f85 Celery

Allergens within Food of Plant Origin

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  • Latin name: Apium graveolens
  • Family: Apiaceae
  • Common names: Celery, Celeriac, Celery root, Root Celery, Celery tuber, Knob Celery
  • Source material: Fresh roots and stalks
Food
A food, which may result in allergy symptoms in sensitised individuals.

Allergen Exposure

Geographical distribution
Celery was first mentioned about 1200 B.C. The pale-green, succulent stalks are eaten raw or cooked. The seeds are dried and used as a spice. As far as allergy is concerned, there is no definite distinction between the stalks, the seeds and the root, known as Celeriac and by other terms.
 
Environment
Celery root is not only consumed raw as fresh salad but also as a cooked vegetable and as a constituent of sauces and soups. Dried and powdered Celery root is widely used as an ingredient of spice mixtures. It is a good source of potassium.
 
Celery is used to treat hypertension in traditional oriental medicine. It helps to maintain healthy blood pressure and also helps kidneys function efficiently. This is evidently from 3 n-butyl phthalide, which also acts as a sedative. The tea made from seeds can aid gout sufferers.
 
Unexpected exposure
Celery has been used as a herbal infusion to induce abortions (1).
 
Allergens
Early allergen studies indicated the presence of specific IgE binding to Celery proteins of molecular weight of around 14 kDa, 15 kDa, 16 kDa, and 17 kDa (2-3). Celery was also shown to contain at least 3 distinct cross-reacting allergens: a homologue of Bet v 1, a homologue of Birch profilin (Bet v 2), and a group of proteins with a molecular-weight range of 46 to 60 kDa (4). These allergens cross-reacted not only with Birch and Mugwort pollen, but also with a number of other fruits and vegetables (5). The allergens were not classed as either heat-labile or heat-stable (6). Early studies did not necessarily differentiate between Root Celery (Celeriac) or stick Celery, possibly presuming the allergens to be similar.
 
Recently, a number of allergens have been identified and characterised.
 
Api g 1, the major allergen, a 16 kDa protein and a Bet v 1 homologue (7-13). Api g 1 was shown to be a heat-labile protein, but stable upon exposure to high voltage, high pressure, gamma rays, drying and powdering, and therefore having allergenicity potential as a spice (14).
 
A number of isoforms have been isolated, including Api g 1.0201. This allergen displays 72% sequence similarity to a previously identified Api g 1.0101 isoform. In general, the former isoform displays a weaker IgE-binding capacity than Api g 1.0101, as concluded from immunoblotting experiments (15).
 
Recombinant rApi g 1 has been cloned by a number of researchers (16-19).
 
Api g 3, a chlorophyll Ab-binding Protein.
 
Api g 4, a minor allergen, a 14.3 kDa protein, and a profilin (10, 11, 14, 20-26).
 
Celery profilin has been cloned and expressed in Escherichia coli (27). Profilin has also been isolated from the Celery tuber (28).
 
A lipid transfer protein (LTP) has been determined (29, 30).
 
Api g 5, a 60 kDa protein, a glycoprotein with homology to FAD-containing oxidases. This allergen may be a protein with cross-reactive carbohydrate determinants (CCD); and importantly, convincing evidence that IgE directed to CCD is capable of eliciting allergic reactions in vivo has been reported (31, 32). This allergen may be similar or identical to a 60 kDa allergen isolated in an earlier study (33).
 
The presence of CCDs (cross-reactive carbohydrate determinants) has been reported in other studies (11). Celery-allergic individuals have been shown to be monosensitised to CCD, with exclusively CCD-specific IgE (20). A report stated that IgE specific for CCD is common in Celery-allergic patients and can represent the major proportion of IgE against this food. Alpha 1, 3-fucose was shown to be an essential part of the IgE epitope, and immunoblotting inhibition indicated the presence of this carbohydrate determinant on multiple glycoproteins in Celery extract (34). Similarly, other studies have concluded that ubiquitous CCDs are important in allergy to Celery (and Zucchini) (7); and that, depending on the structure of the CCD-containing glycoproteins, CCDs can indeed be important epitopes for IgE; they may be clinically relevant allergens in certain patients and irrelevant in others (20).
 
In studies examining the prevalence of IgE against Api g 1, results varied from 59% of 22 patients who had positive DBPCFC to Celery (20), to 80% of 30 patients with pollen allergy reporting immediate allergy after ingestion of raw Celery (35) to 74% of a group of 23 patients with type 1 Celery allergy (4). The sensitisation rate to profilin was similar: 23%, 23% and 30% respectively. This is in contrast with other research reporting that 42% of Celery-allergic individuals were sensitised to Celery profilin (21), and a study reporting that 20% of all patients with pollen allergy were sensitised to the profilin in Celery (26). IgE to CCDs has been found to be present in sera of 55% (and was therefore identified as a major allergen) (20) and 27 % of the study group (35).
 
A major allergen of Celery, possibly the lipid transfer protein, has been shown to be heat-stable. Heating Celery tuber for 30 minutes at 100 degrees C did not deplete the immunoreactivity of the major allergens (36). Other studies have concurred: Celery remained allergenic even after extended thermal treatment (430.5 min/100C), indicating that Celery spice is allergenic for patients with an allergy to raw Celery (37). The in vitro immunochemical stability of 3 known allergenic structures of Celery, investigated for stability when processed by microwaving, drying, gamma irradiation, ultra-high pressure treatment and high-voltage impulse treatment, reported that the heat-stability of the known Celery allergens decreased in the following order: carbohydrate epitopes > profilin > Api g 1 (38). In a study of in vivo stability, EAST inhibition showed that heat resistance of Celery allergens decreases in the following order: CCDs > Api g 4 > Api g 1. Five of 6 patients with a positive DBPCFC to cooked Celery were sensitised to profilin and/or CCDs. The study concluded that in a subset of patients with a positive DBPCFC to cooked Celery, the CCD allergens remain allergenic even after extended thermal treatment (76.07 min/100 degrees C) and that Celery spice is allergenic for patients with an allergy to raw Celery. All patients undergoing DBPCFC with Celery spice (dried and powdered Celery) reported reactions comparable to symptoms observed with raw Celery challenges (37).

Potential Cross-Reactivity

An extensive cross-reactivity among the different individual species of the family could be expected and in fact does occur frequently (39).
 
In an early study of Celery allergy, in 20 patients, among whom the ingestion of Celery resulted in generalised urticaria and angioedema in 18, respiratory symptoms in 7, and anaphylaxis in 4, the main cross-reactivity was to pollen allergens in 16/20. Food allergy to other vegetables, mainly other family members and Apples, coexisted in 12 cases. Fourteen were allergic to Mugwort pollen and 9 to Birch pollen. The study suggested the presence of common antigenic epitopes (40). Similar results were reported in other studies (41-43).
 
Subsequently, Celery allergy was shown in a number of studies to be strongly associated with Birch and Mugwort pollen allergy, a phenomenon often referred to as “Birch-Mugwort-Celery syndrome” (6, 44), or "Celery-Carrot-Birch-Mugwort-spice syndrome” when Carrot and Spices are included (6, 45-47).  Cross-reactivity with other members of the Apiaceae family was reported to be more prevalent, the members including Anise, Fennel, Coriander, Cumin, Caraway, Carrot, Dill, Lovage and Parsley (48-52). The synrome is reported to occur more frequently in females (81.4%) than in males and may be severe, resulting in anaphylactic reactions (53).
 
Up to 70% of patients with tree pollen allergy display allergic symptoms when eating certain fruits and vegetables. Allergy to Celery brought about through sensitisation to Birch tree pollen occurs only in areas where Birch trees are common. In areas where no Birch trees grow, primary sensitisation takes place through other pollen allergens (e.g., Mugwort pollen). Birch pollen allergy and Celery allergy are closely related in Central Europe, whereas in Southern Europe the Mugwort-Celery type is predominant (18).
 
Allergy to Celery is often associated with a pollen allergy, and even if there are no overt symptoms of the pollen allergy, specific IgE may be found, usually to the pollen most common to that region; for example, in Sweden it is Birch, whereas in the area of Lyons in France, Ragweed, Mugwort and Compositae tend to be the culprits. An early study stated that the allergic sensitisation is strictly one-way, Celery-pollen: a patient allergic to Celery is likely to be sensitised to pollen, but not the other way around. But the reverse can occur: the presence of specific IgE to Celery is often found when the allergy is caused by Ragweed or Mugwort (54).
 
