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Background: Immunoglobulin (Ig)E-mediated hypersensitivity is a mechanism suggested to explain adverse reactions to buckwheat. This is the first reported case in the United States of a person who developed asthma and worsening allergic rhinitis after exposure to a buckwheat pillow., Objective: To describe a patient who developed asthma and worsening allergic rhinitis after exposure to a buckwheat pillow and to provide evidence that the adverse reaction was IgE-mediated., Methods: The patient underwent skin prick and ImmunoCAP testing (Pharmacia Diagnostics, Kalamazoo, MI) to buckwheat as well as skin prick testing to several environmental allergens., Results: The patient showed a 4+ skin prick test response to buckwheat. He also showed 4+ positive skin prick responses to multiple trees, grasses, and weeds, Alternaria, Helminthosporium, dog, and histamine control and was 3+ positive to house-dust mites, Penicillium, Aspergillus, cat, and feather mix. His negative control was negative. His ImmunoCAP test for buckwheat-specific IgE was class 4, or strongly positive. He had normal spirometry values. Performance of house-dust mite avoidance measures did not result in improvement of the patient's symptoms. Removal of the patient's two buckwheat pillows resulted in resolution of his asthma and improvement of rhinitis symptoms., Conclusions: The positive skin prick and ImmunoCAP test to buckwheat along with the positive clinical response to buckwheat pillow elimination support an IgE-mediated mechanism in explaining our patient's buckwheat pillow-induced asthma and allergic rhinitis.