CURRENT ALLERGY & CLINICAL IMMUNOLOGY JOURNAL OF THE ALLERGY SOCIETY OF SOUTH AFRICA
Vol 39, No 2 June 2026
- Effects of dietary diversity on food allergies
- Home food gardens for dietary diversity, microbiota health and lifelong immune resilience
- Food additives: Hypersensitivity and gut health
- Sublingual immunotherapy for food allergy
- An evidence-based approach to chronic spontaneous urticaria
- Specialised infant formulas used in the treatment of cow’s milk protein allergy
- The ethics of enteral feeding
- A descriptive study of allergic sensitisation in children
- Chronic pruritis
- Work-exacerbated severe atopy
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GUEST EDITORIAL
Author: Marinda McDonald
Abstract: Science offers us the promise of solutions to challenging medical dilemmas. However, translating exciting emerging science into clinical practice before robust evidence and guideline recommendations become available presents considerable challenges. The enthusiasm generated by emerging science must therefore be balanced against the uncertainty that accompanies early evidence. The language of science is impermanent as it is based on our current understanding of facts; yet anyone in clinical practice knows that this year’s facts are often the future’s discarded hypotheses.
Review article
EFFECTS OF DIETARY DIVERSITY ON FOOD ALLERGIES IN SOUTH AFRICA
Authors: Jandri E Barnard, Unathi Kolanisi, Annette van Onselen
Abstract: Allergic diseases, including food allergies, are a growing public health concern in South Africa and globally. While traditionally rare among rural South Africans, rapid urbanisation and the adoption of ‘Westernised’ diets – high in ultra-processed foods (UPFs), sugar and saturated fats – have led to a ‘second-wave’ rise in the prevalence of allergies. Recent studies indicate a significant divergence between urban and rural areas, with challenge-proven food allergy rates reaching 2.5% in urban Cape Town compared to just 0.5% in rural areas. Dietary diversity, particularly in the first year of life, is a critical protective factor. Research suggests that for every additional food allergen introduced by 12 months, the risk of developing a food allergy is reduced by 33%. This diversity is thought to act through the gut microbiome to build immune tolerance. Conversely, restrictive diets and the heavy consumption of UPFs containing emulsifiers may increase intestinal permeability and allergy risk. However, maintaining dietary diversity faces significant economic hurdles. As at January 2026, the average monthly household food basket in South Africa cost R5 401.44, exceeding the national minimum wage of R5 239.46 per month since March 2026. High food inflation for nutritious staples such as vegetables (+8% to +16%) is forcing low-income families to substitute diverse nutrient-dense foods with cheaper highcalorie staples. To curb the rise in food allergies, prevention strategies should focus on the ‘biodiversity hypothesis’, which encourages the introduction of a wide variety of whole, fresh and fermented foods at about six months of age. Future efforts require collaborative research that includes immunology and nutrition to optimise the human microbiome for allergy prevention in the South African context.
Keywords: food allergies, ultra-processed foods, dietary diversity, allergy prevention, South Africans
Review article
HOME FOOD GARDENS FOR DIETARY DIVERSITY, MICROBIOTA HEALTH AND LIFELONG IMMUNE RESILIENCE
Authors: Suzanne Delport, André van Niekerk
Abstract: A global nutrition transition to a Western diet of fast- and ultra-processed food has occurred over the past three decades. This calorie-dense and nutrient-poor diet has led to an increase in the prevalence of obesity in children and adults of epidemic proportions. Low- and middle-income countries are facing a dual burden of under-nutrition and the collateral effects of obesity: dysbiosis of the gut microbiome, non-communicable diseases, mental disorders, gut dysmotility, allergies and auto-immune dysregulation. A Western diet lacks dietary diversity and plant diversity in particular, which are essential to maintaining the integrity of the gut microbiome and its regulatory effect on the immune system. As a result, immune tolerance and vigilance are forfeited and susceptibility to allergic diseases is increased. Home food gardens present a practical, low-cost and culturally adaptable strategy to improve dietary diversity and plant and micronutrient intake to support the health of the microbiome and the immune system. This article briefly explores the relevance of dietary and plant diversity, the impact of modern diets on microbiome–immune interactions and the possible role of home food gardens in promoting resilience that is applicable to all countries. Practical guidance on establishing home food gardens is provided, with a particular focus on nutrient-dense crops.