Allergy to other pollen may result in a variable degree of cross-reactivity with Celery allergy. Utilising skin-specific IgE tests and RAST inhibition experiments, an important cross-reactivity was found between the pollen of Platanus acerifolia (London Plane tree) and Hazelnut and Banana fruit, and an intermediate cross-reactivity with Celery and Peanut (55). Hop Japanese pollen may have possible links with Celery, Hop, and Sunflower pollens on skin-prick test (56).
 
Recent studies have demonstrated that cross-reactivity among Birch pollen, Mugwort pollen and Celery was due to at least 4 distinct cross-reacting allergens. Bet v 1, the major Birch pollen allergen, occurs in Celery, Apples, stone fruits, Carrot, nuts, Soybean and pollens of several tree species (4). Approximately 70% of patients who are allergic to Birch pollen may experience symptoms after consumption of foods from these groups (57). Two minor allergenic structures - profilin and cross-reactive carbohydrate determinants (CCDs) - were shown to have sensitised approximately 10-20% of all pollen-allergic patients and to be present in Celery and in grass pollen and weed pollen (4, 57). IgE-binding proteins related to the Birch pollen minor allergen Bet v 6 have been found in many plant foods, including Apple, Peach, and Carrot (57). The latter 2 allergens may be the ones indicated in a previous study that reported the presence of a group of proteins with a molecular range of 46 to 60 kDa, which were also present in Mugwort pollen (4).
 
The patterns may appear complex. For example, among sera of 61 patients with specific IgE to Mugwort pollen, 36 were positive for Celery and 23 had specific IgE to Birch pollen (2). Similarly, of 196 Birch pollen-hypersensitive patients with oral allergy syndrome (OAS), 195 had Apple and/or Hazelnut allergy, and 103 had Apiaceae sensitivity; only 1 patient had Apiaceae (Carrot, Celery, and Fennel) allergy alone. The study suggested that most Apiaceae determinants cross-react with Apple or Hazelnut determinants, whereas only some Apple or Hazelnut determinants cross-react with Apiaceae-allergenic determinants (58). Similarly, cross-reactivity has been reported between Celery and Zucchini, and it is stated that a specific association with Birch pollen allergy exists in allergy to Celery (mediated by Api g 1), but not in Zucchini allergy (7).
 
Although Mugwort and Birch pollen allergy are frequently associated with IgE-mediated hypersensitivity to Celery and spices, in a study of sera from 22 patients with the Mugwort-Birch-Celery-Spice syndrome, in a test for IgE binding to the spices Pepper and Paprika by immunoblotting, the IgE cross-reactivity in the Mugwort-Birch-Celery-Spice syndrome to the spices Pepper and Paprika was not caused by homologues of Bet v 1 and profilin (59).
 
The Birch pollen allergen Bet v 1 has a significant role in the cross-reactivity described. Celery Api g 1 has a 40% identity (60% similarity) to the major allergen of Birch pollen, Bet v 1 (16) and Birch pollen-allergic individuals frequently develop type I hypersensitivity reactions to Celery (60, 61). Api g 1 has been identified as the Celery homologue of the major Birch pollen allergen Bet v 1 (15). A number of studies have demonstrated that cross-reactions between Birch pollen, Celery, Carrot, and various fruit and vegetables are based on allergens related to Bet v 1 and Art v 1, the major allergens of Birch and Mugwort pollen, respectively (5, 19, 61-62).
 
Nevertheless, epitope differences between Bet v 1-related food allergens exist, indicating different degrees of cross-reactivity among these allergens (63). 
 
Similar results with other allergens have been reported: concurrent sensitisation to Mugwort and Birch pollen with Camomile may occur, and binding was inhibited by variable degrees by extracts from Celery, Anise, and pollen from Mugwort, Birch and Timothy grass. Profilins (Bet v 2) were not detected in the Camomile extracts (64).
 
A protein related to Bet v 1 was isolated from cells of the Madagascar periwinkle, and shown to also be present in Celery, but it had no allergenic characteristics (65).
 
