{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T06:43:57Z","timestamp":1776062637409,"version":"3.50.1"},"reference-count":34,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T00:00:00Z","timestamp":1776038400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pediatr."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Suspected allergic reactions to cocoa are frequently reported by patients, yet most of these cases are caused by sensitization to other more common allergens contained in chocolate products, such as milk, peanuts or tree nuts. True immunoglobulin E (IgE)-mediated cocoa allergy is rare, with only a few confirmed cases published to date.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>We describe the case of a 2-year-old female with a history of allergic rhinitis and anaphylaxis to tree nuts, who experienced recurrent episodes of perioral erythema and angioedema following chocolate ingestion. Skin prick testing, prick-by-prick testing with cocoa products, and serum specific IgE confirmed sensitization to cocoa. An oral food challenge with a dark chocolate bar was performed under controlled hospital conditions and resulted positive. The patient developed immediate multisystemic clinical manifestations including cough, wheezing, pruritus, perioral erythema, and urticaria, consistent with anaphylaxis. As the reaction occurred in a controlled hospital setting and the symptoms resolved rapidly with oral antihistamines, corticosteroids, and inhaled salbutamol, intramuscular epinephrine was not administered. The patient was discharged in good condition with a strict dietary avoidance of cocoa.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This case describes a rare but definite diagnosis of IgE-mediated cocoa allergy confirmed by oral food challenge. Diagnostic assessments should carefully exclude hidden allergens and consider alternative mechanisms, including contamination of cocoa products during processing or manufacturing. Clinicians should be aware that, although uncommon, cocoa allergies can cause anaphylaxis, and a comprehensive diagnostic workup, including oral challenge, is essential to guide correct management and patient counselling.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fped.2026.1763504","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T05:45:21Z","timestamp":1776059121000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["IgE-mediated cocoa allergy: a pediatric case report and review of the literature"],"prefix":"10.3389","volume":"14","author":[{"given":"Lucrezia","family":"Sarti","sequence":"first","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susanna","family":"Morelli","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mattia","family":"Giovannini","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]},{"name":"Department of Health Sciences, University of Florence","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Simona","family":"Barni","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giulia","family":"Liccioli","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Leonardo","family":"Tomei","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Benedetta","family":"Pessina","sequence":"additional","affiliation":[{"name":"Pediatric Unit, Rho and Garbagnate Milanese Hospital, ASST-Rhodense","place":["Milan, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gabriele","family":"Simonetti","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]},{"name":"Department of Health Sciences, University of Florence","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antonella","family":"Valenza","sequence":"additional","affiliation":[{"name":"Department of Experimental and Clinical Medicine, University of Florence","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Claudia","family":"Valleriani","sequence":"additional","affiliation":[{"name":"Immunology Laboratory, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alberto","family":"Martelli","sequence":"additional","affiliation":[{"name":"School, Family, and Association Task Force, Italian Society of Pediatric Allergy and Immunology","place":["Milan, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Francesca","family":"Mori","sequence":"additional","affiliation":[{"name":"Allergy Unit, Meyer Children\u2019s Hospital IRCCS","place":["Florence, Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,4,13]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"2446","DOI":"10.3390\/ijerph15112446","article-title":"Food allergy prevalence in Salvadoran schoolchildren estimated by parent-report","volume":"15","author":"Cabrera-Ch\u00e1vez","year":"2018","journal-title":"Int