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The Kiss of Death: A Severe Allergic Reaction to a Shellfish Induced by a Good-Night Kiss

2003; Elsevier BV; Volume: 78; Issue: 2 Linguagem: Inglês

10.4065/78.2.221

1942-5546

David P. Steensma,

Contact Dermatitis and Allergies

True (IgE-mediated) allergic reactions to crustaceans are relatively common and can be serious. A young woman with a clinical history of multiple urticarial reactions after touching shrimp and lobster dishes was seen in an emergency department of a Mayo Clinic-affiliated hospital for an anaphylactic reaction that developed immediately after she kissed her boyfriend. The boyfriend had eaten several shrimp just before the kiss. It is important to warn susceptible patients that food does not actually have to be eaten to trigger an allergic reaction; touching the offending food and kissing or touching someone who has recently eaten the food can be enough to cause a major reaction. True (IgE-mediated) allergic reactions to crustaceans are relatively common and can be serious. A young woman with a clinical history of multiple urticarial reactions after touching shrimp and lobster dishes was seen in an emergency department of a Mayo Clinic-affiliated hospital for an anaphylactic reaction that developed immediately after she kissed her boyfriend. The boyfriend had eaten several shrimp just before the kiss. It is important to warn susceptible patients that food does not actually have to be eaten to trigger an allergic reaction; touching the offending food and kissing or touching someone who has recently eaten the food can be enough to cause a major reaction. True (IgE-mediated) allergic reactions to crustaceans are relatively common and can be serious. A young woman with a clinical history of multiple urticarial reactions after touching shrimp and lobster dishes was seen in an emergency department of a Mayo Clinic-affiliated hospital for an anaphylactic reaction that developed immediately after she kissed her boyfriend. The boyfriend had eaten several shrimp just before the kiss. It is important to warn susceptible patients that food does not actually have to be eaten to trigger an allergic reaction; touching the offending food and kissing or touching someone who has recently eaten the food can be enough to cause a major reaction. True (IgE-mediated) food allergies are relatively common; foodstuffs such as tree nuts (pistachios, walnuts, macadamia nuts, almonds, pecans, Brazil nuts, cashews, chestnuts, filberts, hazelnuts, etc), shellfish (mollusks and crustaceans), eggs, soybeans, and peanuts can induce severe and even fatal allergic reactions.1Lehrer SB Ayuso R Reese G Current understanding of food allergens.Ann N Y Acad Sci. 2002; 964: 69-85Crossref PubMed Scopus (82) Google Scholar, 2Bock SA Munoz-Furlong A Sampson HA Fatalities due to anaphylactic reactions to foods.J Allergy Clin Immunol. 2001; 107: 191-193Abstract Full Text PDF PubMed Scopus (1371) Google Scholar A susceptible person does not always need to eat the culpable food item to develop a reaction. In one survey of people who had allergic reactions to peanuts served on commercial airliners, only 48% of patients had actually ingested the peanuts; 33% merely inhaled peanut allergen, and 19% had only skin contact.3Sicherer SH Furlong TJ DeSimone J Sampson HA Self-reported allergic reactions to peanut on commercial airliners.J Allergy Clin Immunol. 1999; 104: 186-189Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar Rarely, food allergens can be conveyed from one person to another through kissing or other physical contact, which can result in an allergic reaction.4Hallett R Haapanen LA Teuber SS Food allergies and kissing [letter].N Engl J Med. 2002; 346: 1833-1834Crossref PubMed Scopus (53) Google Scholar, 5Wuthrich B Dascher M Borelli S Kiss-induced allergy to peanut.Allergy. 2001; 56: 913Crossref PubMed Scopus (42) Google Scholar, 6Mancuso G Berdondini RM Oral allergy syndrome from kiwi fruit after a lover's kiss.Contact Dermatitis. 2001; 45: 41Crossref PubMed Scopus (30) Google Scholar, 7Wuthrich B Oral allergy syndrome to apple after a lover's kiss.Allergy. 1997; 52: 235-236Crossref PubMed Scopus (26) Google Scholar I describe a young woman who experienced a near-fatal anaphylactic reaction to shellfish antigens that were transmitted to her through a good-night kiss from her boyfriend. The patient gave me permission to report her event, and this report was approved by the Mayo Foundation Institutional Review Board. A 20-year-old woman presented to an emergency department of a Mayo Clinic-affiliated hospital with sudden onset of lip angioedema, throat swelling, diffuse flushing, urticaria, abdominal cramps, nausea, wheezing, severe dyspnea, and hypotension (noninvasive blood pressure level of 80/50 mm Hg) that developed immediately after kissing her boyfriend. Intramuscular diphenhydramine and methylprednisolone, nebulized albuterol, intravenous saline, humidified oxygen by face mask, and intravenous epinephrine were administered, and the patient improved rapidly. She had been aware of an allergy to crustaceans (shrimp and lobster) for several years but despite this history had taken a job as a waitress at a seafood restaurant. Although the patient sometimes wore protective gloves while serving food, she reported that her supervisors frowned on this practice