Persimon (kaki fruit, sharon)

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Code: f301
Latin name: Diospyros kaki
Source material: Fresh fruit
Family: Ebenaceae
Common names: Persimmon, Kaki fruit, Sharon fruit

Food

A food, which may result in allergy symptoms in sensitised individuals.

Allergen Exposure

The persimmon tree is native to China and Japan, where it has been cultivated for centuries. It was introduced to Europe and California (where it has become D. virginiana or American persimmon) in the mid-19th century. It is commercially grown in Italy, Spain and the south of France, where it is known as kaki, but it is still most common in the Far East.

The trees can be classified into 2 general categories: those bearing fruit that is astringent until it is extremely ripe, and those bearing non-astringent fruit. (1) Astringent-fruit cultivars contain high levels of soluble tannins and cannot be eaten until very soft unless the astringency has been artificially removed. Non-astringent cultivars contain low levels of soluble tannins and can be eaten at various stages of firmness, from very hard to very soft. The fruit consists of a berry resembling a tomato in shape and texture, but is the size of an apple and orange in colour.

Diospyros is numerically and economically the most important genus of Ebenaceae. The fruits are eaten fresh, dried, cooked, and canned. They are high in glucose and protein, and also have various medicinal and chemical uses. Unique to the genus is its large number of pentacyclic triterpenes and juglone-based 1,4-naphthoquinone metabolites.

Allergen Description 

The following allergen(s) have been characterised:

Dio k 4, a profilin. (2, 3)

A 17 kDa protein, a Bet v 1 homologue, has been isolated. (3)

A Bet v 6-related food allergen, an isoflavone reductase (IFR)/phenylcoumaran benzylic ether reductase (PCBER), has been detected. (3, 4) A pectin methylesterase inhibitor of unknown allergenic potential has been isolated. (5)

The presence of a cross-reactive profilin was shown in 1 patient and IgE cross-reacted with carbohydrate determinants in all patients. (2)

Potential Cross-Reactivity

Cross-reactivity with pollen allergens as a result of the presence of a profilin and Bet v 6-like and Bet v 1-like allergens has been reported. Two patients with hypersensitivity reactions upon first exposure to persimmon, as well as 7 patients with birch-pollen-related apple allergy, were included in a study. Sera from both patients were reactive to Bet v 1 and Bet v 6, which were cross-reactive with persimmon. (3)

The birch pollen allergen Bet v 6 appears to be related to proteins in some fruits. Bet v 6, a plant protein related to a defence mechanism protein, was named phenylcoumaran benzylic ether reductase (PCBER). A study suggested that homologous allergens may be present in many plant foods, such as apple, peach, orange, lychee, strawberry, persimmon, zucchini, and carrot. In extracts of pear, apple, orange, and persimmon, the presence of proteins of approximately 30-35 kDa containing Bet v 6 cross-reactive epitopes was demonstrated with 2 Bet v 6-specific monoclonal antibodies. (3)

Pollen-allergic patients frequently present allergic symptoms after ingestion of several kinds of plant-derived foods. The majority of these reactions are caused by 4 distinct cross-reactive structures that are present in birch pollen: Bet v 1, profilin, cross-reactive carbohydrate determinants (CCDs), and Bet v 6. Bet v 6-like allergens have actually been found in many plant foods such as apple, peach, orange, lychee, strawberry, persimmon, zucchini, and carrot. (6)

Clinical Experience

IgE-mediated reactions

Anecdotal evidence suggests that persimmon can occasionally induce symptoms of food allergy in sensitised individuals; however, few studies have been reported to date. (1, 2, 7, 8, 9)

Oral allergy to persimmon has been reported. One study reports on 3 patients: after the ingestion of persimmon, the first reacted with pruritus, penis oedema, urticaria, and asthma; the second with nausea and vomitus; and the third with rhinoconjunctivitis, asthma, and stomachache. (2)

A 13-month-old Japanese male infant was seen following a reaction to persimmon upon first ingestion. Symptoms included skin rash and itching on the face and soles of the feet. The symptoms had appeared immediately after biting a fresh persimmon and the itching on the soles persisted for more than 13 hours, despite treatment with oral antihistamines. Neither wheeze nor gastrointestinal symptoms were observed. He did not have asthma, eczema, or rhinoconjunctivitis. Skin-prick test was positive with fresh persimmon (18 mm). Serum specific IgE was 3.29 kU/L to persimmon. He was not sensitised to carrot, apple, kiwi, celery, melon, peach, timothy grass, mugwort, alder, birch, beech, oak, or Alternaria. The patient’s serum indicated IgE-binding proteins at positions corresponding to approximately 30 kDa and 60 kDa. (9)

In a study evaluating cross-reactivity with pollen allergens as a result of the presence of a profilin and Bet v 6-like and Bet v 1-like allergens, 2 patients with hypersensitivity reactions upon first exposure to persimmon, as well as 7 patients with birch-pollen-related apple allergy, were assessed. Sera from both patients were reactive to Bet v 1 and Bet v 6, which were cross-reactive with persimmon. The patient with the most severe reactions was reactive to profilin. An open challenge with persimmon in 7 patients allergic to birch pollen and apple, who had not eaten persimmon previously, was positive in 6/7 cases. The study concluded that birch-pollen-related allergy to persimmon is mediated by known cross-reactive pollen allergens, including Bet v 1, and may become more of a problem should persimmon consumption increase. (3)

