Dust mite ingestion–associated, exercise-induced anaphylaxis
2007; Elsevier BV; Volume: 120; Issue: 3 Linguagem: Inglês
10.1016/j.jaci.2007.04.017
ISSN1097-6825
AutoresMario Sánchez‐Borges, Víctor Iraola, Enrique Fernández‐Caldas, Arnaldo Capriles-Hulett, Fernán Caballero-Fonseca,
Tópico(s)Allergic Rhinitis and Sensitization
ResumoTo the Editor:Exercise-induced anaphylaxis (EIA) was reported for the first time in 1980 by Maulitz et al.1Maulitz R.M. Pratt D.S. Shocket A.L. Exercise-induced anaphylactic reaction to shellfish.J Allergy Clin Immunol. 1979; 63: 433-434Abstract Full Text PDF PubMed Scopus (315) Google Scholar The clinical picture of this physical allergy includes premonitory symptoms (diffuse warmth, itching, and erythema) followed by urticaria and angioedema that can progress to include gastrointestinal symptoms, laryngeal edema, and/or vascular collapse.2Lieberman P. Kemp S.F. Oppenheimer J. Lang D. Bernstein I.L. Nicklas R.A. Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter.J Allergy Clin Immunol. 2005; 115: S483-S523Abstract Full Text Full Text PDF PubMed Scopus (517) Google Scholar Drugs (aspirin and nonsteroidal anti-inflammatory drugs) and foods (wheat, shellfish, celery, hazelnut, soy, peanut, pea, cauliflower, and banana) taken before or after exercise have been associated with EIA,3Lewis J. Lieberman P. Treadwell G. Exercise-induced urticaria, angioedema, and anaphylactic episodes.J Allergy Clin Immunol. 1981; 68: 432-437Abstract Full Text PDF PubMed Scopus (53) Google Scholar and individuals with this condition have a higher incidence of a personal and family history of atopy.1Maulitz R.M. Pratt D.S. Shocket A.L. Exercise-induced anaphylactic reaction to shellfish.J Allergy Clin Immunol. 1979; 63: 433-434Abstract Full Text PDF PubMed Scopus (315) Google ScholarOral mite anaphylaxis (pancake syndrome) is a generalized allergic/anaphylactic reaction caused by the ingestion of foods prepared with contaminated wheat flour containing domestic or storage mites, more often foods such as pancakes and beignets.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar, 5Sánchez-Borges M. Capriles-Hulett A. Capriles-Behrens E. Fernández-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens.Cutis. 1997; 59: 311-314PubMed Google Scholar It is observed in atopic individuals generally living in subtropical and tropical regions of the world; a large proportion of these susceptible subjects are intolerant to aspirin and nonsteroidal anti-inflammatory drugs.5Sánchez-Borges M. Capriles-Hulett A. Capriles-Behrens E. Fernández-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens.Cutis. 1997; 59: 311-314PubMed Google ScholarIn this article we report one patient who had a clinical picture resembling EIA occurring after the ingestion of pancakes. The patient is a 16-year-old girl who experienced upper limb and later generalized itching accompanied by facial (eyelid) edema and breathlessness while playing soccer at school. Approximately 30 minutes before starting to play, she had taken lunch consisting of homemade pancakes made from a commercial pancake mixture that had been stored in a previously opened container. It took about 15 minutes of exercising for symptoms to begin. The patient was transported to the emergency department, where intravenous corticosteroids, chlorpheniramine, and nebulized albuterol were administered; after discharge, she received oral methylprednisolone, desloratadine, inhaled budesonide, and formoterol. She had a previous medical history of asthma, allergic rhinoconjunctivitis, atopic dermatitis, and allergy to squids.Immediate-type hypersensitivity skin tests were carried out by means of the skin prick method with commercial allergenic extracts (ALK-Abelló and Laboratorios Leti S.L., Madrid, Spain) with the following results: Dermatophagoides pteronyssinus, 23-mm wheal, Blomia tropicalis, 13-mm wheal; pancake mix extract 1:5 (wt/vol) in normal saline solution, 6-mm wheal; and histamine phosphate 1%, 6-mm wheal. Other allergenic extracts, including mold mix, Bermuda grass, ragweed, rye grass, tree mix, feathers, dog, cat, cockroach, milk, egg, wheat, oat, barley, corn, soy, peanut, orange, chicken, pork, beef, cocoa, shellfish mix, fish mix, tomato, salmon, tuna, pineapple, strawberry, and glycerosaline solution