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Fixed food eruption caused by asparagus

2005; Elsevier BV; Volume: 116; Issue: 6 Linguagem: Inglês

10.1016/j.jaci.2005.09.032

1097-6825

Thomas Volz, D BERNER, Carl Weigert, Martin Röcken, Tilo Biedermann,

Contact Dermatitis and Allergies

To the Editor: A 50-year-old white woman working as a commercial clerk presented with 2 sharply marginated, round, slightly elevated erythemas on her right forearm and left chest wall that appeared a few hours after ingestion of tinned asparagus (Fig 1, A). These erythemas persisted for more than 4 weeks and faded slowly without treatment, leaving circumscribed areas of hyperpigmentation. In spring 2003 and 2004, the patient experienced another 2 episodes, with erythemas at exactly the same locations after eating either fresh or tinned asparagus. These erythemas never developed independent of asparagus intake. The patient had no previous medical history and no symptoms or signs of atopy, and she denied frequent previous contact with asparagus. Skin prick and patch tests with asparagus at extralesional areas (back and left arm), intralesional controls, and skin prick and patch tests with asparagus with 10 controls were negative. Specific reactions to asparagus were detected 72 hours after testing was performed in the hyperpigmented site of the right forearm (Fig 1, B). In agreement with these findings and consistent with the clinical observation, no immediate-type response could be observed in skin prick tests, and no specific IgE antibodies against asparagus could be detected in the patient's serum. A punch biopsy of the skin test reaction detected 72 hours after performing a patch test with tinned asparagus on the right forearm was carried out as marked in Fig 1, B. Immunohistochemical analysis revealed large quantities of CD3+CD8+ T lymphocytes both in the dermis and infiltrating the epidermis (Fig 2). These lymphocytes reaching into the basal layers of the epidermis represented an interface dermatitis–like pattern leading to vacuolated and apoptotic keratinocytes (hematoxylin-and-eosin staining, Fig 2). Moreover, literally all lymphocytes stained positive for the marker CD45RO (not shown). These findings indicate that activated CD3+CD8+ T lymphocytes induced keratinocyte apoptosis as it is found in lesions of fixed drug eruption. Together with the clinical observations and test results, a fixed food eruption to asparagus was diagnosed. In Western countries 20% to 35% of the population complains of food allergies, and the point prevalence of food allergy, as determined by appropriate diagnostic measures, is 2% to 4%.1Sampson H.A. Update on food allergy.J Allergy Clin Immunol. 2004; 113: 805-819Abstract Full Text Full Text PDF PubMed Scopus (1203) Google Scholar, 2Young E. Stoneham M.D. Petruckevitch A. Barton J. Rona R. A population study of food intolerance.Lancet. 1994; 343: 1127-1130Abstract PubMed Scopus (581) Google Scholar, 3Zuberbier T. Edenharter G. Worm M. Ehlers I. Reimann S. Hantke T. et al.Prevalence of adverse reactions to food in Germany—a population study.Allergy. 2004; 59: 338-345Crossref PubMed Scopus (288) Google Scholar Diagnostic measures in food allergy include standardized skin prick testing and measurement of specific IgE in the patient's serum. However, diagnosis of cell-mediated adverse reactions to food remains challenging. Patch testing has been shown to be useful in detecting food allergies in contact dermatitis, atopic dermatitis, or eosinophilic esophagitis.4Niggemann B. Evolving role of the atopy patch test in the diagnosis of food allergy.Curr Opin Allergy Clin Immunol. 2002; 2: 253-256Crossref PubMed Scopus (37) Google Scholar, 5Spergel J.M. Beausoleil J.L. Mascarenhas M. Liacouras C.A. The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis.J Allergy Clin Immunol. 2002; 109: 363-368Abstract Full Text Full Text PDF PubMed Scopus (480) Google Scholar In this report we demonstrate that intralesional skin testing is an important tool to detect food allergy. In agreement with population-based studies on the prevalence of food allergies, allergies to asparagus are also mainly IgE-mediated type I reactions resulting in allergic rhinitis, asthma, or contact urticaria.6Sanchez M.C. Hernandez M. Morena V. Guardia P. Gonzalez J. Monteiserin J. et al.Immunologic contact urticaria caused by asparagus.Contact Dermatitis. 1997; 37: 181-182Crossref PubMed Scopus (12) Google Scholar Among the delayed-type hypersensitivity reactions to foods, contact dermatitis to asparagus has been reported.7Rieker J. Ruzicka T. Neumann N.J. Homey B. Protein contact dermatitis to asparagus.J Allergy Clin Immunol. 2004; 113: 354-355Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Recurring erythemas in identical areas of the skin or mucosa after administration of a drug is known as fixed drug exanthema or fixed drug eruption and can be observed after the application of a variety of drugs. The underlying mechanism of fixed drug eruptions is thought to be represented by drug-specific CD8+ T cells that persist in the skin and respond to the drug of question after reexposure.8Shiohara T. Mizukawa Y. Teraki Y. Pathophysiology of fixed drug eruption: the role of skin-resident T cells.Curr Opin Allergy Clin Immunol. 2002; 2: 317-323Crossref PubMed Scopus (96) Google Scholar As a consequence to activation, these CD8+ T cells are believed to directly induce apoptosis in basal keratinocytes, leading to the typical histologic picture of a fixed eruption with interface dermatitis and vacuolated apoptotic keratinocytes (Fig 2).9Hindsen M. Christensen O.B. Gruic V. Löfberg H. Fixed drug eruption: an immunohistochemical investigation of the acute and healing phase.Br J Dermatol. 1987; 116: 351-360Crossref PubMed Scopus (56) Google Scholar In addition to drugs, other agents, including foods, might elicit these reactions, but no positive skin testing has been demonstrated thus far.10Kelso J.M. Fixed food eruption.J Am Acad Dermatol. 1996; 35: 638-639Abstract Full Text PDF PubMed Scopus (54) Google Scholar, 11Yanguas I. Oleaga J.M. Gonzalez-Guemes M. Goday J.J. Soloeta R. Fixed food eruption caused by lentils.J Am Acad Dermatol. 1998; 38: 640-641Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar We describe here the first patient with fixed food eruption to asparagus experiencing allergic reactions in previously affected skin only. Although cross-reactivity among the Liliaceae family (garlic, onion, chives, leek, and asparagus) has been described for other types of hypersensitivity responses, our patient tolerated all other vegetables of this group. Fixed eruptions in our patient developed only after ingestion of asparagus, and asparagus-specific skin reactions could be elicited by skin testing. Because toxic epidermal necrolysis, erythema multiforme, and fixed drug eruptions share similar pathologic features, are caused by many of the same drugs, and might have a similar pathogenesis, we consequently recommended avoidance of this vegetable.