Individuals may be allergic to Celery without allergy or sensitisation to Birch tree pollen; 8% of Swiss patients allergic to Celery were not sensitised to rBet v 1 or rBet v 2 (66). Similarly, in a study of sera from 4 patients showing strong immediate systemic reactions after contact or ingestion of raw Carrot, all the patients had significant levels of specific IgE to Carrot allergen, Dau c 1, a Bet v 1 homologue, but no specific IgE to Birch pollen was detected in any. The sera contained a single band of around 18 kDa in raw Carrot and in Celery (with a weaker reaction), but no reactive band was found with Birch pollen. The Carrot IgE-binding protein’s N-terminal sequence was homologous to that of Bet v 1 and to allergens previously described in Celery and other foods. The 4 patients studied were not sensitised to Birch pollen, and 3 of them tolerated fruit ingestion. The study indicated that a sensitisation to Dau c 1 induces IgE antibodies that do not cross-react with Birch pollen allergens (67).
 
Research has focused on the T cell response and epitope involvement influencing cross-reactivity between Birch pollen and Celery. In a study evaluating the T cell response to the major allergen Api g 1 in Celery, and the cellular cross-reactivity with its homologous major allergen in Birch pollen, Bet v 1, the latter allergen was identified as the most important T cell epitope for cross-reactivity with Api g 1. The study concluded that the activation of Bet v 1-specific Th2 cells by Api g 1, in particular outside the pollen season, may have consequences for Birch pollen-allergic individuals (68). However, a study investigating the IgE-binding capacity of 2 cross-reactive allergens, Apg1.0101 from Celery and Pru av 1 from Cherry, showed that the IgE-binding epitopes are highly patient-specific (69-70).
 
The panallergen profilin, an allergen homologous to Bet v 2, is particularly important in patients allergic to Celery with a Birch-Mugwort-Celery sensitisatio (4, 35, 71). Celery profilin has a high degree of identity with other plant profilin (71-82%) (27). Profilin is recognised by IgE from about 20% of Birch pollen- and plant food-allergic patients. In a study of the immunological properties of a number of profilins, including profilin from Celery (Api g 4) and Birch pollen (Bet v 2), in 43 of 49 patients (88%) pre-selected for an IgE-reactivity with Bet v 2, specific IgE-antibodies to the Celery protein was demonstrated in 80% of the sera. However, IgE binding profiles also indicated the presence of epitope differences among related profilins. Nevertheless, profilin from a number of plants (Pyr c 4, Pru av 4, Api g 4 and Bet v 2) presented almost identical allergenic properties in cellular mediator release tests (22). Profilin has also been detected in both Hazel pollen and Hazelnut extracts (23). A study suggested that Celery profilin appears to be more important in patients with an additional sensitisation to Mugwort pollen (11).
 
Other studies have demonstrated the importance of profilin in cross-reactivity between Celery, Mugwort, Birch and other plants, including numerous other species like Cynodon dactylon, Sorghum halopense, Poa pratensis, Ambrosia elatior, and Apple and Carrot (10, 24). Lolium perenne grass pollen was shown to contain profilin. In a grass pollen-sensitive population, patients with IgE to vegetables have been reported to have a high incidence of antibodies against profilin (72). However, cross-reactivity as a result of profilin may be variable.
 
Other studies have also reported on the presence of an approximately 60 kDa allergen in fruit and vegetables, resulting in cross-reactivity with the major Mugwort pollen allergen Art v 1. Pre-adsorption of Mugwort-allergic patients' sera with the 60 kDa Mugwort allergen led to a reduction of IgE binding to components of similar molecular weight present in Birch pollen, Timothy grass, Apple, Peanuts, and Celery extracts. The allergen was distinct from Bet v 1 and profilin and was reported to possibly represent a novel cross-reactive allergen in the oral allergy syndrome (33, 73). A 60 kDa Group 4 grass pollen allergen, recognised by 70% of patients sensitive to grass pollen, may be similar to or the same as that reported in previous studies that isolated a similar-size protein. In Timothy grass, Mugwort and Birch pollens, these allergens were located in the cell wall, and in Timothy grass and Birch pollen additionally in the cytoplasm. In Peanut, Apple, Celery, and Carrot, the allergen was detected only in cytoplasmic areas (74).
 
The association of Celery-Mugwort allergy with allergy to Mango fruit was also reported (52).
 
