It’s not just peanuts and bee stings: Anaphylaxis can present in unusual ways

PHOENIX (Nov. 12, 2026) – When people think about anaphylaxis, peanuts, shellfish, or even bee sting often come to mind. Three medically challenging cases presented at the American College of Allergy, Asthma and Immunology (ACAAI) 2026 Annual Scientific Meeting show that severe allergic reactions can come from far less obvious places: a fish ingredient hidden in an energy drink, a natural hair oil and a popular children's sensory toy.

Although the three cases are unrelated, each involved a child or teen who experienced anaphylaxis—a severe, potentially life-threatening allergic reaction—and required epinephrine. Together, the cases underscore how an allergic trigger might be identified when the cause is unclear.

Something fishy in an energy drink

Within minutes of trying a new energy drink, a 15-year-old boy developed widespread hives, wheezing and difficulty breathing. In the emergency department, he received two doses of epinephrine, as well as albuterol, an antihistamine and IV fluids, before his symptoms resolved.

The culprit was an unexpected ingredient. A review of the label showed the drink contained 5 grams of collagen derived from cod. The teen, who has eczema, asthma and allergic rhinitis, had noticed mild throat itching and lip swelling when eating canned tuna, but had eaten salmon without a problem. Skin prick tests for tuna, cod and flounder were all negative.

"This case shows how tricky fish allergy can be," said allergist Annabelle Rowland, MD, study author and ACAAI member. "Collagen from fish is showing up in a growing number of products, from drinks to supplements. Standard fish allergy tests mostly look for a different fish protein and contain very little collagen, so a person can test negative and still react."

Abstract title: Anaphylaxis Following Energy Drink Consumption Reveals Something Fishy

Presenter: Annabelle Rowland, MD 

How castor oil is made can matter when it comes to allergic reactions

Castor oil is a common ingredient in cosmetics, hair products and laxatives. Allergy to the castor bean, from which castor oil is made, is well known. It almost always appears as a workplace allergy from breathing in bean dust. Anaphylaxis is rare from castor oil and has usually only been reported in adults exposed to the seed.

This case describes the first reported anaphylaxis in a child from castor oil applied to the skin. A 10-year-old girl with eczema on her scalp, neck and elbows used heat-pressed castor oil on her hair for years without trouble. The first time cold-pressed castor oil was applied to her scalp, she developed hives on her face and neck, wheezing and shortness of breath. She was treated in the emergency room with epinephrine, albuterol and steroids. Skin prick testing with her own products was positive for the cold-pressed oil and negative for the heat-pressed oil.

"Cold pressing keeps certain castor bean proteins intact, while the heat used in refining breaks them down," said allergist Keyun Wang, DO, lead author of the study and ACAAI member. "We believe years of applying oil to eczema-damaged skin may have caused her to develop an allergy, and the protein-rich cold-pressed oil then triggered a reaction. When evaluating allergy risk from plant oils, we must consider how the oil is processed, not just the plant source."

Abstract Title: Pediatric Anaphylaxis Due to Topical Castor Oil Application

Presenter: Keyun Wang, DO 

Two squishy toys and two trips to the ER

Squishy squeeze ball toys are popular with some kids for stress relief and sensory play. Known risks include choking and skin irritation, but anaphylaxis has not been reported until now.

An 11-year-old girl with allergic rhinitis and asthma developed hives, swelling and throat tightness after handling a squishy toy at home and touching her face. She received epinephrine in the ambulance, then had a rebound of breathing symptoms that needed further treatment in the emergency department. One week later, she felt her throat tighten within an hour of using a different squishy toy at school. She used her own epinephrine and was taken to the ER again. The girl had no prior history of anaphylaxis, food allergy or latex allergy, but blood testing showed she was sensitized to latex. No other trigger was found.

"These toys are often marketed as non-toxic rubber, but they can contain a long list of chemical additives, and their exact makeup usually isn't disclosed," said Megan Marte, MD, lead author of the case report and ACAAI member. "Toy-related anaphylaxis has been linked to latex in ball pit materials, which raises the question of latex contamination or cross-reactivity in squishy toys. If a child has an unexplained severe reaction after playing with a toy, it's worth looking at the toys they've been playing with and possibly see an allergist."

Abstract Title: Anaphylaxis Following Exposure to a Squishy Squeeze Ball Toy: A Case Report

Presenter: Megan Marte, MD

Anyone with symptoms of a severe allergic reaction should seek emergency care. To learn more about anaphylaxis, and find an allergist near you, visit AllergyandAsthmaRelief.org The ACAAI Annual Scientific Meeting is Nov. 12-16. For more news and research from the ACAAI Scientific Meeting, go to our newsroom and follow the conversation on X/Twitter #ACAAI26.

About ACAAI

The American College of Allergy, Asthma & Immunology (ACAAI) is a professional medical organization of more than 6,500 allergists-immunologists and allied health professionals, headquartered in Arlington Heights, Ill. Founded in 1942, the College fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy, and research. ACAAI allergists are board-certified physicians trained to diagnose allergies and asthma, administer immunotherapy, and provide patients with the best treatment outcomes. For more information and to find relief, visit AllergyandAsthmaRelief.org. Join us on Facebook, Instagram, Threads and X.

