Pruritus was noted with ingestion of orange juice, but not with cumin. symptoms if he ate the sandwich during Autumn-Winter or with comparable sandwiches from option restaurants. He denied any history of food allergies. The patient was unable to identify other possible causes for his symptoms other than the sandwich. Upon thorough history taking, we determined that this used on the specific sandwich was the main difference between that restaurants recipe as well as others with which the patient never had any symptoms. is usually prepared with several cooked ingredients (garlic, cumin, black pepper, oregano, unripe orange, and olive oil) boiling for 10C20 moments. There were no commercial extracts available for We performed prick-to-prick screening to pork, whole (from your same restaurant) and each of its ingredients along with commercially available aeroallergens (Physique 1). The test resulted positive for whole ripe orange, cumin, cedar, and oak. Open in a separate window Physique 1: A. Prick to prick with Mojo B. Aeroallergens and positive control We then performed prick-to-prick assessments with using undiluted and ten-fold dilutions (1:10; 1:100; 1:1,000; 1:10,000; 1:100,000 and 1:1,000,000) on five healthy subjects and the patient. All dilutions and undiluted mojo were negative in healthy subjects. The patient experienced a positive reaction to undiluted and 1:10 dilution. We then performed an oral challenge where the patient ate same type of sandwich at the medical center under close surveillance. Within 10 minutes of ingestion, patient reported pruritus of the buccal mucosa, tongue, and lips. There was no urticaria, rashes, angioedema or evidence of other systemic IgE-mediated reactions. Further, Oral challenges for individual component of were done. Pruritus was noted with ingestion of orange juice, but not with cumin. Patient was advised to avoid ingestion of foods containing during spring-summer to prevent worsening symptoms with pollen peaks and to use oral antihistamines in case of same presentation. Spices, like the ones used in are used in a wide array of foods, and beverages and may act as hidden allergens. Citrus fruit allergy, as seen our patient (orange), is often associated with cross-reactivity and sensitization to other plants such as, birch or grass pollen.3 Symptoms of allergy to orange is mainly local unlike other food allergy which have more generalized symptoms such as vomiting, diarrhea and abdominal pain.3 During an acute episode, a physical examination may reveal angioedema as well Hexacosanoic acid as perioral urticarial eruptions.1,4 There is no consensus Hexacosanoic acid on the recommendation of a specific method of prick testing for patients with allergic reactions to spices. Testing for spices is a challenge with a lack of reliable commercially available extracts, such that it becomes necessary to test these patients with fresh foods. For several years, the prick-to-prick testing for fresh produce has been shown to be a more reliable method than the commercial extracts.5 In contrast, skin prick test can be unreliable because the cross-reactive Hexacosanoic acid epitopes get denaturalized by the manufacturing process6 and this also possess the risk of provoking clinical reactions.7 Prick-to-prick testing with freshly prepared extracts is more sensitive in detecting allergen-specific IgE antibody.8 Oral provocation test can help confirm the presence of the disease. For an accurate diagnosis, patients should be advised to keep a diary of food consumption based on which determination of food challenge tests should be performed. SPARC Patient education is the most effective long-term management of this condition. Patients and their families should be made aware and instructed to read food and beverage labels, where all ingredients of the food are mentioned. In situations of hidden allergens, as in our case, patients with OAS can be treated with a combination of allergen avoidance and pharmacotherapy (antihistamines). Patients with history of anaphylaxis should have an epinephrine auto injector with them at all times. Acknowledgments Sources of Support/ Funding: Dr. Shrestha is funded under NIH trainee grant T32 GM008685-22. Footnotes Conflicts of interest statement: The authors declare no conflicts of interest Publisher’s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers Hexacosanoic acid we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting.