doi: 10.1111/j.1365-2222.2012.04071.x Clinical & Experimental Allergy, 42, 1529–1539 ORIGINAL ARTICLE Allergens © 2012 Blackwell Publishing Ltd Lipid transfer protein syndrome: clinical pattern, cofactor effect and profile of molecular sensitization to plant-foods and pollens M. Pascal 1,2 , R. Mun ˜ oz-Cano 2,3,4 , Z. Reina 2 , A. Palacı ´n 5 , R. Vilella 1,2 , C. Picado 2,3,4 , M. Juan 1,2 , J. Sa ´nchez-Lo ´pez 2,3,4 , M. Rueda 3 , G. Salcedo 5 , A. Valero 2,3,4 , J. Yagu ¨e 1,2 and J. Bartra 2,3,4 1 Servei d’Immunologia, Centre de Diagnòstic Biomèdic (CDB), Hospital Clínic, Barcelona, Spain, 2 Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 3 Unitat d’ Allèrgia, Servei de Pneumologia, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain, 4 Centro de Investigaciones en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain and 5 Centro de Biotecnología y Genómica de Plantas (UPM-INIA), Madrid, Spain Clinical & Experimental Allergy Correspondence: J. Bartra, MD, PhD. Servei de Pneumologia i Alle `rgia Respirato `ria, ICT, Hospital Clı ´nic C/Villarroel, 170, Esc 6 – Pl. 0, Barcelona 08036, Spain. E-mail: jbartra@clinic.ub.es Cite this as: M. Pascal, R. Mun ˜oz- Cano, Z. Reina, A. Palacı ´n, R. Vilella, C. Picado, M. Juan, J. Sa ´nchez-Lo ´pez, M. Rueda, G. Salcedo, A. Valero, J. Yagu ¨e and J. Bartra, Clinical & Experimental Allergy, 2012 (42) 1529–1539. Summary Background Multiple plant-food sensitizations with a complex pattern of clinical manifes- tations are a common feature of lipid transfer protein (LTP)-allergic patients. Component- resolved diagnosis permits the diagnosis of the allergen sensitization profile. Objective We sought to clinically characterize and describe the plant-food and pollen molecular sensitization profile in patients with LTP syndrome. Methods Forty-five subjects were recruited, after being diagnosed with multiple plant- food allergies sensitized to LTP, but not to any other plant-food allergen, according to the molecular allergen panel tested (Pru p 3 (LTP), Pru p 1 (Bet v 1-like), Pru p 4 (profilin) and those included in a commercial microarray of 103 allergenic components). IgE-medi- ated food-allergy symptoms and pollinosis were collected. Patients were skin prick tested with a plant-food and pollens panel, and specific IgE to Tri a 14 was evaluated. Results A heterogeneous group of plant-foods was involved in local and systemic symp- toms: oral allergy syndrome (75.6%), urticaria (66.7%), gastrointestinal disorders (55.6%) and anaphylaxis (75.6%), 32.4% of which were cofactor dependent (Non-Steroidal Anti- inflammatory Drugs, exercise). All tested subjects were positive to peach and Pru p 3, Tri a 14 and to some of the LTPs included in the microarray. Pollinosis was diagnosed in 75.6% of subjects, with a broad spectrum of pollen and pollen-allergen sensitization. Plane tree and mugwort were the statistically significant pollens associated with Pru p 3. Conclusions and Clinical Relevance Several plant-foods, taxonomically unrelated, inde- pendent of peach involvement, are implicated in LTP syndrome. Local symptoms should be evaluated as a risk marker for anaphylaxis because they are frequently associated with cofactor-dependent anaphylaxis. The association of these symptoms with pollinosis, especially plane tree pollinosis, could be part of this syndrome in our area. Keywords clinical characterization, cofactors, component-resolved diagnosis, pollen, LTP syndrome Submitted 30 January 2012; revised 29 May 2012; accepted 28 June 2012 Introduction Plant-food allergy is the food allergy most commonly found in older children and adults [1–4]. In the Medi- terranean area, tree nuts (mainly hazelnuts) and fruits – especially Rosaceae and kiwi – stand out as the most important allergens [5–7]. Lipid transfer proteins (LTPs) are plant panallergens that have mainly been considered clinically relevant in plant-foods but have also been described in pollens [8–10]. Their relevance is mostly limited to the Mediter- ranean Basin [8, 11]. Clinical manifestations of LTP- sensitization can be of varying severity and either gen- eralized (anaphylaxis) or restricted to the oropharingeal area, skin or gastrointestinal tract [12]. Clinically rele- vant cross-reactivity between plant-foods and pollens has been documented [8, 9]. Thus, multiple plant-food sensitization is a common feature of LTP-allergic