ANAPHYLAXIS FOLLOWING ENERGY DRINK CONSUMPTION REVEALS SOMETHING FISHY
M517
A. Rowland^*, Atlanta, GA.

Introduction

A teenager presents with anaphylaxis after consuming energy drink containing fish collagen. 

Case Description

This case describes a 15-year-old boy with history of eczema, asthma, allergic rhinitis, and idiopathic pulmonary hemosiderosis who presented to allergy clinic following anaphylaxis. He was trying a new energy drink, and within minutes, he developed diffuse hives, wheezing, and difficulty breathing. He was evaluated in the emergency department and treated with intramuscular epinephrine twice as well as albuterol, cetirizine, and isotonic fluids with resolution of symptoms. He was in his usual state of health earlier that day and denies exercise or NSAID use prior to reaction.  He has noticed throat itching and mild lip swelling with ingestion of canned tuna fish. He tolerates salmon as well as the other top-9 allergens without concern. History is also notable for localized urticaria following exposure to chlorhexidine wash. Review of drink ingredients revealed 5 grams of fish collagen derived from cod. Skin prick testing (SPT) in clinic was negative for tuna, cod, and flounder but positive for environmental allergens. Family was asked to bring fresh cod for prick-to-prick testing, but working diagnosis for this patient is allergy to fish collagen as further testing is pending.

Discussion

This case demonstrates nuances of fish allergy which are important to consider as fish collagen is included in a growing number of products. A previous study demonstrated sensitization to fish collagen in patients without evidence of sensitization to parvalbumin¹. Commercial fish extracts have minimal collagen and can lead to missed diagnoses².

PEDIATRIC ANAPHYLAXIS DUE TO TOPICAL CASTOR OIL APPLICATION
M055
K. Wang^*, M. Vastardi, Brooklyn, NY.

Introduction

Ricinus communis L. (castor bean) yields an oil that is commonly used in cosmetics, laxatives, and hair products. Castor sensitization is well described but almost always as an occupational inhalant allergy. Anaphylaxis is rare and previously reported only in adults exposed to the seed. We describe the first pediatric anaphylaxis attributed to topically applied castor oil, with reactivity dependent on the oil's processing method.

Case

A 10-year-old girl with atopic dermatitis of the scalp, nape, and antecubital fossae with previous use of heat-pressed castor oil for hair care, developed urticaria of the face and neck, wheeze, and dyspnea within minutes of the first topical application of cold-pressed castor oil to her scalp. In the emergency room, she responded to intramuscular epinephrine, nebulized albuterol, and systemic corticosteroids. Skin prick testing with her own products was positive to cold-pressed oil and negative to the heat-pressed oil. Laboratory results revealed total serum IgE of 573 kU/L with broad aeroallergen polysensitization including latex allergy. Castor specific IgE testing was unavailable.

Discussion

This is the first reported anaphylaxis case from topical castor oil and the first clinical demonstration of processing-dependent reactivity. Cold pressing preserves native, heat-labile storage proteins (2S albumins Ric c 1 and Ric c 3), whereas thermal refining denatures them. Years of heat-pressed oil use on barrier-impaired, eczematous skin possibly enabled epicutaneous sensitization, with the protein-rich cold-pressed oil later crossing the reaction elicitation threshold. Processing methods, not merely the source ingredient, should be considered when assessing the allergenic risk of plant-derived oils.

ANAPHYLAXIS FOLLOWING EXPOSURE TO A SQUISHY SQUEEZE BALL TOY: A CASE REPORT
M082
M. Marte^*, A. Nowak-Wegrzyn, E. Putter, New York, NY.

Introduction: Squishy Squeeze Ball Toys are popular sensory toys. Health risks include choking, chemical burns, skin irritation, or toxic fume inhalation, but anaphylaxis has not been reported to date. We report a case of anaphylaxis temporally associated with squishy toy exposure in an atopic child with latex sensitization.?
Case Description: An 11-year-old female with allergic rhinitis and asthma developed acute-onset urticaria, angioedema, and throat tightness after handling a squishy toy and touching her face at home. During ambulance transport, the patient received intramuscular epinephrine with initial improvement, followed by rebound respiratory symptoms treated with intravenous diphenhydramine, then observation in the ED. One week later, she experienced throat tightness within an hour of handling a different squishy toy at school, prompting self-administered epinephrine and another ED visit for oral prednisone. Serum latex-specific IgE was elevated (3.2 kUa/L), indicating latex sensitization. The presentation met clinical criteria for anaphylaxis, and no alternate trigger was identified. She had no history of anaphylaxis, food, or latex allergies.
Discussion: This case highlights squishy toys as a potential source of severe allergic reactions in children. Although marketed as non-toxic thermoplastic rubber (TPR), these toys may contain numerous chemical additives, including volatile solvents, vulcanization accelerators, diisocyanates, styrene monomers, and phthalate plasticizers. Toy-related anaphylaxis has been linked to latex-contaminated ball pit materials, raising concern for latex contamination or cross-reactivity within squishy toy products. The undisclosed composition of children’s toys makes allergen identification challenging, emphasizing the need for comprehensive allergy workup and evaluation of toy materials in unexplained anaphylaxis.

 

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