IgE-mediated cocoa allergy: a pediatric case report and review of the literature

Background: 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. Case presentation: 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. Conclusion: 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.