J Environ Res Public Health"},{"key":"B2","doi-asserted-by":"publisher","first-page":"673","DOI":"10.3389\/fimmu.2019.00673","article-title":"Food-induced anaphylaxis: role of hidden allergens and cofactors","volume":"10","author":"Skypala","year":"2019","journal-title":"Front Immunol"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.3390\/nu15061386","article-title":"Hidden and rare food allergens in pediatric age","volume":"15","author":"Tomei","year":"2023","journal-title":"Nutrients"},{"key":"B4","doi-asserted-by":"publisher","first-page":"992","DOI":"10.2174\/1871530320666200128141900","article-title":"Nickel allergy: epidemiology, pathomechanism, clinical patterns, treatment and prevention programs","volume":"20","author":"Tramontana","year":"2020","journal-title":"Endocr Metab Immune Disord Drug Targets"},{"key":"B5","doi-asserted-by":"publisher","first-page":"124","DOI":"10.1016\/j.anai.2023.09.015","article-title":"Anaphylaxis: a 2023 practice parameter update","volume":"132","author":"Golden","year":"2024","journal-title":"Ann Allergy Asthma Immunol"},{"key":"B6","doi-asserted-by":"publisher","first-page":"2779","DOI":"10.1089\/ars.2010.3697","article-title":"Cocoa and chocolate in human health and disease","volume":"15","author":"Katz","year":"2011","journal-title":"Antioxid Redox Signal"},{"key":"B7","doi-asserted-by":"publisher","first-page":"125124","DOI":"10.1016\/j.foodchem.2019.125124","article-title":"Anti-inflammatory effects of flavonoids","volume":"299","author":"Maleki","year":"2019","journal-title":"Food Chem"},{"key":"B8","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1016\/j.jnutbio.2021.108854","article-title":"Consumption of 85% cocoa dark chocolate improves mood in association with gut microbial changes in healthy adults: a randomized controlled trial","volume":"1","author":"Shin","year":"2022","journal-title":"J Nutr Biochem"},{"key":"B9","first-page":"603","article-title":"A diet enriched with cocoa prevents IgE synthesis in a rat allergy model","volume-title":"Pharmacol Res","author":"Abril-Gil","year":"2012"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.3390\/molecules24040812","article-title":"Relationship between cocoa intake and healthy status: a pilot study in university students","volume":"24","author":"Rodr\u00edguez-Lagunas","year":"2019","journal-title":"Molecules"},{"key":"B11","doi-asserted-by":"publisher","first-page":"362","DOI":"10.1016\/j.anai.2017.07.009","article-title":"Frequency of self-reported drug allergy: a systematic review and meta-analysis with meta-regression","volume":"119","author":"Sousa-Pinto","year":"2017","journal-title":"Ann Allergy Asthma Immunol"},{"key":"B12","doi-asserted-by":"publisher","first-page":"1851","DOI":"10.2147\/JAA.S394526","article-title":"Prevalence of food allergy and common food allergen among Saudi adults in makkah region, Saudi Arabia","volume":"15","author":"Alotiby","year":"2022","journal-title":"J Asthma Allergy"},{"key":"B13","doi-asserted-by":"publisher","first-page":"4470","DOI":"10.1021\/jf010497b","article-title":"Isolation and characterization of 2S cocoa seed albumin storage polypeptide and the corresponding cDNA","volume":"49","author":"Kochhar","year":"2001","journal-title":"J Agric Food Chem"},{"key":"B14","doi-asserted-by":"publisher","first-page":"908","DOI":"10.1016\/j.jaci.2004.06.020","article-title":"Lipid transfer protein and vicilin are important walnut allergens in patients not allergic to pollen","volume":"114","author":"Pastorello","year":"2004","journal-title":"J Allergy Clin Immunol"},{"key":"B15","first-page":"521","article-title":"Immunologic findings in confectionary workers","volume":"73","author":"Zuskin","year":"1994","journal-title":"Ann Allergy"},{"key":"B16","doi-asserted-by":"publisher","first-page":"2868","DOI":"10.1016\/j.jaip.2019.04.023","article-title":"Not so sweet: true chocolate and cocoa allergy","volume":"7","author":"Lopes","year":"2019","journal-title":"J Allergy Clin Immunol Pract"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1002\/ccr3.8803","article-title":"Allergy to Theobroma Cacao","volume":"12","author":"Nin Valencia","year":"2024","journal-title":"Clin Case Rep"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1016\/j.waojou.2020.100472","article-title":"World allergy organization anaphylaxis guidance 2020","volume":"13","author":"Cardona","year":"2020","journal-title":"World Allergy Organ J"},{"key":"B19","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1016\/j.chroma.2017.11.039","article-title":"Liquid chromatography coupled to tandem mass spectrometry for detecting ten