f92 Banana

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• Latin name: Musa acuminata / sapientum / paradisiaca
• Family: Musaceae
• Common names: Banana, Plantain
• Source material: Ripe fresh fruit

Allergen Exposure

• Mus xp 1, a profilin (2-7).
   
• Mus a Glucanase, (from M. acuminate), a member of the beta-1,3-glucanase family (8-11).
   
• Mus xp Chitinase, a 32-33 kDa protein, a class 1 chitinase, a hevein-like protein (6,12-14).
   
• Mus xp Hevein, a hevein-like protein (12).
   
• Mus xp TLP, a thaumatin-like protein (15).

IgE binding to the recombinant Banana profilin was demonstrated in 7 of 16 Banana-allergic subjects (5).

Although no other allergens have been characterised to date, there have been a number of antigenic proteins identified. In a Latex-allergic patient study, 16 allergenic components were identified in Banana, with molecular weights ranging from 17 to 128 kDa. Two were considered to be major allergens: a 33 kDa protein was detected in 15 of 19 sera (88%), and a 37 kDa in 13 of 19 sera (76%) (6). The 33 kDa allergen may be a chitinase similar to that reported in a study describing the isolation of 32 kDa and 34 kDa allergens, class I chitinases with a hevein-like domain, shown to be major allergens in Banana fruit. The 2 purified allergens detected Banana skin reactivity in more than 50% of 15 Banana-allergic patients (13,16). Proteins of 40, 52, 58, 88 and 94 kDa have also been detected (2). Other studies have isolated from Banana extract a 40 kDa protein showing strong IgE binding, and allergens of 52, 58, 88 and 94 kDa were detected (17). In a patient sensitised to Avocado, but not to Latex or pollen, a single allergen of 70 kDa was detected (2).

Among sera from 22 Latex-allergic patients, 10 (45%) recognised 14 allergens in Banana. The most frequently identified Banana allergens were 23, 32, 36, 39 and 47 kDa proteins. Skin reactivity to Banana was found in 14 of 18 Latex-allergic patients studied, and Banana RAST in 12 of 14 patient sera tested (18).

The pulp of ripe Bananas contains an abundant thaumatin-like protein (TLP) (19). Thaumatin allergens have allergenic potential, but in Banana, TLP may be different and was not evaluated. Although the Banana thaumatin-like protein adopts an overall fold similar to that of thaumatin and thaumatin-like PR-5 proteins, and TLPs have antifungal properties, the Banana TLP was apparently devoid of antifungal activity. Pulp of Plantains also contains a very similar TLP, which is even more abundant than its Banana homologue (20).

One of the predominant proteins in the pulp of ripe Bananas and Plantains has been identified as a lectin. The clinical relevance of this Banana lectin to food safety is at present unknown (21).

Potential cross-reactivity
An extensive cross-reactivity among the different individual species of the genus, basically Banana and Plantain, could be expected (22).

Allergy to Latex is a increasing occupational and public health problem. Through the analysis of IgE antibodies against Latex, the prevalence of Latex sensitisation in the general population has been estimated to be approximately 4-7% (23). Certain groups are at higher risk. Approximately 24-60% of patients with spina bifida may be sensitised to Latex. Between 3 and 25% of healthcare workers may be sensitised (24-25). Other high-risk groups include greenhouse and rubber workers. Approximately 42%-50% of patients with Latex allergy have hypersensitivity to some foods; Avocado, Banana, Chestnut and Kiwi are those most frequently detected (26-38). In a study examining food items that led to anaphylactic reactions in Latex-allergic individuals, several patterns of cross-reactivity have been demonstrated: Banana and Avocado; Banana, Avocado and Buckwheat; and Banana, Avocado and Tomato (39). Furthermore, cross-reactivity may occur between Banana and Avocado without concomitant sensitisation to Latex (40).

