but it's an allergy
that's caused by a tick bite.
- The tick is the vector forthe transmission. Right. So people
that are bitten by certain ticks,and we used to think these were
specifically the Lone Star tick,develop a sensitization to ALPH
and then develop what is knownas a delayed red meat allergy.
(02:58):
But it's not just the Lone Startick anymore. Right.
- Luke, this is probably a topicfor another episode, but there's
new ticks out there, new ticksare dropping that are causing
Alpha Gal. So the black leg dogor wood tick is common in Maine,
and then the Western black legtick is common in Washington. So.
- And we just saw a couple ofreports coming out of the CDC
of case reports from both ofthose areas implicating those
(03:22):
ticks. So, yeah, we'll have moreon that, I'm sure, in future
episodes. But the Alpha Galstory is far from.
- If you're interested in learningmore about alpha gal, episode 11
and episode 29, Gary and Idiscussed that. But outside of
bites, stings and inhalation,how else may patients react to
insects? And the answer that Iknow we don't really want to
think about is. Well, why don'tyou say, Gary?
(03:45):
- Well, so entomophagy or eds.
- Yes. So insects are closerto food than we think. Some
people eat insects on purpose,and some people eat insects
because of contamination. Andactually, when it comes to being
on purpose, it's really commonin Asia and African countries,
but it's gaining popularityin Europe.
- It is. I mean, as we see,you know, our global population
(04:07):
continues to expand. This isone of the areas that has been
really, you know, looked at asa potential, you know, new food
source to be able to feed allof the people that we're gonna.
We're gonna have on the planet.
- Yeah. And when somebody doeseat insects, they are actually
getting some pretty good nutrients.Polyunsaturated fatty acids,
essential amino acids, micronutrientsand other types of protein.
- Yeah. Many of the nutrientsthat we need to survive can be
(04:29):
supplied by insects.
- Which may be why in 2021,the EU approved mealworms and
locusts. Safer human consumption.And actually recently, more
recently, Italy has startedusing cricket flour, which is,
as you can guess, flour madefrom crickets and said to taste
like pumpkin seeds, hazelnuts,and a little bit like shrimp.
(04:50):
- Just a little bit like shrimp.There's also other positive aspects.
Right. The general thinking isit's. There's less environmental
impact from using insects asfood than, you know, than occurs
when we breed livestock.
- Yeah, yeah. And. And I thinkthat these are all reasons that,
you know, in the future it maybe more and more common that we
see patients eating insectsintentionally. But where it is
(05:13):
now, at least in America, mostpatients are exposed to ingesting
insects due to contamination.And here's a little disgusting
fact for all of you listening.The average eats about 2 pounds
of insects or insect parts ina year. And that's from the
center of Invasive SpeciesResearch. Not on purpose. This
is all contamination. So twopounds.
(05:35):
- And that's from the centerfor Invasive Species Research
right out of the Universityof California?
- Yes. And it's not just thiscenter that has done this research
on insects and food. The FDAactually has a food Defect levels
handbook where they outlinethat peanut butter and other
foods, well, peanut butterspecifically, they will only
allow an average of 30 or moreinsect fragments per a hundred
(05:56):
grams. Anything more than that,it's not safe per 100 grams.
- So 100 grams is, I don't know,three and a half ounces in that
26 ounce jar of peanut butterthat's sitting in my closet.
What are we talking about there?A lot of insect fragments that
the FDA like literally allows.Right.
- You can have 25 insect fragmentsper 3.5 ounces. But yeah, 30
is where we draw the line andactually hops, for anyone out
(06:20):
there who drinks beer, the averagethat they'll cut off before it's
unsafe for consumption is 2005.500 aphids per 10 grams.
- 10 grams is not a lot of hops.I gotta think, even though we're
making beer out of it, that'sa lot of aphids.
- So bugs, they're in our food.It's a brutal truth. But what
does this have to do with allergies?
(06:43):
- When we think about goingback to those respiratory allergies
with dust mites, right? That'snot the only way we're exposed
to dust mites. And that's whereit comes. Kind of brings us back
to what you mentioned earlier,right, Luke, this pancake syndrome,
or otherwise known as oral miteanaphylaxis. Tell us a little
bit about that.
- Like the name oral mite anaphylaxis.Suggests it's from ingesting
(07:05):
dust mites or storage mitesthat are commonly found in flour.