did not induce immediate cutaneous reactions (0-mm wheal).To investigate possible cross-reactions between mites present in the pancake mixture, skin prick tests with D pteronyssinus, B tropicalis (Laboratorios Leti S.L., Madrid, Spain), Dermatophagouides farinae, Acarus siro, Chortoglyphus arcuatus, Lepidoglyphus destructor, and Tyrophagus putrescientiae extracts (Diater Laboratories, Buenos Aires, Argentina), as well as with pancake mix extract, were carried out in 20 unselected patients (13 female and 7 male patients) with allergic rhinitis (n = 11), rhinitis and asthma (n = 4), rhinitis and atopic dermatitis (n = 1), rhinitis and chronic urticaria (n = 1), vasomotor rhinitis (n = 1), chronic angioedema (n = 1), or acute urticaria (n = 1). Two patients, one who had vasomotor rhinitis and another who had acute urticaria, did not react either to mite extracts or to Suidasia species–contaminated pancake mix. Seven of the remaining 18 patients reacted to various mite species but did not react to contaminated pancake mix, whereas 11 patients had positive skin prick test results to mite extracts and Suidasia species–contaminated flour.Pancake flour ingested by the patient before the initiation of the clinical picture was available for study. No live contaminants were observed during direct microscopic examination of the flour. However, after clarification and staining, Suidasia medanensis in a concentration of 4814.8 mites per gram of flour was found (Fig 1 shows several S medanensis mites contaminating the flour). Levels of Der p 1 and Der f 1 in the flour were quantified by means of enzymatic immunoassay with species-specific mAbs (Indoor Biotechnologies, Manchester, United Kingdom). Der p 1 and Der f 1 levels were less than the detection level of the assays (0.05 μg/g of flour), confirming the absence of D pteronyssinus and D farinae.We present in this article one patient who experienced signs and symptoms of anaphylaxis precipitated by physical exercise. Wheat flour pancakes heavily contaminated only with the mite species S medanensis were ingested before the exercise. In our previous studies on oral mite anaphylaxis, we found a number of mite species, such as D pteronyssinus, Aleuroglyphus ovatus, L destructor, B tropicalis, and Suidasia species, contaminating foods made with wheat flour. The quantity of mites present in this flour is within the range of inducing anaphylaxis, as observed previously by our group.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar Skin prick test results were positive for D pteronyssinus, B tropicalis, and pancake mix extract and negative for other inhalant and food extracts, including wheat.Presently the patient described in this report is under our observation, and she has been recommended not to exercise within 4 hours after eating,2Lieberman P. Kemp S.F. Oppenheimer J. Lang D. Bernstein I.L. Nicklas R.A. Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter.J Allergy Clin Immunol. 2005; 115: S483-S523Abstract Full Text Full Text PDF PubMed Scopus (517) Google Scholar to carry an Epipen autoinjector, and to preserve the flour in the freezer as a preventive measure to avoid mite and insect contamination.6Codina R. Jaen C. Lockey R.F. Cockroach debris in purchased flour.Allergy. 2002; 57: 260-261Crossref PubMed Scopus (3) Google Scholar She continues to practice sports without recurrence of symptoms. Both the family and the patient rejected a double-blind food challenge with the purported food.The diversity of mite species in our environment has been recently demonstrated by Capriles-Hulett et al,7Capriles-Hulett A, Sánchez-Borges M, Fernández-Caldas E, Iraola V, Daboin de Veer M, Caplin J. Why some allergic patients develop an isolated IgE response to Blomia tropicalis? Genetics versus environment [abstract]. In: XXV Congress of the European Academy of Allergology and Clinical Immunology; 2006; Wien, AustriaGoogle Scholar who have shown the presence of several species of mites, including D pteronyssinus, D farinae, Euroglyphus maynei, B tropicalis, S medanensis, and other mite species, in mattress dust from allergic Venezuelan patients. Thus there is a potential risk for some of these species present in human dwellings to contaminate foods, as demonstrated by this and previous investigations.Cross-reactivity between Suidasia species and other mite species has been previously investigated. The results suggested high-to-moderate degrees of cross-reactivity between Suidasia species and B tropicalis and between Suidasia species and Dermatophagoides species.8Puerta L. Lagares A. Mercado D. Fernandez-Caldas E. Caraballo L. Allergenic composition of the mite Suidasia medanensis and cross-reactivity with Blomia tropicalis.Allergy. 