Celery contains a lipid transfer protein, which may result in cross-reactivity among a number of vegetables and fruits, including members of the Rosaceae family (Peach), cereals from the Gramineae family, Pistachio, Broccoli, Carrot, Tomato, Melon, and Kiwi. Many of these cross-reactivities may be accompanied by clinical food allergy, frequently including systemic reactions (30). It has been stated that in view of the high prevalence and severity of the allergic reactions induced, Hazelnut, Walnut, and Peanut should be regarded as potentially hazardous for patients allergic to lipid transfer proteins (75). In a study aimed at examining the relationship between Peach LTP-specific IgE levels and cross-reactivity to several non-Rosaceae plant-derived foods, results suggested that all allergenic determinants in LTP from vegetable foods other than Peach cross-react with Peach LTP determinants, whereas only some Peach LTP epitopes cross-react with allergenic determinants on botanically unrelated plant-derived foods (29).
 
A number of reports indicate cross-reactivity between Celery and Ragweed. (54, 61, 76)
 
Frequently, the occurrence of cross-reactive IgE antibodies is not correlated with the development of clinical food allergy. In particular, the clinical relevance of sensitisation to cross-reactive carbohydrate determinants (CCD) was reported to not be important (57). However, recently inhibition experiments with a purified carbohydrate moiety clearly showed that the IgE epitope mannose-xylose-fucose-glycan or a closely related structure is present in Celery and is important in patients with clinical allergy to Celery (20).
 
A study investigated the relationship between pollen sensitivity and sensitivity to food in Latex-allergic patients. Forty-four Latex-allergic patients, 24 of whom were also allergic to tree and/or grass pollen, and 25 pollen-allergic patients who were not allergic to Latex, were studied. Latex-allergic patients were most likely to have a positive skin test and a history of a reaction to Avocado or Banana, whereas patients with pollinosis only were most likely to have positive skin-specific IgE and a history of a reaction to Apple, Peach or Celery (77). Notably, healthcare providers who have coexisting risk factors, such as atopy and food allergies (Chestnuts, Bananas, Avocados, Passion fruit, Celery, Potatoes, and Peaches), have been reported to be at an even greater risk for severe allergic reactions following repeated latex exposure (78).

Clinical Experience

IgE-mediated reactions
The first case of allergic reaction to Celery root was reported in 1926 (79). Since then, a number of studies from across the world, and in particular from European countries, have documented the high prevalence of allergy to Celery, especially in association with cross-allergy to pollen (3, 4, 7, 34, 40, 46, 53, 54, 76, 80, 89).
 
Specific IgE to Celery may be present in an individual’s sera but without clinical sensitisation (4).
 
In Switzerland, about 40% of patients with food allergy are sensitised to Celery, some with severe anaphylactic reactions (87-88). Other studies have reported a higher prevalence of allergy to Celery, of 42% (90), and in 69% of a group of 32 patients with a history of Celery allergy, DBPCFC resulted in systemic reactions in 50% (11/22) (7). In a study from 1978 to 1982, 173 cases of food allergy were diagnosed in patients (predominantly adults) attending the University of Zurich. The most frequent food allergens were found to be Celery in 40.5%, Carrots (20%), Green beans (6%), eggs (21%), milk and dairy products (20%) and fish (12%) (91).
 
In France, 30% of 580 patients with food allergy were sensitised to Celery, as determined by serum-specific IgE. Sixty presented with severe, near-fatal reactions, in which the most common food implicated was Celery: 30% of severe anaphylactic reactions to food were thought to be due to Celery, according to patient histories (89).
 
In Germany, of 167 patients with a pollen-related food allergy, 70% were sensitised to Celery, based on serum- or skin-specific IgE, and 14% reported allergy to Celery (14).
 
In a Swiss/German study, 22 of 32 patients claiming to be allergic to Celery were positive on DBPCFC with Celery. Celery serum-specific IgE (> or = 0.7 kU/L) in patients with a positive DBPCFC result was detected in 73%; in 48%  to 86% for skin-specific IgE (> or =3 mm) with various commercial extracts; and in 96% for prick-to-prick tests with raw Celery. The positive predictive value of the skin-specific IgE and serum-specific IgE tests was between 87% and 96%, whereas the specificity and negative predictive values were poor. The study concluded that the skin- and serum-specific IgE methods proved to be reliable for the diagnosis of a relevant allergy to Celery in regard to sensitivity and positive predictive value, but not to specificity and negative predictive value (44).
 