because of concerns about customer perceptions and frequently asked her to remove them. As a result, she often developed urticaria on her arms during her work shifts, but she had never had angioedema or anaphylaxis. The patient established a romantic relationship with a male coworker at the restaurant. On the night of the reaction described earlier, her boyfriend, who had eaten some shrimp less than 1 hour earlier, gave the patient a passionate good-night kiss at her home. The patient's symptoms began less than 1 minute after the kiss. She had been asymptomatic at the time she left the restaurant earlier in the evening. After treatment and a period of observation in the emergency department, the patient was dismissed home. She was given a prescription for an epinephrine injection kit, counseled to scrupulously avoid shellfish exposure, and instructed to follow up with her primary care physician. She pledged to seek new employment. True anaphylactic reactions are defined as systemic, inflammatory, immediate hypersensitivity reactions mediated by antigen-IgE binding, with subsequent mast cell and basophil degranulation and release of histamine and other vasoactive substances. Food exposures, insect envenomation, and drugs or other therapeutic biological agents are among the most common causes of these reactions.8Lieberman P Anaphylaxis and anaphylactoid reactions.in: Middleton Jr, E Reed CE Ellis EF Adkinson Jr, NF Yunginger JW Busse WW 5th ed. Allergy: Principles and Practice. Vol 2. Mosby, St Louis, Mo1998: 1079-1092Google Scholar The typical responsible food allergens differ according to regional eating habits; peanuts, tree nuts, and crustaceans are among the most common causes of severe allergic reactions in the United States, whereas buckwheat reactions often are seen in the Far East.9Wieslander G Norback D Buckwheat allergy [editorial].Allergy. 2001; 56: 703-704Crossref PubMed Scopus (61) Google Scholar Kissing, an ancient technique for expressing simple affection or erotic desire,10Cane W The Art of Kissing. St Martin's Press, New York, NY1995: 180Google Scholar has been recognized only recently as a vector for transmitting food allergens.4Hallett R Haapanen LA Teuber SS Food allergies and kissing [letter].N Engl J Med. 2002; 346: 1833-1834Crossref PubMed Scopus (53) Google Scholar, 5Wuthrich B Dascher M Borelli S Kiss-induced allergy to peanut.Allergy. 2001; 56: 913Crossref PubMed Scopus (42) Google Scholar, 6Mancuso G Berdondini RM Oral allergy syndrome from kiwi fruit after a lover's kiss.Contact Dermatitis. 2001; 45: 41Crossref PubMed Scopus (30) Google Scholar, 7Wuthrich B Oral allergy syndrome to apple after a lover's kiss.Allergy. 1997; 52: 235-236Crossref PubMed Scopus (26) Google Scholar In a recent review of 379 cases of apparent IgE-mediated food-induced allergic reactions seen at the University of California at Davis, 20 patients (5.3%)—mostly young adults—reported kissing-related reactions, primarily to peanuts and tree nuts.4Hallett R Haapanen LA Teuber SS Food allergies and kissing [letter].N Engl J Med. 2002; 346: 1833-1834Crossref PubMed Scopus (53) Google Scholar Only one of these reactions was considered life-threatening. The only patient in this series who was allergic to fish was intolerant to sea bass and catfish, not to crustaceans (S. Teuber, written communication, June 12, 2002). Our patient had been exposed repeatedly to a variety of crustacean dishes cutaneously through her employment and as a consequence had experienced a series of mild allergic reactions. These minor reactions may have served to "prime" her immune system to produce more IgE antibodies directed at crustacean proteins, a phenomenon that is well described with respect to seasonal allergens such as ragweed and other noxious pollens.11Henderson LL Larson JB Gleich GJ Maximal rise in IgE antibody following ragweed pollination season.J Allergy Clin Immunol. 1975; 55: 10-15Abstract Full Text PDF PubMed Scopus (58) Google Scholar A much more severe reaction was then induced by intraoral mucosal allergen contact to shrimp peptides from her boyfriend's tongue, saliva, and mouth. It is possible that she also had some degree of inhalational exposure to the offending substance, but the relative contribution of the 2 routes of exposure remains uncertain. Detailed immunologic testing such as the radioallergosorbent test or skin prick test was not performed in this patient. To my knowledge, this is the first report of a life-threatening reaction to shellfish transmitted by passionate kissing. Although most people are aware that passionate kissing can result in a variety of physical and emotional effects, patients with food allergies should be made aware that such intimate physical contact may present extreme dangers that are peculiar to their situation. This case report underscores the importance of carefully counseling all patients who are allergic to food that they must avoid exposure to offending proteins via all potential routes of contact, including kissing and touching. Carrying an injectable epinephrine kit (and having been instructed in its use) and wearing or bearing emergency medical information (eg, a Medic-Alert bracelet) may also be helpful for patients susceptible to severe allergic reactions. I thank Dr Suzanne S. Teuber of the University of California at Davis for helpful discussion of this case.