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Generalized urticaria caused by sesame seeds with negative prick test results and without demonstrable specific IgE antibodies

1995; Elsevier BV; Volume: 96; Issue: 4 Linguagem: Inglês

10.1016/s0091-6749(95)70302-0

1097-6825

Bernadette Eberlein-König, Franziska Ruëff, Bernhard Przybilla,

Urticaria and Related Conditions

Investigation of patients with suspected food allergy comprises a clinical history, skin tests, and determination of specific IgE antibodies to food. However, a definite diagnosis can only be established by adequately performed oral challenge tests with the suspected allergens.1Sampson H Immunologically mediated food allergy: the importance of food challenge procedures.Ann Allergy. 1988; 60: 263-269Google Scholar This is demonstrated by the case of a patient with generalized urticaria provoked by sesame seeds in whom no evidence of an IgE-mediated mechanism could be found. A 58-year-old man reported that he had facial erythema and swelling, generalized wheals, and itching all over the body about 30 minutes after he had eaten a slice of crisp bread with sesame seeds and one small salami sausage in June 1993. About 2 months later, a similar reaction occurred after ingestion of a buttered slice of bread containing sesame seeds. On both occasions the patient had been successfully treated with clemastine intravenously. The patient was otherwise healthy and did not take any medications. He had no personal history of hay fever, asthma, or atopic eczema. Skin prick tests, performed in October 1993 with a standard series of common aeroallergens and food allergens (including sesame), yielded a 1+ reaction to Dermatophagoides pteronyssinus and baker's yeast. Crushed sesame seeds were tested after suspension in a drop of physiologic saline solution by means of the prick test technique without a positive result. Intracutaneous skin tests with a standard series of foods yielded a 3+ reaction to malt, 2+ reactions to baker's yeast and shredded wheat, and 1+ reactions to garlic, cocoa, and orange. A commercial intracutaneous skin test solution for sesame seeds was not available in Germany. Specific IgE antibodies could not be detected against shredded sesame (tested twice), wheat flour, rye flour, barley flour, oatmeal, malt, buckwheat flour, or baker's yeast (Pharmacia CAP system; Pharmacia, Uppsala, Sweden). Oral challenge tests were performed in the hospital under careful control. Challenges were performed with 200 mg, 1 gm, and 2 gm of sesame seeds (each 30 minutes apart). Twenty-five minutes after ingestion of 2 gm of sesame seeds, the patient experienced flushing of the head, generalized itching, and whealing. The eruption cleared rapidly after intravenous administration of 2 mg of clemastine and 200 mg of prednisolone. Additional challenges were performed with 600 mg, 3 gm, and 6 gm of shredded wheat; with one tenth, one half, and one whole small salami sausage (as ingested by the patient before the previous reaction); and with 1.2 ml, 6 ml and 12 ml of barley malt extract (1-hour intervals between challenges). No reactions were observed. Six days after the oral challenge with sesame seeds, the test was repeated after the patient had taken 200 mg of sodium cromoglycate 90 and 180 minutes before he ingested 1 and 2 gm of sesame seeds, respectively. No clinically apparent symptoms occurred, and he only felt “shivering” 2 hours after the last ingestion of sesame seeds. Sesame seeds and sesame oil are traditional food ingredients in the Orient, in China, in Japan, or in Mexico. Their use has increasingly spread also to the United States and to Europe during recent decades. Ingestion of sesame seeds and sesame oil has been reported as the cause of immediate-type hypersensitivity.2James C Williams-Akita A Rao YAK Charmonte LT Scheider AT Sesame seed anaphylaxis.NY State J Med. 1991; 91: 457-458PubMed Google Scholar, 3Vocks E Borga A Szliska HU Seifert B Burow G Borelli S Common allergenic structures in hazelnut, rye grain, sesame seeds, kiwi, and poppy seeds.Allergy. 1993; 48: 168-172Crossref PubMed Scopus (80) Google Scholar, 4Kägi MK Wüthrich B Falafel burger anaphylaxis due to sesame seed allergy.Ann Allergy. 1993; 71: 127-129PubMed Google Scholar The clinical picture includes oral pruritus; angioedema of the lips, tongue, and uvula; generalized erythema or urticaria; rhinitis, respiratory distress, asthma, nausea, vomiting, weakness, or hypotension. In 19 of 26 cases reported in the literature a skin test was done. Seventeen of these 19 patients showed a scratch, prick, or intracutaneous test reaction to sesame. The skin tests were usually done with self-made sesame seed extracts. In the two patients with negative skin test responses, specific IgE antibodies could be demonstrated in the serum. Altogether, sesame-specific serum IgE was demonstrable in 15 of 18 patients evaluated in this manner.2James C Williams-Akita A Rao YAK Charmonte LT Scheider AT Sesame seed anaphylaxis.NY State J Med. 1991; 91: 457-458PubMed Google Scholar, 3Vocks E Borga A Szliska HU Seifert B Burow G Borelli S Common allergenic structures in hazelnut, rye grain, sesame seeds, kiwi, and poppy seeds.Allergy. 1993; 48: 168-172Crossref PubMed Scopus (80) Google Scholar, 4Kägi MK Wüthrich B Falafel burger anaphylaxis due to sesame seed allergy.Ann Allergy. 1993; 71: 127-129PubMed Google Scholar Our case demonstrates that a clinically manifest sesame seed hypersensitivity can exist without a positive skin test response or demonstrable specific IgE antibodies in the serum. Oral challenge was definitely necessary for a diagnosis of food hypersensitivity.1Sampson H Immunologically mediated food allergy: the importance of food challenge procedures.Ann Allergy. 1988; 60: 263-269Google Scholar With regard to the mechanism of the hypersensitivity reaction in our patient, one can speculate that the reaction was not IgE-mediated or that epitopes recognized by IgE antibodies were not present in the skin test solution or in the allergens used in the CAP system because they might have developed as a result of digestion. The only available therapy for food hypersensitivity is avoidance. With regard to sesame seeds, this is easy if seeds are visible on the food (e.g., bread, pretzels) or if the patient is aware of the food groups that frequently contain sesame seeds (most likely oriental specialities, ready-made foods, crackers, chips). However, sometimes (e.g., when dining at a restaurant) definite information on the composition of food is not available. Oral sodium cromoglycate has been reported to be effective in suppressing urticaria and angioedema in some patients with food allergies, and it also protected our patient. The patient was instructed to avoid sesame and to take sodium cromoglycate 1 to 2 hours before eating any food that could not be checked for the presence of sesame. Also, he was supplied with emergency medications to be used in the case of a reaction after an unintentional ingestion of sesame seeds.