A case was reported of a 33-year-old man with an anaphylactic reaction immediately after ingestion of persimmon fruit. A skin-prick test with persimmon fruit was positive. Serum-specific IgE was demonstrated. (1)

In another case of anaphylaxis, a 20-year-old man reported itching, generalised urticaria, facial oedema, asthma, gastrointestinal symptoms and diarrhoea 10 minutes after eating a fresh persimmon fruit. Prick-to-prick and SPT were positive. RAST was negative. (10)

Other reactions

Some patients complain of abdominal distension and excessive flatus after ingesting persimmon, and these reactions were attributed to fructose intolerance. (11)

Persimmon phytobezoar, although in general an infrequent entity, is not rare in some countries. (12) Because of their particular features, management of diospyrobezoars is difficult. (13) Most patients with bezoars have ingested unpeeled fruits. While ingestion of Persimmon carries a 9.8-fold elevated risk of bezoar development, ingestion of the unpeeled fruit increases the risk of this complication 56 times over that of age- and sex-matched controls. (14) Small bowel obstruction in children due to persimmon phytobezoars may occur. (15)

Lycopenaemia is a benign condition, secondary to an excessive dietary intake of lycopene-rich fruits. It was described in a 68-year-old Caucasian woman who presented with red-orange-tinged skin on her palms and soles. Her diet included about 1 kg of persimmon daily. The discolouration of the palms and soles resulted from pigment deposits, due to the slow conversion of carotene to vitamin A. This condition resolved after changes in her dietary habits. (16)

Compiled by Dr Harris Steinman, harris@allergyadvisor.com 

References

  1. Martinez JC, Armentia A, Bartolome B, Callejo A, Fuentes MJ, Fernandez A. Anaphylaxis after ingestion of sharon fruit. Allergol Immunopathol (Madr). 2001;29(2):69-71.
  2. Anliker MD, Reindl J, Vieths S, Wüthrich B. Allergy caused by ingestion of persimmon (Diospyros kaki): detection of specific IgE and cross-reactivity to profilin and carbohydrate determinants. J Allergy Clin Immunol 2001;107(4):718-23.
  3. Bolhaar ST, van Ree R, Ma Y, Bruijnzeel-Koomen CA, Vieths S, Hoffmann-Sommergruber K, Knulst AC, Zuidmeer L. Severe allergy to sharon fruit caused by birch pollen. Int Arch Allergy Immunol 2004;136(1):45-52.
  4. Karamloo F, Wangorsch A, Kasahara H, Davin LB, Haustein D, Lewis NG, Vieths S. Phenylcoumaran benzylic ether and isoflavonoid reductases are a new class of cross-reactive allergens in birch pollen, fruits and vegetables. Eur J Biochem. 2001;268(20):5310-20.
  5. Ciardiello MA, Tamburrini M, Tuppo L, Carratore V, Giovane A, Mattei B, Camardella L. Pectin methylesterase from kiwi and kaki fruits: purification, characterization, and role of pH in the enzyme regulation and interaction with the kiwi proteinaceous inhibitor. J Agric Food Chem 2004;52(25):7700-3.
  6. Vieths S, Scheurer S, Ballmer-Weber B. Current understanding of cross-reactivity of food allergens and pollen. Ann N Y Acad Sci. 2002;964:47-68.
  7. Yamamoto T, Asakura K, Shirasaki H, Himi T. Clustering of food causing oral allergy syndrome in patients with birch pollen allergy. [Japanese] Nippon Jibiinkoka Gakkai Kaiho 2008;111(8):588-93.
  8. Zuidmeer L, Goldhahn K, Rona RJ, Gislason D, Madsen C, Summers C, Sodergren E, Dahlstrom J, Lindner T, Sigurdardottir ST, McBride D, Keil T. The prevalence of plant food allergies: a systematic review. J Allergy Clin Immunol 2008;121(5):1210-1218.
  9. Kitano A, Miyazaki T, Yoshioka K, Kurono T, Kurono S, Matsumoto T. Facial rash and palmoplantar pruritus in an infant after first contact with kaki. J Investig Allergol Clin Immunol 2009;19(3):237-8.
  10. Prandini M, Marchesi S. Anaphylaxis to persimmon. Allergy. 1999;54(8):897.
  11. Mann NS, Cheung EC. Fructose-induced breath hydrogen in patients with fruit intolerance. J Clin Gastroenterol 2008;42(2):157-9.
  12. Choi SO, Kang JS. Gastrointestinal phytobezoars in childhood. J Pediatr Surg 1988;23(4):338-41.
  13. Gaya J, Barranco L, Llompart A, Reyes J, Obrador A. Persimmon bezoars: a successful combined therapy. Gastrointest Endosc. 2002;55(4):581-3.
  14. Benharroch D, Krugliak P, Porath A, Zurgil E, Niv Y. Pathogenetic aspects of persimmon bezoars. A case-control retrospective study. J Clin Gastroenterol. 1993;17(2):149-52.
  15. Zafar A, Ahmad S, Ghafoor A, Turabi MR. Small bowel obstruction in children due to persimmon phytobezoars. J Coll Physicians Surg Pak. 2003;13(8):443-5.
  16. Caroselli C, Bruno G, Manara F. A rare cutaneous case of carotenosis cutis: lycopenaemia. Ann Nutr Metab 2007;51(6):571-3.

As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.