What are the dietary recommendations for an 18-year-old female patient with significant allergies to peanuts, wheat, walnuts, hazelnuts, and sesame seeds, as well as elevated IgE levels for cow's milk, soybean, almond, and macadamia nut?

Management Recommendations for 18-Year-Old Female with Multiple Food Allergies

This patient requires strict avoidance of peanuts, tree nuts (walnut, hazelnut, almond, macadamia), wheat, and sesame, along with prescription of epinephrine autoinjectors and referral to an allergist for comprehensive management and consideration of oral immunotherapy. 1

Immediate Actions Required

Strict Dietary Avoidance

• Eliminate all foods with Class 3-4 IgE levels: peanut (22.50 kU/L, Class 4), walnut (20.90 kU/L, Class 4), hazelnut (21.20 kU/L, Class 4), wheat (11.10 kU/L, Class 3), sesame (10.40 kU/L, Class 3), and almond (5.12 kU/L, Class 3) 1

• Exercise caution with moderate sensitizations: macadamia nut (4.84 kU/L, Class 3) and soybean (3.32 kU/L, Class 2) should be avoided unless tolerance has been confirmed by supervised oral food challenge 1, 2

• Cross-reactivity considerations: Given the high peanut IgE (Class 4), this patient has 59-86% sensitization risk to tree nuts and 19-79% sensitization to soy, with 33-34% clinical reactivity to tree nuts 1, 3. The elevated walnut, hazelnut, and almond IgE levels confirm this cross-reactivity pattern 3, 4

Emergency Preparedness

• Prescribe epinephrine autoinjectors (two devices) for emergency treatment of anaphylaxis, as this patient has multiple Class 4 allergens and is at high risk for severe reactions 1

• Provide comprehensive training on recognizing anaphylaxis symptoms and proper autoinjector administration technique 1

• Develop written emergency action plan detailing symptoms requiring epinephrine use and emergency contact information 1

Foods That Can Be Safely Consumed

Confirmed Safe (Class 0)

• Egg whites, codfish, shrimp, scallop, salmon, and tuna all show IgE <0.10 kU/L (Class 0) and can be consumed without restriction 1

Borderline Sensitizations Requiring Clinical Correlation

• Cow's milk (0.21 kU/L, Class 0/1): This minimal elevation likely represents asymptomatic sensitization rather than clinical allergy 2, 5. If the patient has no history of reactions to dairy, it can likely be consumed, but confirm tolerance history before advising 1

• Cashew (0.48 kU/L, Class 1) and Brazil nut (0.18 kU/L, Class 0/1): These borderline elevations have poor positive predictive value (40-60%) and may represent sensitization without clinical allergy 2, 6. However, given the high-risk profile with multiple Class 4 tree nut allergies, avoid these nuts until supervised oral food challenge confirms tolerance 1, 2

Critical Management Considerations

Cross-Reactivity Patterns

• Tree nut cross-reactivity is extensive: With Class 4 reactions to walnut, hazelnut, and peanut, this patient demonstrates the 92% sensitization rate and 12-37% clinical reactivity pattern seen among tree nuts 1. Higher IgE correlations exist between cashew-pistachio and pecan-walnut pairs 1

• Peanut-soy cross-reactivity: The elevated soybean IgE (3.32 kU/L) in context of severe peanut allergy reflects the 19-79% sensitization pattern, though clinical reactivity is only 3-5% 1, 3. Avoid soy unless tolerance confirmed by challenge 1

Nutritional Counseling

• Refer to registered dietitian to ensure adequate nutrition while avoiding wheat, multiple tree nuts, and potentially soy 1. Wheat elimination requires careful planning to maintain adequate B vitamins, iron, and fiber intake 1

• Monitor for nutritional deficiencies including calcium, vitamin D, and protein, particularly with multiple food restrictions 2

Allergist Referral for Long-Term Management

• Comprehensive allergy evaluation should include component-resolved diagnostics (e.g., Ara h2 for peanut, Jug r 1 for walnut) to better predict clinical reactivity and guide management 5

• Consider oral immunotherapy (OIT): For this 18-year-old with multiple Class 4 allergens, multi-food OIT with omalizumab adjunct therapy may be appropriate 1. The FDA-approved peanut OIT (Palforzia) could address the highest-risk allergen, though it requires ongoing daily dosing 1

• Supervised oral food challenges for borderline allergens (cashew, Brazil nut, cow's milk, soy) to prevent unnecessary dietary restrictions 2, 6

Common Pitfalls to Avoid

• Do not assume all elevated IgE levels represent clinical allergy: Positive IgE testing has only 40-60% positive predictive value and may reflect asymptomatic sensitization 2, 6. Clinical history and oral food challenges are essential for confirmation 1, 2

• Avoid advisory labeling confusion: "May contain" warnings are voluntary and unregulated, leading to unnecessary avoidance 1. Focus on confirmed allergens in ingredient lists 1

• Recognize high-risk factors: This patient's multiple Class 4 allergens place her at increased risk for severe anaphylaxis 7, 8. If she has comorbid asthma, risk is further elevated and requires aggressive asthma management 1, 7

• Address psychosocial impact: Young adults are high-risk for non-compliance and delayed epinephrine use 1. Provide age-appropriate counseling on managing food allergy in social situations, dating, and college settings 1