So this is flour that is usedfor pizza, pasta, cornmeal cake,
et cetera. It's really morecommon in tropical and subtropical
environments. But, yes, there'sdust mites in the flour. The
wheat flour is contaminatedwith dust.
- Mites, and people actuallydevelop or exhibit food allergy
(07:26):
symptoms after ingesting thedust mites that are contained
in this flower. And I guess,you know, mostly if the flour
is not, well, sealed or it'sexposed to a lot of moisture.
We know, you know, we've talkedabout how dust mites require
moisture to live, so I assumethat kind of goes hand in hand
with them being in the flourin the tropical area.
- Yeah. And they actually recommendthat to store wheat flour in
(07:48):
low temperatures or in the refrigeratorif this is something that may
affect you.
- I'm in Florida, so it probablywould affect.
- Oh, yeah, yeah. Oh, definitely.But it's a really interesting
syndrome. And so it technicallyis a dust mite allergy, though.
Right. The patient is eatingflour that has these mites in
it. So what does that mean,though, for patients who have
a respiratory dust mite allergyif they have flour that has mites
(08:10):
in it?
- Yeah, I think because we knowto diagnose this kind of oral
mite anaphylaxis, Right. Weneed to do, like, always a history
that equates ingestion of thesuspected food with symptoms.
So once we've equated ingestionof flour, we need to rule out
wheat allergy as opposed todust mite allergy that's in the
wheat. So, know, definitelytesting for wheat allergy is
(08:33):
important. But also then lookingat, you know, if someone has
respiratory symptoms, we shouldprobably be testing them for
specific ige to dust mites tosee if we can make that connection
to pancake syndrome. Again,this isn't super common, but
it does happen. And there'sbeen multiple cases reported
throughout the U.S. yeah.
- And this is one of those raresyndromes where we have, like,
(08:54):
an overlap between respiratoryand food allergies, where we
have the respiratory allergywith dust mite. And then if you
eat the dust mite, you mightexperience some food allergy
symptoms similar to pollen foodallergy symptom or similar to
pollen food allergy syndrome,which is a cross reaction between
pollen and some fruits and vegetables.But what exactly, Gary, in the
(09:15):
dust mite is causing this reaction?And why can they eat baked pizza,
baked cake?
- No, they can't actually somajor proteins that are associated
with this oral mite anaphylaxisare thought to be the tropomyosins.
And the tropomyosins are heatstable, heat resistant proteins
(09:36):
that are present in both uncookedand cooked versions of the foods.
- Yeah. And so you can't bakeaway the dust mites or the troptomyosin.
- But, you know, there's alsosomething interesting about this
pancake syndrome. There's evena subset of patients who have
pancake syndrome and it's relatedto exercise. So remember back
(09:58):
in our. I'm trying to rememberthe.
- Oh, our Olympic episode wasathletes.
- Yes, right, right. It wasour Olympic athletes and how
exercise can impact allergy.And we talked about the syndrome,
wheat dependent exercise inducedanaphylaxis. Well, this is another
wheat dependent exercise inducedanaphylaxis, except it's because
(10:19):
of the dust mites. So there'sa dust mite anaphylaxis pancake
syndrome that's related to exerciseas well. So a lot of interrelationships
here.
- We keep saying dust mites,but it's really that, that protein,
the tropomyosin that is causingthat reaction. And tropomyosin,
for those providers out therewho may not know it, is a muscle
(10:39):
contraction protein. And it'sactually found throughout life.
- Yeah, all eukaryotes. So fromhumans to dust mites to everything
in between, including shellfish.Right. Where we see those tropomyosins
that are very cross reactivewith the dust mite.
- Proteins, you're getting atwhat we were hinting at with
(11:00):
the shrimp earlier is in shellfishmeat, tropomyosin is actually
an abundant protein, and nearly20% of the total protein content
in shellfish is tropomyosin.And when it comes to allergic
sensitization to tropomyosin,it's seen in up to 80% of shellfish
allergic individuals.
(11:22):
- So let me just repeat that,Luke. So when people have, you
know, an individual, a patienthas a shellfish allerg, 80% of
the time, it's the tropomycinthat's actually driving that
allergy. And we also know that1 in 10 patients who are sensitized
to dust mites and have a dustmite allergy will also have a
shellfish or specifically ashrimp allergy. Correct?