Keywords: dietary diversity, immune tolerance, immune resilience, home food gardens, low- and middle-income countries
Review article
FOOD ADDITIVES: HYPERSENSITIVITY AND GUT HEALTH – A CLINICAL OVERVIEW
Authors: Natalie Heydenrych, Francoise Pinillos
Abstract: Additives are used to improve the shelf life, safety, flavour and appearance of food products, beverages and medications. In today’s fast-paced evolving environment individuals are relying more on convenience foods, which are generally either processed or ultra-processed, leading to an increase in the consumption of additives. The prevalence of allergies is also increasing globally, and there is a growing concern about the impact of these processed and ultra-processed products on people’s health – especially the gut microbiome – emphasising the need for more research. The aim of this article is to provide a clinical overview of the most commonly used food additives, their potential to cause allergic reactions and their effect on the gut microbiome.
Keywords: food additives, hypersensitivity, gut microbiome, gut health, processed foods, ultra-processed foods, allergies
Review article
SUBLINGUAL IMMUNOTHERAPY FOR FOOD ALLERGY: EFFICACY, SAFETY AND POTENTIAL FOR USE IN SOUTH AFRICA
Author: Sarah Karabus
Abstract: Food allergy is a global health concern that is increasing in prevalence and has a significant impact on quality of life. Current management relies primarily on allergen avoidance and emergency treatment, highlighting the need for diseasemodifying therapies. Sublingual food immunotherapy (SLIT) has emerged as a potential intervention that offers a more favourable safety profile with fewer systemic adverse events than that of oral immunotherapy (OIT). Clinical studies demonstrate that SLIT may increase allergen reaction thresholds, particularly in peanut, cow’s milk and tree nut allergies, although its efficacy is generally more modest than that of OIT. In the South African context, SLIT presents a more accessible therapeutic option due to its simpler dosing protocols and reduced risk of side-effects. However, challenges remain, including the lack of standardised protocols and limited availability of commercial products.
Keywords: food allergy, peanut allergy, food oral immunotherapy, food sublingual immunotherapy
Review article
AN EVIDENCE-BASED APPROACH TO CHRONIC SPONTANEOUS URTICARIA: DIETARY INTERVENTION, CAUSATION, PREVENTION AND MANAGEMENT
Author: Cathryn McDougall
Abstract: Chronic spontaneous urticaria (CSU) is defined by the spontaneous occurrence of wheals, angioedema or both for a duration of six weeks or longer.1 Despite the advances made in understanding mast-cell-driven disease, the underlying pathophysiology of CSU remains incompletely understood, and in most cases no clear precipitating factor is identified. Although IgE-mediated food allergy is rarely the cause of CSU, diet remains an important consideration for a select subgroup of patients. Dietary manipulation in CSU remains a controversial topic in both the literature and clinical practice. This article provides an overview of the current evidence relating to diet and CSU, including proposed mechanisms and reported clinical outcomes. It focuses on the practical implications for clinicians who are managing patients with CSU in our local setting.
Keywords: chronic spontaneous urticaria, dietary interventions, mast-cell-driven disease
Review article
SPECIALISED INFANT FORMULAS USED IN THE TREATMENT OF COW’S MILK PROTEIN ALLERGY: A SOUTH AFRICAN PERSPECTIVE
Authors: Natalie Heydenrich, Marinda McDonald
Abstract: Cow’s milk protein allergy (CMPA) is becoming increasingly common in infants. Its treatment requires removing cow’s milk protein (CMP) from the diet if breastfeeding is not possible, insufficient or contraindicated. This article covers the classification of CMPA, definitions and indications of hypoallergenic formulas and lists the hypoallergenic infant formula available in South Africa, based on the latest World Allergy Organisation (WAO) Diagnosis and Rationale for Action against Cow’s Milk Allergy (DRACMA) 2024 guidelines. Extensively hydrolysed cow’s milk and hydrolysed rice formulas are recommended as first-line options, while amino acid-based formulas are recommended as second-line options and, finally, soy infant formula as a third-line option in certain circumstances. When choosing a formula, it is important to consider the type of CMPA, its cost, its availability and the local regulations (R991) to achieve the best outcome.