A number of panallergens may be involved in Latex-fruit cross-reactivity. Banana, Avocado, Chestnut and Kiwi are the most frequently implicated foods, but associations with several other fruits and vegetables have been reported. The allergen responsible for most cases of this syndrome is an isolated hevein (Hev b 6.02), the amino-terminal fragment of prohevein, but not the 31 kDa endochitinase. The homologous protein in Banana is Mus xp Hevein (12,41). This panallergen has recently been shown to occur in Custard apple, with affected individuals also experiencing anaphylaxis to Banana (42). Endo-beta-1,3-glucanase, the Banana glucanase, may account for some of the IgE-binding cross-reactivity frequently reported in patients with Latex-fruit syndrome (9). This allergen has also been shown to occur in Olive (Ole e 9), Ash and Birch pollens, and in Tomato, Potato, Bell pepper and Latex (10).

Approximately 45% of Latex-allergic individuals are also allergic to Banana, Kiwi and Avocado (35,43-44). In a study of 47 Latex-allergic patients, immunological reactivity to foods was found in 33. Positive Banana SPT was demonstrated most frequently with Avocado (53%) and Banana (38%) (35). In another study, 8 of 16 Latex-allergic patients (50%) reported symptoms after eating Bananas, and skin reactivity was found to Banana in 5 of 14 patients (36%). Banana RAST results were positive in 12 of the 19 patients (63%). Seventeen of the 19 patients (89%) exhibited specific Banana IgE antibodies (6).
Other studies have had similar findings. Among 82 adult patients with Latex allergy, Banana skin reactivity was found in 17 (45).

Not all Latex-allergic individuals are also allergic to Banana. In a study examining the sera of 47 Latex-allergic individuals by RAST, 66% were shown to be positive to Latex and 55% to Banana. Of the 31 Latex-positive sera, 25 were also Banana-positive. Skin reactivity to Banana was found in 11 of the 31 patients tested, and symptoms after eating Bananas were reported by 16 (52%) of the 31 patients. Cross-reactivity between Banana and Latex was demonstrated in inhibition studies and other studies (46). Similarly, in 2 children with Latex hypersensitivity, Banana SPT and SPT to a number of other fruits were positive, but the children presented no symptoms after ingestion of these fruits (47).

The association between Latex and Banana allergy has been shown to be due to a class I chitinase panallergen (13,16,48). In a study of patients allergic to Latex, 9 of 15 sera with IgE to hevein showed IgE binding to 32 and 33 kDa Banana proteins. The 33 kDa protein showed over 90% identity to endochitinases of several plants (14). The role of chitinase has been demonstrated in other studies (49). The Banana, Avocado, and Chestnut chitinases share 65-70% sequence identity with the Latex hevein chitinase (50). Therefore, although Banana contains a number of allergens, individuals allergic to the class I chitinase allergen in Banana will likely be cross-reactive with other class I chitinase-containing foods, e.g., Avocado, Chestnut, Cherimoya, Passion fruit, Kiwi, Papaya, Mango, Tomato and Wheat (these allergens are heat-inactivated and appear to be activated by ”stress” to the plant) (51). Chitinases have been shown to play a major role in the cross-reactivity between Banana, Chestnut and Kiwi (52).

The corollary holds, that in Banana-allergic children (or children with allergies to other fruits), co-existing Latex allergy should be considered, in particular in cases of urticaria or anaphylaxis for which the cause is unknown (32,53). Among 57 fruit-allergic patients, immunologic Latex sensitisation occurred in 49 (85.9%). Six out of 57 (10.5%) suffered from clinically relevant Latex allergy. In all patients, clinical symptoms to fruits preceded a history of Latex allergy. The fruits most often associated were Melon, Peach, and Banana (54).
Banana contains a profilin panallergen. Banana profilin has been demonstrated to have a 71-84% sequence identity to other pollen and ingested profilins. Cross-reactivity between pollen and exotic foods containing profilin is possible (5). Ten percent to 15% of Birch pollen-allergic individuals have IgE antibodies to the 35 kDa minor Birch pollen allergen, and there is cross-reactivity with proteins of comparable size from Litchi, Mango, Banana, Orange, Apple, Pear and Carrot (55). In a study of Birch pollen allergy, hypersensitivity to Bet v 2 was strongly associated with clinical allergy to citrus fruits, Melon and Watermelon, Banana, and Tomato. The efficacy of a history of allergy to gourd fruits, citrus fruits, Tomato, Banana, or a combination thereof as a means of detecting profilin-hypersensitive patients was 85% (41/48). The study concluded that in clinical settings in which laboratory investigations are not easy to carry out, allergy to Melon, Watermelon, citrus fruits, Tomato, and Banana can be used as a marker of profilin hypersensitivity once a sensitisation to Natural rubber latex and lipid transfer protein is ruled out (7,56).

In some instances, cross-reactivity has been described for which a panallergen had not been determined. In individuals sensitised to Ficus allergens, sensitisation to Kiwi fruit, Papaya, and Avocado, as well as to Pineapple and Banana, may occur (57). Sensitisation to Ficus benjamina Latex has been shown to be specifically associated with positive skin tests to fresh Fig (83%), dried Fig (37%), Kiwi fruit (28%), Papaya (22%), Avocado (19%), Banana (15%), and Pineapple (10%). This cross-reactivity is mediated at least in part by the thiol proteases ficin and Papain (58).

Similarly, sensitisation to the Latex of F. benjamina, H. brasiliensis, breadfruit and Banana was demonstrated in a patient allergic to Banana, F. benjamina and breadfruit. RAST inhibition studies showed that IgE antibodies to breadfruit Latex cross-reacted more strongly with Latex of H. brasiliensis and Banana than it did with Latex of F. benjamina (59). Two of 4 patients with an allergy to Ficus benjamina had a cross-allergy to Latex and the associated cluster of tropical fruit (Banana, Kiwi, Avocado) and Chestnut, implying that the panallergen chitinase is responsible for these items cross-reacting (60).

A positive allergenic correlation between Platanus (London plane tree) pollen and Hazelnut, Peanut, Banana and Celery has been described. RAST inhibition experiments indicated an important cross-reactivity among the pollen of Platanus acerifolia and Hazelnut and Banana fruit, and an intermediate cross-reactivity with Celery and Peanut as foods (61). Whether this cross-reactivity occurs as a result of the panallergen profilin was not determined.

In a study of 53 patients (19 positive on a DBPCFC) with Melon allergy, the most common foods associated with this allergy were Avocado (n=7), Banana (n=7), Kiwi (n=6), Watermelon (n=6), and Peach (n=5) (62).

Similarly, in a study investigating the prevalence of Avocado allergy, in 100 consecutive atopic patients with allergic rhinitis, 4 reported similar symptoms upon eating Banana (63).

In 11 Greek patients studied for allergy to Grape, wine, or other Grape products, other foods that induced anaphylaxis were Apples (54.5%), Cherries (18.6%), Peaches (18.6%), and Bananas (9.3%). Potential allergens were not investigated (64).

Associations between weed pollen allergy and hypersensitivity to certain kinds of food have also been observed, such as the Ragweed-Melon-Banana association (65). The panallergen was not identified. Goosefoot profilin has been shown to be inhibited by Banana by 68% (66).

Clinical Experience

IgE-mediated reactions
Banana may commonly induce symptoms of food allergy in Latex-sensitised individuals, but may also induce symptoms of food allergy in non-Latex sensitised individuals (2,67-69). Allergenicity of Banana increases with ripeness. Case reports describe a wide heterogeneity of responses to Banana (4). For example, in a study of 4 patients who were Banana-allergic, 1 reported itching of the mouth and throat, followed 30 minutes later by urticaria, angioedema, and hypotension, a second reported oral itching (OAS) only, and a third experienced urticaria, conjunctivitis and OAS. One patient was co-sensitised to Avocado, but not to Latex or pollen. One patient worked with Bananas (4).

In one of the earliest reports of adverse reactions to Banana, 2,067 allergic patients studied in 1968-1969 included 36 patients who complained of various symptoms after eating Banana. Among these symptoms were itching throat, “gassiness” and indigestion, cramps, diarrhoea, vomiting, sore mouth or tongue, “canker sores”, swollen lips, wheezing, hoarseness, urticaria and other rashes, and angioedema (67). Another report indicates that adverse reactions may include oral allergy syndrome, urticaria and, in severe instances, anaphylaxis (5).

