While almond-specific IgE-mediated food allergies have traditionally been equated
with other tree nut allergies, outcomes of oral food challenges to almond and the
utility of clinical testing to predict IgE-mediated almond hypersensitivity is not
well known. To describe almond oral challenge outcomes and assess the predictive value
of clinical testing. 603 almond challenges performed for 590 patients, aged 1 to 66
years, were analyzed from Massachusetts General Hospital allergy practices. Reactions
were graded using the Niggemann and Beyer allergic reaction grading system and the
Sampson 2006 NIAID anaphylaxis definition. Almond challenges included 545 passes (92%),
15 (3%) indeterminates, and 30 (5%) failures, in contrast with 31% challenge failures
for other foods. Most reactions were mild; 21 (4%) had Grade 2/3 allergic symptoms,
and 3 (0.5%) had anaphylaxis. Median almond-specific IgE was 0.89 kU/L (range: <0.35,
>100), median skin prick test (SPT) was 4.0 mm (0, 28), and 475 subjects (81%) were
sensitized to almond. Failure was associated with higher almond-specific IgE (p<0.001),
larger almond SPT (p=0.001), higher peanut IgE (p=0.003), and a history of almond
reaction (p<0.029). Almond-specific IgE, almond SPT, and age at challenge combined
demonstrated good predictive value for Grade 2/3 allergic reactions by ROC analysis
(AUC 0.83). The proportion of failed almond challenges (5%) was low in contrast with
other allergens, suggesting that some almond challenges may be safely conducted with
higher patient-to-staff ratios or potentially introduced at home. Though reactions
are usually uncommon and mild, anaphylaxis is possible with high almond sensitization.