Keywords: Cow’s milk protein allergy (CMPA), cow’s milk protein (CMP), hypoallergenic infant formula, WAO DRACMA 2024 guidelines, breastmilk substitutes
Ethics article
THE ETHICS OF ENTERAL FEEDING
Author: Sharon Kling
Abstract: Enteral feeding or nutrition constitutes one component of ‘artificially’ administered nutrition. The terminology includes ‘medical nutrition therapy’ (MNT), ‘medical nutrition and hydration’ (MNH) and ‘artificial nutrition and hydration’ (ANH). MNT is used to provide nutrition to patients who are unable to ingest food or fluids or where oral intake does not fulfil their nutritional requirements and is considered to be a medical treatment. The core ethical principles of autonomy, beneficence, non-maleficence and justice underpin ethical decision-making in MNT. Informed consent and shared decision-making are important considerations, but patients requiring MNT are often not competent to make decisions; in such cases, a surrogate or proxy decision-maker is required. As MNT is a medical treatment, an assessment of the burdens and benefits must first be made. In cases where the outcome is uncertain, a trial of MNT may be appropriate.
Keywords: enteral feeding, enteral nutrition, medical nutrition therapy, medical nutrition and hydration, ethics of enteral feeding, artificial nutrition and hydration
Research article
A DESCRIPTIVE STUDY OF ALLERGIC SENSITISATION IN CHILDREN ATTENDING AN ALLERGY CLINIC IN JOHANNESBURG
Authors: Ntebatse R Tladi, Debbie A White
Background: Allergic diseases are increasing in prevalence worldwide, including in sub-Saharan Africa. Patterns of allergen sensitisation in South African children remain underexplored, particularly in urban high-risk populations. The objectives of this study were to describe the sensitisation patterns related to aeroallergens and food allergens among paediatric patients who attended an allergy clinic in Johannesburg and to examine any age-related differences between and associations with respiratory versus skin diseases.
Methods: A retrospective review was conducted of the medical files of patients aged between six months and 18 years who were seen at Charlotte Maxeke Johannesburg Academic Hospital between August 2018 and July 2024. Patients diagnosed with asthma, allergic rhinitis, atopic dermatitis, food allergy or urticaria were included if they had undergone skin prick tests (SPT) or serum-specific IgE measurement. Sensitisation was defined as an SPT wheal of ≥ 3 mm or an IgE of ≥ 0.35 kU/L. The data were analysed using both descriptive statistics (means, standard deviation, frequencies and percentages) and comparative statistics (Kruskal-Wallis and Mann-Whitney U test).
Results: Among the 127 eligible patients (mean age 6.8 ± 3.7 years; 54.3% male), the most common diagnoses were asthma (80.3%) and allergic rhinitis (66.9%). The house dust mites (HDM) Dermatophagoides pteronyssinus (40.9%) and D farinae (40.2%) were the predominant aeroallergens, followed by grass pollens and moulds. Peanut (26.8%) and egg white (25.2%) were the leading food allergens, with wheat and maize also common. An age-related analysis showed significant differences in sensitisation to grass pollens, HDM and cat epithelia, with younger children (< 10 years) being the most affected. Food allergen sensitisation was more frequent in children with skin diseases than in those with respiratory conditions (p < 0.05). Polysensitisation was common, with children being sensitised to an average of four allergens.
Conclusion: In this high-risk paediatric population, HDM, grass pollens, peanut and egg white were the most frequent allergens. Sensitisation peaked in mid-childhood and food sensitisation was more strongly linked to skin disease. These results underline the importance of early allergen identification and personalised management strategies in urban South African settings.
Keywords: allergy, children, sensitisation, aeroallergens, food allergens
Case report
CHRONIC PRURITIS: UNMASKING A SINISTER DIAGNOSIS
Authors: Miguel J Teixeira, Jason Thoresen
Abstract: Chronic pruritus (CP) is a debilitating condition with diverse aetiologies that range from dermatological and allergic disorders to neoplastic, drug-induced, infectious and haematological diseases. While often thought of as being related to benign causes, CP may rarely be the initial manifestation of an underlying malignancy. We report a case of a 63-year-old male who presented with intractable pruritus, which was initially suspected to be chronic spontaneous urticaria (CSU). Despite treatment with high-dose antihistamines and corticosteroids, the symptoms persisted and repeated clinical assessments failed to identify a dermatological or allergic cause. Further investigation revealed a persistent monocytosis. A bone marrow aspirate and trephine (BMAT) biopsy confirmed the diagnosis of chronic myelomonocytic leukaemia (CMML), a rare myelodysplastic or myeloproliferative disorder. This case highlights the importance of maintaining a high index of suspicion of haematological malignancies in patients with CP who are unresponsive to antihistamines, particularly in the absence of objective dermatological findings. Early referral and investigation can facilitate the timely diagnosis and management of a potentially serious underlying medical condition.