(11:46):
- Yeah. And again, this is becausethat tropomyosin found in the
dust mite is very similar tothe tropomyosin found in the
shrimp. So out of the 10 patientsthat you have that Come into
your office who have a housedust mite allergy, one of those
patients may also react withshrimp.
- Exactly. Which is why doinga thorough allergy assessment
(12:06):
and history is very importantfor patients who have both respiratory
and food allergy like complaints.
- So you may have a patientthat you've clinically diagnosed
using clinical history and specificIgE testing as having a dust
mite allergy. And I know thatin a perfect world, people are
exposed to things, or an imperfectworld, people are exposed to
(12:27):
things that they may not know.But if we imagine. Imagine a
patient who has never toucheda shrimp in their life, if they
have been exposed to house dustmites and develop an allergy,
even though they haven't beensensitized to the shrimp directly
ImmunoCAST is brought to you byThermo Fisher Scientific, creators of
(00:03):
ImmunoCap specific IGE diagnosticsand FADIA Laboratory systems.
- I'm Gary Falcetano, a licensedand board certified PA with over
12 years experience in allergyand immunology.
- And I'm Luke lemons, with over6 years experience writing for
healthcare providers andeducating on allergies.
(00:25):
You're listening to ImmunoCAST,your source for medically and
scientifically backedallergy insights.
What do cockroaches, dust mitesand shrimp have to do with pancakes?
- Oh, it does not sound likea very good pancake mix.
- No, no, it doesn't. We're gonnago into that a little bit more later on.
But to give everyone listeninga hint, we're gonna be talking about
(00:46):
bug or insect allergies today.
But before we dive in to some ofthe lesser known ways pancakes that
insects may come in contact withpatients and cause reactions,
we'd be remiss to not some ofthe more conventional allergies
that insects may cause.
- Yeah, absolutely. So, you know,I think when we think about insects
(01:08):
and how they affect our healthand allergy, we typically think
of respiratory issues. Right.We think of rhinitis and asthma
and how exposure to cockroachand dust mites. Right. Are such
big drivers. Right. When you'resensitized to cockroaches and
dust mites, how much that actuallydrives our respiratory allergies.
But there's more to bug allergiesthan just that.
(01:30):
- Yeah. And I think that most ofthe providers listening, when they
think of insect allergies, theymight go straight towards bees
or vespids.
- Yeah, that's true.
- And that's common. But someproviders may not know actually
that a lot of those severereactions to bees and vespid
stings and their venom areactually underreported by patients.
And also that the venomimmunotherapy, in which you may
(01:51):
refer to an allergist, if you dohave a patient who had a severe
reaction, it's very successfulform of therapy.
- We've talked about this inprevious episodes. We had Dr. Golden
with us on our anaphylaxis andstinging insects episode back in
episode 27. I think we did oneourselves, episode 13 on stinging
insects. And it really is, it'svital that providers have that
index. Right. Of suspicion ofanytime we're seeing patients.
(02:14):
You know, part of that initialhistory should be, have you ever
had a systemic reaction to aninsect sting? Because people
don't report it.
- And I'm Glad you mentioned thepast episodes that we've done
because we've talked about insectsin the past and we've definitely
talked about em from a respiratorypoint of view with dust mites
and asthma. We've definitelytalked about them when it comes
(02:37):
to stinging insect venom. Andthen also Alpha Gal syndrome,
which isn't necessarily an allergyto an insect, but it's an allergy
that's caused by a tick bite.
- The tick is the vector forthe transmission. Right. So people
that are bitten by certain ticks,and we used to think these were
specifically the Lone Star tick,develop a sensitization to ALPH
and then develop what is knownas a delayed red meat allergy.
(02:58):
But it's not just the Lone Startick anymore. Right.
- Luke, this is probably a topicfor another episode, but there's
new ticks out there, new ticksare dropping that are causing
Alpha Gal. So the black leg dogor wood tick is common in Maine,
and then the Western black legtick is common in Washington. So.
- And we just saw a couple ofreports coming out of the CDC
of case reports from both ofthose areas implicating those
(03:22):
ticks. So, yeah, we'll have moreon that, I'm sure, in future
episodes. But the Alpha Galstory is far from.