2005; 60: 41-47Crossref PubMed Scopus (23) Google ScholarWe acknowledge that in our study the patients were not skin tested with a standardized S medanensis extract. However, the large numbers of S medanensis present in the flour sample and the fact that this species was the only one colonizing the sample in the absence of wheat allergy suggested to us that these mites could be responsible for the clinical picture.Furthermore, the allergens responsible for these reactions seem to be heat resistant, as we have previously reported.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar Also, it is interesting to point out that 9 of 20 additional patients tested with the contaminated flour extract did not react, suggesting that this preparation is not an irritant and does not induce false-positive skin test results.To the best of our knowledge, there is only one report in the literature in which EIA was associated with food contaminant ingestion. This was a report of a 14-year-old asthmatic boy who presumably had 3 episodes of EIA after eating salami contaminated with the fungus Penicillium lanoso-caeruleum and running in the school or playing soccer.9Fiocchi A. Mirri G.P. Santini I. Bernardo L. Ottoboni F. Riva E. Exercise-induced anaphylaxis after food contaminant ingestion in double-blinded, placebo-controlled, food-exercise challenge.J Allergy Clin Immunol. 1997; 100: 424-425Abstract Full Text Full Text PDF PubMed Scopus (36) Google ScholarWe would like to propose that dust mite ingestion–associated, exercise-induced anaphylaxis be recognized as a new disease and its diagnosis considered in allergic patients who experience anaphylactic manifestations after eating foods prepared with flour contaminated with mites and performing physical activities. To the Editor: Exercise-induced anaphylaxis (EIA) was reported for the first time in 1980 by Maulitz et al.1Maulitz R.M. Pratt D.S. Shocket A.L. Exercise-induced anaphylactic reaction to shellfish.J Allergy Clin Immunol. 1979; 63: 433-434Abstract Full Text PDF PubMed Scopus (315) Google Scholar The clinical picture of this physical allergy includes premonitory symptoms (diffuse warmth, itching, and erythema) followed by urticaria and angioedema that can progress to include gastrointestinal symptoms, laryngeal edema, and/or vascular collapse.2Lieberman P. Kemp S.F. Oppenheimer J. Lang D. Bernstein I.L. Nicklas R.A. Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter.J Allergy Clin Immunol. 2005; 115: S483-S523Abstract Full Text Full Text PDF PubMed Scopus (517) Google Scholar Drugs (aspirin and nonsteroidal anti-inflammatory drugs) and foods (wheat, shellfish, celery, hazelnut, soy, peanut, pea, cauliflower, and banana) taken before or after exercise have been associated with EIA,3Lewis J. Lieberman P. Treadwell G. Exercise-induced urticaria, angioedema, and anaphylactic episodes.J Allergy Clin Immunol. 1981; 68: 432-437Abstract Full Text PDF PubMed Scopus (53) Google Scholar and individuals with this condition have a higher incidence of a personal and family history of atopy.1Maulitz R.M. Pratt D.S. Shocket A.L. Exercise-induced anaphylactic reaction to shellfish.J Allergy Clin Immunol. 1979; 63: 433-434Abstract Full Text PDF PubMed Scopus (315) Google Scholar Oral mite anaphylaxis (pancake syndrome) is a generalized allergic/anaphylactic reaction caused by the ingestion of foods prepared with contaminated wheat flour containing domestic or storage mites, more often foods such as pancakes and beignets.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar, 5Sánchez-Borges M. Capriles-Hulett A. Capriles-Behrens E. Fernández-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens.Cutis. 1997; 59: 311-314PubMed Google Scholar It is observed in atopic individuals generally living in subtropical and tropical regions of the world; a large proportion of these susceptible subjects are intolerant to aspirin and nonsteroidal anti-inflammatory drugs.5Sánchez-Borges M. Capriles-Hulett A. Capriles-Behrens E. Fernández-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens.Cutis. 