Keywords: chronic myelomonocytic leukaemia, chronic pruritus, myelodysplastic syndrome, non-histaminergic pruritus
Allergies in the Workplace
WORK-EXACERBATED SEVERE ATOPY WITH MULTISYSTEM INVOLVEMENT IN AN OFFICEBASED WORKER: A CASE REPORT
Authors: Munyadziwa Muvhali, Nompumelelo Ndaba
Abstract: Work-related and work-exacerbated allergic diseases are increasingly recognised outside traditional high-risk occupational settings. Office environments may harbour clinically relevant aeroallergen exposures capable of triggering severe allergic disease in sensitised individuals. We describe a middle-aged male office-based worker with severe atopy, recurrent urticaria, chronic allergic rhinosinusitis with nasal polyposis and probable allergic asthma. Symptoms were reproducibly triggered by workplace exposure to dust, mites, mould and botanical allergens, with marked improvement during periods away from work. A lung function test was conducted, and blood analyses included inhalant-specific IgE screening as well as specific IgE testing for common aeroallergens, including animal dander, house dust mites, grasses, plane tree pollen, and moulds. The worker was diagnosed with adult-onset work-exacerbated upper respiratory disorder (allergic rhino sinusitis) due to common aeroallergens (Bermuda grass, house-dust mites and mould), which may be present within the workplace. This case highlights the potential for significant work-exacerbated allergic disease in office environments and underscores the importance of having adequate environmental control and exposure mitigation in sensitised individuals. Furthermore, this case highlights the need for a multi-faceted approach (eg, employers, occupational health and safety, and medical professionals) when dealing with occupational-related diseases, which can lead to earlier interventions and better outcomes.
Keywords: aeroallergens, occupational allergy, asthma, office building
ABC of Allergy
The T cell: A study in precision, adaptation and biological elegance
Authors: Shaunagh Emanuel, Di Hawarden
Introduction: In this contribution, Dr Do-a-lot discusses T Cells. She uses the words ‘miraculous’ and ‘extraordinary’ in her description, and asks the students to explore T-cell maturation, functional subsets, cytokine profiles, hypersensitivity mechanisms and emerging therapies, highlighting the wonder that makes the T cell one of biology’s most remarkable cells. The students commence their presentation by illustrating the complex process of T-cell maturation, using a canine analogy.
DR SPUR’S MYSTERY CASE
A wolf in allergy clothing
Authors: Louise Murray, Lizelle Nagel, Sylvia van den Berg
Introduction: The diagnosis of IEI rests upon five clinical pillars which include infections, severe allergic disease, autoimmunity or autoinflammation, granulomatous disease and lymphoproliferative or malignant disease (see Figure 1). An IEI should ALWAYS be considered if two or more clinical pillars coexist, as in your patient with severe allergic disease and recurrent viral infections. Clinical disease patterns in IEI are often severe, persistent, unusual or recurrent (SPUR), and patients tend to return in bad shape (RIBS) after standard appropriate therapy.
Nutrition Tuition
WHEN IT’S NOT POSSIBLE TO HAVE YOUR DOSE OF WINTER VITAMIN C
Author: Jandri Barnard
Introduction: The winter season, meaning the season of citrus fruits, is upon us, and they and other fruits full of vitamin C – including kiwis and guavas – are available to help boost our immune systems. Citron, grapefruit, lemon, lime, mandarin, orange, tangerine and naartjies fall under citrus fruit classification. The recommended daily allowance of vitamin C for adults is 60 mg, while citrus fruits contain an average of 70 mg vitamin C per serving, with other fruits also being high in vitamin C, including guavas (125 mg), kiwifruit (64 mg) and strawberries (49 mg). The intake of apples, kiwi fruit and oranges has been shown to reduce the incidence of asthma symptoms, as apples are high in quercetin (being an anti-allergy phytonutrient), making it a recommendation of vitamin C intake to help calm down allergic reactions. Vitamin C has been found to be a natural antihistamine for certain allergic reactions such as hay fever reactions: it enhances the action of the enzyme histaminase and quickly breaks down histamine. But this reaction occurs only when the correct dose of vitamin C plays a role – 1 g of vitamin C reduces blood histamine by 20% and 2 g reduces histamine by more than 30%.