- If you're interested in learningmore about alpha gal, episode 11
and episode 29, Gary and Idiscussed that. But outside of
bites, stings and inhalation,how else may patients react to
insects? And the answer that Iknow we don't really want to
think about is. Well, why don'tyou say, Gary?
(03:45):
- Well, so entomophagy or eds.
- Yes. So insects are closerto food than we think. Some
people eat insects on purpose,and some people eat insects
because of contamination. Andactually, when it comes to being
on purpose, it's really commonin Asia and African countries,
but it's gaining popularityin Europe.
- It is. I mean, as we see,you know, our global population
(04:07):
continues to expand. This isone of the areas that has been
really, you know, looked at asa potential, you know, new food
source to be able to feed allof the people that we're gonna.
We're gonna have on the planet.
- Yeah. And when somebody doeseat insects, they are actually
getting some pretty good nutrients.Polyunsaturated fatty acids,
essential amino acids, micronutrientsand other types of protein.
- Yeah. Many of the nutrientsthat we need to survive can be
(04:29):
supplied by insects.
- Which may be why in 2021,the EU approved mealworms and
locusts. Safer human consumption.And actually recently, more
recently, Italy has startedusing cricket flour, which is,
as you can guess, flour madefrom crickets and said to taste
like pumpkin seeds, hazelnuts,and a little bit like shrimp.
(04:50):
- Just a little bit like shrimp.There's also other positive aspects.
Right. The general thinking isit's. There's less environmental
impact from using insects asfood than, you know, than occurs
when we breed livestock.
- Yeah, yeah. And. And I thinkthat these are all reasons that,
you know, in the future it maybe more and more common that we
see patients eating insectsintentionally. But where it is
(05:13):
now, at least in America, mostpatients are exposed to ingesting
insects due to contamination.And here's a little disgusting
fact for all of you listening.The average eats about 2 pounds
of insects or insect parts ina year. And that's from the
center of Invasive SpeciesResearch. Not on purpose. This
is all contamination. So twopounds.
(05:35):
- And that's from the centerfor Invasive Species Research
right out of the Universityof California?
- Yes. And it's not just thiscenter that has done this research
on insects and food. The FDAactually has a food Defect levels
handbook where they outlinethat peanut butter and other
foods, well, peanut butterspecifically, they will only
allow an average of 30 or moreinsect fragments per a hundred
(05:56):
grams. Anything more than that,it's not safe per 100 grams.
- So 100 grams is, I don't know,three and a half ounces in that
26 ounce jar of peanut butterthat's sitting in my closet.
What are we talking about there?A lot of insect fragments that
the FDA like literally allows.Right.
- You can have 25 insect fragmentsper 3.5 ounces. But yeah, 30
is where we draw the line andactually hops, for anyone out
(06:20):
there who drinks beer, the averagethat they'll cut off before it's
unsafe for consumption is 2005.500 aphids per 10 grams.
- 10 grams is not a lot of hops.I gotta think, even though we're
making beer out of it, that'sa lot of aphids.
- So bugs, they're in our food.It's a brutal truth. But what
does this have to do with allergies?
(06:43):
- When we think about goingback to those respiratory allergies
with dust mites, right? That'snot the only way we're exposed
to dust mites. And that's whereit comes. Kind of brings us back
to what you mentioned earlier,right, Luke, this pancake syndrome,
or otherwise known as oral miteanaphylaxis. Tell us a little
bit about that.
- Like the name oral mite anaphylaxis.Suggests it's from ingesting
(07:05):
dust mites or storage mitesthat are commonly found in flour.
So this is flour that is usedfor pizza, pasta, cornmeal cake,
et cetera. It's really morecommon in tropical and subtropical
environments. But, yes, there'sdust mites in the flour. The
wheat flour is contaminatedwith dust.
- Mites, and people actuallydevelop or exhibit food allergy
(07:26):
symptoms after ingesting thedust mites that are contained
in this flower. And I guess,you know, mostly if the flour
is not, well, sealed or it'sexposed to a lot of moisture.
We know, you know, we've talkedabout how dust mites require
moisture to live, so I assumethat kind of goes hand in hand
with them being in the flourin the tropical area.
- Yeah. And they actually recommendthat to store wheat flour in
(07:48):
low temperatures or in the refrigeratorif this is something that may
affect you.
- I'm in Florida, so it probablywould affect.
