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the development of food allergies is an increasingly common concern among consumers worldwide . in the united states ,
approximately 6% of infants and young children , and 3.7% of adults exhibit some degree of allergic reaction to certain foods .
the most common causal foods in young children are cows ' milk , eggs , peanuts , wheat , soy , tree nuts , fish , and shellfish ; in adults , shellfish , peanuts , tree nuts , and fish lead the list .
anisakis simplex is a nematode belonging to the order ascaridida , family anisakidae , and subfamily ascaridoidea .
codfish , hake , sardines , anchovies , salmon , tuna , and squid are among the most frequently parasitized species .
symptoms of anisakiasis arise when the nematode penetrates the gastric mucosa , which leads to serious abdominal and allergic symptoms .
van thiel et al .   reported the first case of anisakiasis , in the netherlands in 1960 .
subsequently , many cases have been reported in japan and western europe , where raw fish are consumed frequently .
kim et al .   reported a case of anisakis larvae present in the human oropharynx as the first case of anisakiasis in korea , in 1971 .
thereafter , several patients suffering acute anisakiasis and presenting mainly with gastrointestinal symptoms such as abdominal pain , nausea , vomiting , and diarrhea have been analyzed via gastroduodenoscopy .
described a method for detecting specific ige against a. simplex in 1985 . since that time , kasuya et al
have confirmed the allergic potential of a. simplex in two clinical reports and emphasized this species as a causative allergen related to fish consumption in urticaria patients . in korea , since kim et al .  
reported the first case of gastroallergic anisakiasis , which developed after the patient had consumed raw fish on jeju island , there have been no published reports on anisakis - induced allergic reactions , although koreans freely ingest raw fish . here ,
ten patients ( 6 men and 4 women ) who developed abdominal pain , acute or chronic urticaria / angioedema , or anaphylaxis less than 24 hours after ingesting seafood were enrolled in our study .
sensitization to a. simplex was assessed by detecting serum specific ige to a. simplex ( immunocap system ; phadia , uppsala , sweden ) .
we investigated the clinical parameters of each patient , including age , gender , allergic symptoms , fish species ingested , associated allergic diseases including food allergies , atopic dermatitis , bronchial asthma , allergic rhinitis , chronic urticaria , and atopy status .
we also measured the serum total ige , specific ige to a. simplex , and eosinophilic cationic protein ( ecp ) level using an immunocap system ( phadia ) .
atopy status was defined in patients showing a positive response to one or more common inhalant allergens such as house dust mites , tree pollen , and weed pollen on an allergic skin prick test .
the clinical features and laboratory findings of the 10 patients with anisakis allergy are summarized in table 1 .
the mean age of the patients was 50 years ( range , 22 - 71 years ) .
all 10 patients had high serum specific ige to a. simplex , ranging from 0.45 - 100 ku / l , and this was not related to the severity of the allergic reactions .
the total peripheral eosino - phil counts were above baseline in two patients , and all but one of the patients in whom the serum ecp level was assessed exhibited an increased ecp levels .
chronic urticaria was noted in four patients ( 40% ) , food allergy was recorded in three ( 30% ) , and allergic rhinitis was exhibited by two ( 20% ) .
bronchial asthma and atopic dermatitis symptoms were not identified in any of the anisakis allergy patients .
the most common manifestation of anisakiasis in our study was urticaria / angioedema ( 100% ) , followed by abdominal pain ( 30% ) and anaphylaxis ( 30% ) .
the fish implicated in transmitting the parasites were flatfish ( 40% ) , congers ( 40% ) , squid ( 30% ) , whelk ( 10% ) , and tuna ( 10% ) ( fig .
the clinical features and laboratory findings of the 10 patients with anisakis allergy are summarized in table 1 .
the mean age of the patients was 50 years ( range , 22 - 71 years ) .
all 10 patients had high serum specific ige to a. simplex , ranging from 0.45 - 100 ku / l , and this was not related to the severity of the allergic reactions .
the total peripheral eosino - phil counts were above baseline in two patients , and all but one of the patients in whom the serum ecp level was assessed exhibited an increased ecp levels .
chronic urticaria was noted in four patients ( 40% ) , food allergy was recorded in three ( 30% ) , and allergic rhinitis was exhibited by two ( 20% ) .
bronchial asthma and atopic dermatitis symptoms were not identified in any of the anisakis allergy patients .
the most common manifestation of anisakiasis in our study was urticaria / angioedema ( 100% ) , followed by abdominal pain ( 30% ) and anaphylaxis ( 30% ) .
the fish implicated in transmitting the parasites were flatfish ( 40% ) , congers ( 40% ) , squid ( 30% ) , whelk ( 10% ) , and tuna ( 10% ) ( fig .