In a German study, 20.8% of 1537 subjects reported symptoms to food. One quarter of the subjects (25.1%) were sensitised to at least 1 food allergen, as shown by skin-specific IgE tests, with Hazelnut (17.8%), Celery (14.6%), and Peanut (11.1%) being the most prevalent (83). A second German study, of 229 patients experiencing immediate-type allergy to 1 or more specific foodstuffs and diagnosed from 1983 to 1987, reported that Celery was responsible in 44.5%, followed by Carrots (14.4%) and Spices (16.6%) (53).
 
In a multi-centre Polish study, the greatest number of positive skin prick tests with food allergens were to nuts, Celery, Rye flour, Carrot, Strawberry, Pork and Beans (91). Twenty to forty percent of Polish children sensitised to Birch pollen were shown to have skin-specific IgE to Celery, Carrot, Potato, Tomato, Apple, Peach and Grape (84).
 
In an American study of 132 children aged 3-19 years, 58% reported food-allergic reactions in the past 2 years. The offending food was identified in 34 of 41 reactions, milk being the causative food in 11 (32%); Peanut in 10 (29%); Egg in 6 (18%); tree nuts in 2 (6%); and Soy, Wheat, Celery, Mango, or Garlic in 1 (3%) each (92).
 
In a study of 229 patients, showing an immediate-type allergy to 1 or more specific foodstuffs and diagnosed from 1983 to 1987, the most food allergens were found to Celery, with 44.5%, followed by Carrots (14.4%) and spices (16.6%). In 24 cases, Celery-spice sensitisation was responsible for severe anaphylactic reactions (53).
 
Celery can cause oral symptoms (aphthae, stomatitis, swelling of the lips or tongue, pharyngitis, hoarseness and laryngeal oedema) and can often also induce acute generalised symptoms, such as severe laryngeal oedema, bronchial asthma, urticaria or allergic shock (93). Oral allergy syndrome has been reported (16, 94) and the symptoms have been reported to be more marked in severity compared to reactions to other vegetables (95).
 
Symptoms, including oral allergy syndrome, may occur with cooked Celery. In a DBPCFC with cooked Celery, 5 of 11 patients reacted with oral allergy symptoms. During DBPCFC with Celery powder, 4 patients developed symptoms of oral allergy syndrome. One patient also had rhinoconjunctivitis and angioedema, and another patient responded with a flush and angioedema (37). Similarly, in 12 patients with a history of allergic reactions to raw or raw and cooked Celery, DBPCFC with raw Celery (n=10), cooked Celery (110 degrees C/15 min; n = 11), and Celery spice (n=5) was performed. Nine patients underwent an open mucosal challenge with 4 samples of canned Celery retorted at Co-values (cooking effect) of 7.45-76.07 (corresponding to the time periods in minutes at a thermal influence of 100 degrees C). Six out of 11 patients showed a positive DBPCFC to cooked Celery, and 5 out of 5 patients to Celery spice. The allergenicity of Celery was preserved for 4 patients with a positive DBPCFC to cooked Celery, even if Celery was treated at a Co-value of 76.07 (37).
 
In a study of 20 patients, the ingestion of Celery was responsible for generalised urticaria and angioedema in 18 and respiratory symptoms in 7. Four cases of systemic anaphylaxis were reported. Sixteen had concomitant pollen allergy. Food allergy to other vegetable products, mainly other Umbelliferae and Apples, coexisted with Celery allergy in 12 cases. Cosensitisation with Mugwort pollen (14 cases) and Birch pollen (9 cases) was found. The study reported that Celery allergens responsible for clinical sensitisation originate chiefly in the tuber and are at least partly thermally labile, and a higher incidence of allergic reactions to the root than the leaves was reported (40). In a similar study, the same author reported on 20 patients with Celery allergy and concomitant hypersensitivity to Mugwort and Birch pollen. He found that symptoms induced by eating Celery were attacks of urticaria and angioedema in 17 of the 20, respiratory complaints in 8, and systemic anaphylaxis with vascular collapse in 3 (47).
 
Laryngeal oedema and bronchospasm have been reported (3). A 54-year-old woman experiencing increasing difficulty breathing, with onset 3 hours after eating raw Celery that resulted in laryngeal oedema, has been described (96).
 