allergens in complex and incurred foodstuffs","volume":"1530","author":"Planque","year":"2017","journal-title":"J Chromatogr A"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.3390\/foods12040726","article-title":"Multi-target detection of nuts and peanuts as hidden allergens in bakery products through bottom-up proteomics and high-resolution mass spectrometry","volume":"12","author":"Luparelli","year":"2023","journal-title":"Foods"},{"key":"B21","doi-asserted-by":"publisher","first-page":"692","DOI":"10.4315\/0362-028X.JFP-16-443","article-title":"A limited survey of dark chocolate bars obtained in the United States for undeclared milk and peanut allergens","volume":"80","author":"Bedford","year":"2017","journal-title":"J Food Prot"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1016\/j.jfp.2023.100069","article-title":"Recalls associated with food allergens and gluten in FDA-regulated foods from fiscal years 2013 to 2019","volume":"86","author":"Sharma","year":"2023","journal-title":"J Food Prot"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1016\/j.fct.2021.112196","article-title":"Probabilistic risk assessment for milk in dark chocolate, cookies and other baked goods with PAL sold in Canada","volume":"152","author":"Manny","year":"2021","journal-title":"Food Chem Toxicol"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.3390\/foods14101737","article-title":"Unexpected cow\u2019s milk proteins in a \u201cvegan\u201d easter egg as a cause of anaphylaxis","volume":"14","author":"Bani","year":"2025","journal-title":"Foods"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.3390\/nu14081571","article-title":"The risk of undeclared allergens on food labels for pediatric patients in the European union","volume":"14","author":"Mart\u00ednez-Pineda","year":"2022","journal-title":"Nutrients"},{"key":"B26","doi-asserted-by":"publisher","first-page":"1185","DOI":"10.1093\/ajcn\/85.5.1185","article-title":"Histamine and histamine intolerance","volume":"85","author":"Maintz","year":"2007","journal-title":"Am J Clin Nutr"},{"key":"B27","doi-asserted-by":"publisher","first-page":"454","DOI":"10.3390\/biom12030454","article-title":"Histamine intolerance\u2014a kind of pseudoallergic reaction","volume":"12","author":"Zhao","year":"2022","journal-title":"Biomolecules"},{"key":"B28","doi-asserted-by":"publisher","first-page":"227","DOI":"10.1111\/cod.13327","article-title":"Nickel allergy and allergic contact dermatitis: a clinical review of immunology, epidemiology, exposure, and treatment","volume":"81","author":"Ahlstr\u00f6m","year":"2019","journal-title":"Contact Dermatitis"},{"key":"B29","first-page":"1289","article-title":"Systemic nickel allergy syndrome: tips and tricks on how to be suspected and treated","volume-title":"J Biol Regul Homeost Agents","author":"Ricciardi","year":"2019"},{"key":"B30","doi-asserted-by":"publisher","first-page":"A89","DOI":"10.1186\/1939-4551-8-S1-A89","article-title":"Systemic nickel allergy syndrome","volume":"8","author":"Da Mata Perez","year":"2015","journal-title":"World Allergy Organ J"},{"key":"B31","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1177\/039463201402700118","article-title":"Systemic-nickel-allergy-syndrome epidemiological data from four Italian allergy units","volume":"27","author":"Ricciardi","year":"2014","journal-title":"Int J Immunopathol Pharmacol"},{"key":"B32","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1111\/pde.12490","article-title":"Easter egg hunt dermatitis: systemic allergic contact dermatitis associated with chocolate ingestion","volume":"32","author":"Jacob","year":"2015","journal-title":"Pediatr Dermatol"},{"key":"B33","first-page":"335","volume-title":"Pediatr Dermatol","author":"Krecisz","year":"2011"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.3390\/medicina56030111","article-title":"Immunoglobulin E (IgE)-mediated food allergy in children: epidemiology, pathogenesis, diagnosis, prevention, and management","volume":"56","author":"Barni","year":"2020","journal-title":"Medicina"}],"container-title":["Frontiers in Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2026.1763504\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T05:45:22Z","timestamp":1776059122000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fped.2026.1763504\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,13]]},"references-count":34,"alternative-id":["10.3389\/fped.2026.1763504"],"URL":"https:\/\/doi.org\/10.3389\/fped.2026.1763504","relation":{},"ISSN":["2296-2360"],"issn-type":[{"value":"2296-2360","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,13]]},"article-number":"1763504"}}