parasitic a. simplex can infest humans and cause anisakiasis when ingested with fish in its raw or undercooked form . since kasuya et al .  
first reported on anisakis allergies in mackerel - induced urticaria patients in 1990 , many anisakis - induced allergic reactions have been reported , especially in japan and spain .
infestation with a. simplex causes direct tissue damage following an invasion of the gut wall , the development of an eosinophilic granuloma , the perforation of the gut , and strong allergic reactions .
the most frequent clinical manifestation of an anisakis allergy is urticaria with or without facial angioedema .
audicana et al .   reported the clinical manifestations of allergies attributable to a. simplex in 67 cases in spain : urticaria / angioedema was observed in all patients , gastrointestinal symptoms occurred in 40% of the patients , and anaphylactic shock was observed in 12% .
uncommon manifestations of anisakiasis include anisakis - induced eosinophilic gastroenteritis , occupational disease , rheumatic manifestations , and contact dermatitis . in our patient cases , we determined the most common allergic symptoms to be acute or chronic urticaria / angioedema , which was observed in all patients ; abdominal pain and anaphylaxis occurred in three ( 30% ) patients .
this study represents the first report on the clinical features of 10 cases of anisakis allergy in korea .
we suggest that anisakis allergy should be considered in the differential diagnosis of korean patients presenting with a range of allergic symptoms , from urticaria to anaphylactic shock , especially if these patients present with atopy and recent seafood ingestion .
described the role of hidden allergens in allergic reactions , reporting that of 530 allergic reactions to food , 119 ( 22.4% ) cases were considered to be responses to hidden allergens .
furthermore , 65 reactions ( 12% ) were anaphylaxis , and 38 ( 58.5% ) of those were the result of hidden allergens .
abarro and colleagues   also showed that a. simplex was the cause of 58% of their anaphylaxis cases and was the most common cause of hidden food reactions ( 45% ) , followed by nuts ( 13% ) and fish ( 7.9% ) .
thus , a. simplex should be considered a prevalent hidden allergen involved in food allergic reactions .
the fish species most frequently involved in anisakis allergy are hake , anchovy , and cod , although studies have reported these fish in different orders of importance . in our study , flatfish and congers were implicated most often , followed by squid , whelk , and tuna .
we postulate that the differences result from variations in the fish species consumed in korea .
flatfish and conger are the fish most frequently consumed raw in korea ; seol et al
.   stated that the main source of anisakis infection in their patients was conger myriaster .
the diagnosis of anisakis allergy is based on three criteria : a compatible history such as urticaria , angioedema , or anaphylaxis that developed following fish consumption ; a positive skin prick test or the presence of serum specific ige to a. simplex ; and the lack of a reaction to proteins from the host fish . in the present study ,
all of the patients had a history compatible with anisakis allergy and had high serum specific ige to a. simplex .
all of the patients , with the exception of three who refused the test , showed negative responses to host fish extracts in skin prick tests .
the failure to perform the skin test in three cases may be a limitation of our study
the larvae can not survive in temperatures above 60 for 10 min or below -20 for 24 h .
we requested that our patients avoid eating raw fish while we were monitoring allergic symptoms and serum specific ige to a. simplex . in conclusion
, we recommend that a. simplex be considered as a possible causative food allergen in adults presenting with urticaria , angioedema , or anaphylaxis following raw fish or seafood consumption .
anisakidae larvae can cause anisakiasis when ingested by humans . 
 although several groups have reported a gastrointestinal anisakis allergy among people in spain and japan , our report is the first to summarize the clinical features of 10 anisakis allergy cases in korea . 
 we enrolled 10 korean patients ( 6 men and 4 women ) who complained of aggravated allergic symptoms after ingesting raw fish or seafood . 
 sensitization to anisakis was confirmed by detecting serum specific ige to anisakis simplex . 
 the most common manifestation of anisakiasis was urticaria ( 100% ) , followed by abdominal pain ( 30% ) and anaphylaxis ( 30% ) . 
 all patients presenting with these symptoms also exhibited high serum specific ige ( 0.45 to 100 ku / l ) to a. simplex . 
 nine patients ( 90% ) exhibited atopy and increased total serum ige levels . 
 the fish species suspected of carrying the anisakis parasite were flatfish ( 40% ) , congers ( 40% ) , squid ( 30% ) , whelk ( 10% ) , and tuna ( 10% ) . 
 anisakis simplex should be considered as a possible causative food allergen in adult patients presenting with urticaria , angioedema , and anaphylaxis following the consumption of raw fish or seafood .