1997; 59: 311-314PubMed Google Scholar In this article we report one patient who had a clinical picture resembling EIA occurring after the ingestion of pancakes. The patient is a 16-year-old girl who experienced upper limb and later generalized itching accompanied by facial (eyelid) edema and breathlessness while playing soccer at school. Approximately 30 minutes before starting to play, she had taken lunch consisting of homemade pancakes made from a commercial pancake mixture that had been stored in a previously opened container. It took about 15 minutes of exercising for symptoms to begin. The patient was transported to the emergency department, where intravenous corticosteroids, chlorpheniramine, and nebulized albuterol were administered; after discharge, she received oral methylprednisolone, desloratadine, inhaled budesonide, and formoterol. She had a previous medical history of asthma, allergic rhinoconjunctivitis, atopic dermatitis, and allergy to squids. Immediate-type hypersensitivity skin tests were carried out by means of the skin prick method with commercial allergenic extracts (ALK-Abelló and Laboratorios Leti S.L., Madrid, Spain) with the following results: Dermatophagoides pteronyssinus, 23-mm wheal, Blomia tropicalis, 13-mm wheal; pancake mix extract 1:5 (wt/vol) in normal saline solution, 6-mm wheal; and histamine phosphate 1%, 6-mm wheal. Other allergenic extracts, including mold mix, Bermuda grass, ragweed, rye grass, tree mix, feathers, dog, cat, cockroach, milk, egg, wheat, oat, barley, corn, soy, peanut, orange, chicken, pork, beef, cocoa, shellfish mix, fish mix, tomato, salmon, tuna, pineapple, strawberry, and glycerosaline solution did not induce immediate cutaneous reactions (0-mm wheal). To investigate possible cross-reactions between mites present in the pancake mixture, skin prick tests with D pteronyssinus, B tropicalis (Laboratorios Leti S.L., Madrid, Spain), Dermatophagouides farinae, Acarus siro, Chortoglyphus arcuatus, Lepidoglyphus destructor, and Tyrophagus putrescientiae extracts (Diater Laboratories, Buenos Aires, Argentina), as well as with pancake mix extract, were carried out in 20 unselected patients (13 female and 7 male patients) with allergic rhinitis (n = 11), rhinitis and asthma (n = 4), rhinitis and atopic dermatitis (n = 1), rhinitis and chronic urticaria (n = 1), vasomotor rhinitis (n = 1), chronic angioedema (n = 1), or acute urticaria (n = 1). Two patients, one who had vasomotor rhinitis and another who had acute urticaria, did not react either to mite extracts or to Suidasia species–contaminated pancake mix. Seven of the remaining 18 patients reacted to various mite species but did not react to contaminated pancake mix, whereas 11 patients had positive skin prick test results to mite extracts and Suidasia species–contaminated flour. Pancake flour ingested by the patient before the initiation of the clinical picture was available for study. No live contaminants were observed during direct microscopic examination of the flour. However, after clarification and staining, Suidasia medanensis in a concentration of 4814.8 mites per gram of flour was found (Fig 1 shows several S medanensis mites contaminating the flour). Levels of Der p 1 and Der f 1 in the flour were quantified by means of enzymatic immunoassay with species-specific mAbs (Indoor Biotechnologies, Manchester, United Kingdom). Der p 1 and Der f 1 levels were less than the detection level of the assays (0.05 μg/g of flour), confirming the absence of D pteronyssinus and D farinae. We present in this article one patient who experienced signs and symptoms of anaphylaxis precipitated by physical exercise. Wheat flour pancakes heavily contaminated only with the mite species S medanensis were ingested before the exercise. In our previous studies on oral mite anaphylaxis, we found a number of mite species, such as D pteronyssinus, Aleuroglyphus ovatus, L destructor, B tropicalis, and Suidasia species, contaminating foods made with wheat flour. The quantity of mites present in this flour is within the range of inducing anaphylaxis, as observed previously by our group.