In 142 adults among 7,698 patients visiting an outpatient clinic and reporting sensitisation to foods, 120 experienced clinical symptoms after consumption of 1 or more foods. The most frequently recorded symptoms were urticaria/angioedema (70%), oral allergy syndrome (54%), asthma (37%) and anaphylaxis (27.5%). Banana sensitisation occurred in 12 patients (70). In a cross-sectional, descriptive, questionnaire-based survey conducted in Toulouse schools in France to determine the prevalence of food allergies among schoolchildren, it was reported that, out of 2,716 respondents, 192 self-reported a food allergy, but that there was only a single reported case of allergy to Banana (71). A study was conducted at 17 clinics in 15 European cities to evaluate the differences among some Northern countries regarding what foods, according to the patients, elicit hypersensitivity symptoms. It was reported, based on a questionnaire concerning 86 different foods, that among 1,139 individuals, Banana was the 38th most reported food allergen, resulting in adverse effects in 14% (72). In a Japanese survey of 1,383 patients concerning self-reported severe food allergies, 319 patients reported food allergy, of whom 9 (2.8%) reported allergy to Banana (73). Of 3,025 children with asthma followed up at a clinic in Ankara, Turkey, only 2 were skin prick test positive for Banana (74). In Delhi, India, of 216 asthmatics with food sensitisation, skin prick tests were positive to Banana in 11 (75). In an Indian study of 24 children, aged 3 to 15 years with documented deterioration in control of their perennial asthma, IgE antibodies to Banana were found in 20 (83%) (76).

Banana allergy may occur early in life, as reported in 2 infants. A 6-month-old girl developed vomiting, generalised urticaria with erythema, and wheezing an hour after ingesting fresh Banana with yogurt.  IgE antibody level was 1.97 kUA/l. This was the third time she had ingested Banana. The second patient was a 6-month-old boy who developed urticarial rash on his whole body and erythema around the lips 1 hour after eating fresh Banana (with yogurt) for the first time. His mother had frequently eaten Banana since the baby’s birth, and she had been breastfeeding him. IgE antibody level was 1.25 kUA/l. The authors speculated that sensitisation may have occurred through the mother’s breast milk (77). Similarly, a 6-month-old boy with mild eczema developed 30 minutes after ingestion of a spoonful of mashed fresh Banana pulp, urticarial rash with erythema on the face and neck, extending over the whole body. He had been breastfed only, and this was the first time he ate Banana. He was show to have IgE antibodies against Avocado and Banana, but not to Latex or pollen (40). A 5-month-old boy suffered 3 episodes of generalised urticaria 20 minutes after the ingestion of a fruit purée containing Apple, Banana and Orange. Skin testing was positive for Banana and Chestnut. IgE antibody levels to Banana was 58 kUA/l, to Orange
9.7 kUA/l, to Chestnut 5.6 kUA/l, and to Latex 1.6 kUA/l. However, Orange, Apple and Latex products were well tolerated. He had never eaten Chestnut. The authors of reports of Banana-allergic infants suggest that the route of sensitisation may have been via placenta, breast-milk, inadvertent oral intake of food, or even via inhalation (40,78).

Anaphylaxis may occur to Banana (42,46, 68,79-80). A 15-year-old girl developed anaphylactic shock, asthma, angioedema, and urticaria after eating a Banana. She had eaten Banana 2 weeks earlier without adverse effects (81). Anaphylaxis was reported in a 32-year-old woman. She experienced swelling of her lips, developed severe oro-pharyngeal symptoms and generalised urticarial rash, and had difficulty breathing. Skin reactivity to Banana and Kiwi was demonstrated. Serum Banana RAST was 0.68 kUA/l. She had no Latex-associated symptoms (82). A 33-year-old woman with multiple episodes of anaphylaxis after ingestion of Apple, Banana and Lychee was described. Skin prick tests for Apple and Banana were positive. She was allergic to fruit without concomitant allergy to other common airborne/contact allergens (68). Significantly, individuals who have developed anaphylaxis to Banana may be negative to commercial skin tests (79). A 6-year-old boy presented with a history of cutaneous and respiratory reactions to Banana and Avocado and was Latex-allergic; he was shown to have high IgE antibody level to Latex, equivocal IgE to Avocado and Chestnut, and no IgE to Banana or Kiwi fruit. However, skin sensitisation was demonstrated to Banana, Avocado and Chestnut (83).