- Oh, yeah, yeah. Oh, definitely.But it's a really interesting
syndrome. And so it technicallyis a dust mite allergy, though.
Right. The patient is eatingflour that has these mites in
it. So what does that mean,though, for patients who have
a respiratory dust mite allergyif they have flour that has mites
(08:10):
in it?
- Yeah, I think because we knowto diagnose this kind of oral
mite anaphylaxis, Right. Weneed to do, like, always a history
that equates ingestion of thesuspected food with symptoms.
So once we've equated ingestionof flour, we need to rule out
wheat allergy as opposed todust mite allergy that's in the
wheat. So, know, definitelytesting for wheat allergy is
(08:33):
important. But also then lookingat, you know, if someone has
respiratory symptoms, we shouldprobably be testing them for
specific ige to dust mites tosee if we can make that connection
to pancake syndrome. Again,this isn't super common, but
it does happen. And there'sbeen multiple cases reported
throughout the U.S. yeah.
- And this is one of those raresyndromes where we have, like,
(08:54):
an overlap between respiratoryand food allergies, where we
have the respiratory allergywith dust mite. And then if you
eat the dust mite, you mightexperience some food allergy
symptoms similar to pollen foodallergy symptom or similar to
pollen food allergy syndrome,which is a cross reaction between
pollen and some fruits and vegetables.But what exactly, Gary, in the
(09:15):
dust mite is causing this reaction?And why can they eat baked pizza,
baked cake?
- No, they can't actually somajor proteins that are associated
with this oral mite anaphylaxisare thought to be the tropomyosins.
And the tropomyosins are heatstable, heat resistant proteins
(09:36):
that are present in both uncookedand cooked versions of the foods.
- Yeah. And so you can't bakeaway the dust mites or the troptomyosin.
- But, you know, there's alsosomething interesting about this
pancake syndrome. There's evena subset of patients who have
pancake syndrome and it's relatedto exercise. So remember back
(09:58):
in our. I'm trying to rememberthe.
- Oh, our Olympic episode wasathletes.
- Yes, right, right. It wasour Olympic athletes and how
exercise can impact allergy.And we talked about the syndrome,
wheat dependent exercise inducedanaphylaxis. Well, this is another
wheat dependent exercise inducedanaphylaxis, except it's because
(10:19):
of the dust mites. So there'sa dust mite anaphylaxis pancake
syndrome that's related to exerciseas well. So a lot of interrelationships
here.
- We keep saying dust mites,but it's really that, that protein,
the tropomyosin that is causingthat reaction. And tropomyosin,
for those providers out therewho may not know it, is a muscle
(10:39):
contraction protein. And it'sactually found throughout life.
- Yeah, all eukaryotes. So fromhumans to dust mites to everything
in between, including shellfish.Right. Where we see those tropomyosins
that are very cross reactivewith the dust mite.
- Proteins, you're getting atwhat we were hinting at with
(11:00):
the shrimp earlier is in shellfishmeat, tropomyosin is actually
an abundant protein, and nearly20% of the total protein content
in shellfish is tropomyosin.And when it comes to allergic
sensitization to tropomyosin,it's seen in up to 80% of shellfish
allergic individuals.
(11:22):
- So let me just repeat that,Luke. So when people have, you
know, an individual, a patienthas a shellfish allerg, 80% of
the time, it's the tropomycinthat's actually driving that
allergy. And we also know that1 in 10 patients who are sensitized
to dust mites and have a dustmite allergy will also have a
shellfish or specifically ashrimp allergy. Correct?
(11:46):
- Yeah. And again, this is becausethat tropomyosin found in the
dust mite is very similar tothe tropomyosin found in the
shrimp. So out of the 10 patientsthat you have that Come into
your office who have a housedust mite allergy, one of those
patients may also react withshrimp.
- Exactly. Which is why doinga thorough allergy assessment
(12:06):
and history is very importantfor patients who have both respiratory
and food allergy like complaints.
- So you may have a patientthat you've clinically diagnosed
using clinical history and specificIgE testing as having a dust
mite allergy. And I know thatin a perfect world, people are
exposed to things, or an imperfectworld, people are exposed to
(12:27):
things that they may not know.But if we imagine. Imagine a
patient who has never toucheda shrimp in their life, if they
have been exposed to house dustmites and develop an allergy,
even though they haven't beensensitized to the shrimp directly
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