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar Skin prick test results were positive for D pteronyssinus, B tropicalis, and pancake mix extract and negative for other inhalant and food extracts, including wheat. Presently the patient described in this report is under our observation, and she has been recommended not to exercise within 4 hours after eating,2Lieberman P. Kemp S.F. Oppenheimer J. Lang D. Bernstein I.L. Nicklas R.A. Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter.J Allergy Clin Immunol. 2005; 115: S483-S523Abstract Full Text Full Text PDF PubMed Scopus (517) Google Scholar to carry an Epipen autoinjector, and to preserve the flour in the freezer as a preventive measure to avoid mite and insect contamination.6Codina R. Jaen C. Lockey R.F. Cockroach debris in purchased flour.Allergy. 2002; 57: 260-261Crossref PubMed Scopus (3) Google Scholar She continues to practice sports without recurrence of symptoms. Both the family and the patient rejected a double-blind food challenge with the purported food. The diversity of mite species in our environment has been recently demonstrated by Capriles-Hulett et al,7Capriles-Hulett A, Sánchez-Borges M, Fernández-Caldas E, Iraola V, Daboin de Veer M, Caplin J. Why some allergic patients develop an isolated IgE response to Blomia tropicalis? Genetics versus environment [abstract]. In: XXV Congress of the European Academy of Allergology and Clinical Immunology; 2006; Wien, AustriaGoogle Scholar who have shown the presence of several species of mites, including D pteronyssinus, D farinae, Euroglyphus maynei, B tropicalis, S medanensis, and other mite species, in mattress dust from allergic Venezuelan patients. Thus there is a potential risk for some of these species present in human dwellings to contaminate foods, as demonstrated by this and previous investigations. Cross-reactivity between Suidasia species and other mite species has been previously investigated. The results suggested high-to-moderate degrees of cross-reactivity between Suidasia species and B tropicalis and between Suidasia species and Dermatophagoides species.8Puerta L. Lagares A. Mercado D. Fernandez-Caldas E. Caraballo L. Allergenic composition of the mite Suidasia medanensis and cross-reactivity with Blomia tropicalis.Allergy. 2005; 60: 41-47Crossref PubMed Scopus (23) Google Scholar We acknowledge that in our study the patients were not skin tested with a standardized S medanensis extract. However, the large numbers of S medanensis present in the flour sample and the fact that this species was the only one colonizing the sample in the absence of wheat allergy suggested to us that these mites could be responsible for the clinical picture. Furthermore, the allergens responsible for these reactions seem to be heat resistant, as we have previously reported.4Sánchez-Borges M. Capriles-Hulett A. Fernández-Caldas E. Suarez-Chacón R. Caballero F. Castillo S. et al.Mite-contaminated foods as a cause of anaphylaxis.J Allergy Clin Immunol. 1997; 99: 738-743Abstract Full Text PDF PubMed Scopus (111) Google Scholar Also, it is interesting to point out that 9 of 20 additional patients tested with the contaminated flour extract did not react, suggesting that this preparation is not an irritant and does not induce false-positive skin test results. To the best of our knowledge, there is only one report in the literature in which EIA was associated with food contaminant ingestion. This was a report of a 14-year-old asthmatic boy who presumably had 3 episodes of EIA after eating salami contaminated with the fungus Penicillium lanoso-caeruleum and running in the school or playing soccer.9Fiocchi A. Mirri G.P. Santini I. Bernardo L. Ottoboni F. Riva E. Exercise-induced anaphylaxis after food contaminant ingestion in double-blinded, placebo-controlled, food-exercise challenge.J Allergy Clin Immunol. 1997; 100: 424-425Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar We would like to propose that dust mite ingestion–associated, exercise-induced anaphylaxis be recognized as a new disease and its diagnosis considered in allergic patients who experience anaphylactic manifestations after eating foods prepared with flour contaminated with mites and performing physical activities.
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