Anaphylaxis has been described in a 3-year-old boy with associated Latex allergy. He had undergone 5 successive surgical operations during the first months of life and had had eaten Banana previously without any untoward effects. He developed generalised urticarial rash, difficulty in breathing, and oro-pharyngeal symptoms, including itching and swelling of the lips, after eating a Banana. On interrogation, it was found that swelling of the lips had occurred after blowing up rubber balloons; and a week later, periorbital oedema occurred after he touched a balloon. Banana SPT was positive, and IgE antibody level was 6.10 kUA/l. For Latex, it was 5.2 kUA/l (84).
Among 107 cases reported in 2002 to the French Allergy Vigilance Network, 59.8% involved anaphylaxis, 18.7% systemic reactions, 15.9% laryngeal angioedema, and 5.6% serious acute asthma. Latex-fruit was the fourth-most-common cause (9 patients), following Peanut (n=14), nuts (n=16), and shellfish (n=9). In the Latex-fruit group, the following were involved: Avocado (n=4), Kiwi (n=2), Fig (n=2), and Banana (n=1) (85).

In Latex-fruit cross-reactivity, the expression of adverse reactions to the implicated allergens may not occur concomitantly. For example, a 48-year-old female nurse with asthma and rhinitis developed contact urticaria to Latex gloves, but only two years later developed glottic oedema after the ingestion of Chestnuts, and only subsequently experienced adverse effects to Banana and Kiwi (generalised urticaria). Level of IgE antibodies to Latex was 49 kUA/l, Chestnut 3.5 kUA/l, Kiwi 1.5 kUA/l and Banana 0.86 kUA/l. Skin prick tests were positive (52).
Banana may be a “hidden” allergen. An IgE-mediated reaction to a Banana-flavoured drug additive was described in an 8-year-old girl, who developed oral itching with wheals over her face and trunk and angioedema on both eyelids within 1 hour of her first oral dose of penicillin containing a Banana essence as a flavouring additive. Tests for penicillin allergy were negative, but  IgE antibody level to Banana was positive (1.25 kUA/l). The presence of Banana proteins in the Banana essence was demonstrated (86). Similarly, a 42-year-old woman, with a history of 8 episodes of angiooedema over 2 years from Latex gloves or from eating Banana, developed similar symptoms while working on a production line of a company manufacturing a natural Banana hair conditioner. Skin prick was positive to Latex, Banana, Cucumber, Avocado, Kiwi, and Banana hair conditioner (87).

Adverse effects to Banana may manifest only in the skin. Symptoms include contact urticaria (88), urticaria-angioedema (89), and worsening of eczema (46). In a study investigating the prevalence of Natural rubber latex sensitisation and allergy in 74 children with atopic dermatitis, 12 had circulating IgE antibodies to Latex. Twenty children without proven Latex sensitisation showed increased food-specific IgE, most frequently to Potato, Banana, and Chestnut (90).

Other reactions
Banana has been reported to precipitate migraine in susceptible individuals (91-92). This may result from the normal presence of vasoactive substances such as serotonin and tyramine.

A forty-seven-year-old female was described who had experienced 3 attacks of acute pancreatitis after eating Banana. Elevated serum and urine amylase levels returned to normal in parallel with the clinical symptoms. Total serum IgE was 644 kU/l, and Banana-specific IgE antibody level was 2.18 kUA/l. Endoscopic examination of the upper digestive tract showed the ampulla of Vater swollen and edematous. Biopsy specimens showed mast cells accumulating in mucosa and submucosa (93).

Compiled by Dr Harris Steinman, developer of Allergy Advisor, http://allergyadvisor.com

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• References