Celery and Parsley were shown to be responsible aetiological agents in 14 patients with severe attacks of angioedema and urticaria (97) and may have severe effects, with urticaria-oedema-anaphylaxis (76).
 
A number of studies have reported anaphylaxis following the ingestion of Celery (98-101). A French study reported that the food products most frequently incriminated in anaphylactic reactions were not of a primary nutritional importance: Celery (30%), crustaceans (17%), fish (13%), Peanuts (12%), Mango (6%), and Mustard (3%); but they are often hidden allergens in commercial foods. In a group of 580 patients, sensitisation to food products was demonstrated, in decreasing order of frequency, as follows: Wheat (39%), Peanuts (37%), Crab (34%), Celery (30%), and Soy (30%). The authors reported that the frequency of sensitisation to various foods had changed and that sensitisation to a number of foods, including Celery, was definitely increasing (89).
 
In 102 patients with an initial diagnosis of idiopathic anaphylaxis, tested with a battery of 79 food-antigen skin-specific IgE tests, 32 patients (31%) had positive tests to 1 or more food antigens, and in 5, subsequently eating a food that had elicited a positive test provoked an anaphylactic reaction. Celery was one of the foods implicated (102).
 
Celery has been associated with food-dependant exercise-induced anaphylaxis (FDEIA) (103-104). Four patients with Celery FDEIA were described in a study: 2 developed symptoms when Celery ingestion preceded exercise, and 1 when exercise preceded Celery. A fourth, a woman 23 years of age, abruptly developed a diffuse erythematous rash, oedema, syncope, and sustained hypotension while exercising. Within 20 minutes, a sensation of throat tightness occurred, along with warmth, dizziness, blurred vision, and swelling of the extremities. She vomited once, then developed a several-second syncopal episode. She experienced abdominal pain (105).
 
Celery has also been reported to be responsible for dermatitis (106), and particularly for occupational dermatitis in gardeners (107).
 
Other reactions
Phytophotodermatitis is a phototoxic dermatitis resulting from contact with psoralen-containing plants such as Celery, Limes, Parsley, Figs, and Carrots (108-109). A number of studies have reported that Celery may result in pytodermatitis (108-109). Skin reactions have been reported in grocery workers (110-111). An epidemic of dermatitis was reported: a vesicular, peeling rash due to occupational exposure to blanched Celery. A phytophototoxic dermatitis due to exposure to blanched Celery was diagnosed (112).  An outbreak of phytophotodermatitis among 11 workers in a Celery harvest in southern Israel was reported. It was found that the Celery harvested in the south of the country contained 84 micrograms/g fresh weight (f.wt.) total psoralens, as compared to 35 micrograms/g f.wt. in Celery harvested in the north of the country at the same time. A late harvest in the south of the country was incriminated as the cause of the unusually high levels of psoralens in the Celery of that year (113).
 
Berloque dermatitis is a variant of phytophotodermatitis and is caused by high concentrations of psoralen-containing fragrances, most commonly oil of bergamot. Berloque dermatitis is rarely seen today because of the removal of these fragrances from most cosmetic products in the United States. There is a report, however, of a group of patients still at risk for berloque dermatitis. These patients use the colognes "Florida Water" and "Kananga Water," which are popular in Hispanic, African-American, and Caribbean populations. These fragrant waters are used for spiritual blessing, treating headaches, and personal hygiene (114).
 
Reactions may occur following Celery ingestion and exposure to sunlight, as described in a 65-year-old woman who developed a severe, generalised phototoxic reaction following a visit to a suntan parlour. Further interrogation showed that she had consumed a large quantity of Celery root 1 hour earlier (115-116). Similarly, ingestion of Celery soup can result in severe phototoxicity during PUVA therapy, even if the soup is cooled (117).
 
A new Celery cultivar (a result of plant breeding to produce a more pest-resistant variety) was responsible for significant incidences of phytophotodermatitis in grocery employees (118). Adverse reactions may not be due to Celery per se:11 men developed a severe phototoxic dermatitis of the hands and forearms after harvesting Celery infected with Sclerotinia sclerotiorum (119).
 
Celery in a herbal product was reported to increase the risk of bleeding or potentiate the effects of warfarin therapy (120).
 
Compiled by Dr Harris Steinman, harris@zingsolutions.com

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