Chieira, C

Loureiro, G

Lundberg, M

Pereira, C

Tavares, B

Repositório Institucional dos Hospitais da Universidade de Coimbra

*Wellington Asthma Research GroupWellington School of Medicine and HealthSciencesPO Box 7343WellingtonNew ZealandE-mail: rob.siebers@otago.ac.nzAccepted for publication 8 December 2006Allergy 2007: 62:451–452 2007 The AuthorsJournal compilation  2007 BlackwellMunksgaardDOI: 10.1111/j.1398-9995.2006.01311.xReferences1. Siebers RW, Lane J, Yasueda H, SakaguchiM, Fitzharris P, Crane J. Reduction ofallergen by occlusive covering. Allergy2002;57:465.2. Woodcock AA, Steel N, Moore CB,Howard SJ, Custovic A, Denning DW.Fungal contamination of bedding. Allergy2006;61:140–142.3. Siebers R, Parkes A. Crane. ß-(1,3)-glucanon pillows. Allergy 2006;61:901–902.4. Douwes J, Zuidhof H, Doekes G, van derZee SC, Wouters I, Boezen MH et al. (1.a`3)beta-D-glucan and endotoxin in house dustand peak flow variability in children. Am JRespir Crit Care Med 2000;162:1348–1354.5. Douwes J, van Strien R, Doekes G, Smit J,Kerkhof M, Gerritsen J et al. Does earlyindoor microbial exposure reduce the riskof asthma? The prevention and incidence ofasthma and mite allergy birth cohort study.J Allergy Clin Immunol 2006; 117:1067–1073.6. Siebers R, Nam HS, Crane J. Permeabilityof synthetic and feather pillows to livehouse dust mites and house dust. Clin ExpAllergy 2004;34:888–890.Turnip and zucchini: newfoods in the latex-fruitsyndromeC. Pereira*, B. Tavares, G. Loureiro, M. LundbergC. ChieiraKey words: allergy; anaphylaxis; latex; turnip;zucchini.Since the ﬁrst description of systemicreaction induced by plant-derived food ina patient allergicto latex (1), sev-eral reports ofcross-reactivitybetween latex,fruits and vege-tables had beendescribed. In1994, Blancoet al. (2) suggested the designation latex-fruit syndrome to describe this syndrome.Turnip (Brassica rapa) belongs to theBrassicaceae family also called Crucifer-ae. This is known as the mustard orcabbage family. Turnip is a root veget-able commonly grown in temperate cli-mates worldwide for its white, bulboustaproot.Zucchini (Cucurbita pepo), also knownhas courgette, belongs to Cucurbitaceaefamily. It is a small summer marrow orsquash, also commonly called Italiansquash. Despite being a fruit, zucchini isconsidered to be a vegetable in culinaryand is traditionally picked when veryimmature.We report the case of a female patient,42 years old, worker in the mineralextraction industry for several years, withsigniﬁcant exposure to rubber, describingmultiple episodes of anaphylaxis. Theﬁrst episode took place 30 min afteringestion of chestnut when she was25 years old. After this, she reportedother episodes after ingestion of almondnut, hazelnut, banana, kiwi, mango,avocado, ﬁg and tomato and recentlyalso with both raw and cooked zucchiniand turnip. The symptoms always inclu-ded oral allergy syndrome, urticaria,angioedema and glottis oedema. All theepisodes needed medical attention in theEmergency Department. She also des-cribes an anaphylaxis episode afterblowing latex balloons. The only medicalcare with exposure to latex material wasat 23 years old when she had normaldelivery.After the ﬁrst observation in ourAllergy Department (2005), it becameclear a clinical history suggestive of latex–fruit syndrome.The skin prick tests with commercialextracts to aeroallergens, latex (ALKAbello´, Madrid, Spain), fruits, nuts,vegetables and legumes (Leti, Madrid,RAST inhibition Latex ImmunoCAP010203040506010 000 1000 100 10Dilution of extractTurnipZucchini% inhibitionA10 000 1000 100 10 1RAST inhibition rHev b 6.01 ImmunoCAP010203040506070Dilution of extract% inhibitionTurnipZucchiniBFigure 1. RAST inhibition with turnip and zucchini extracts. (A) RAST inhibition of latex ImmunoCAP.(B) RAST inhibition of rHev b6.01 ImmunoCAP.Turnip and zucchini:new vegetablesresponsible for cross-reactivity betweenlatex and plant-derivedfoods.ALLERGY Net452Spain) revealed positive (wheal diameter3 mm above the negative control) to kiwi,pear, banana, watermelon, cherry, pas-sion fruit, walnut, pistachio and latex(wheal diameters of 4, 5, 5, 6, 5, 5, 4, 3and 12 mm, respectively; positive control8 mm and negative control 0 mm).The skin prick–prick tests to severalraw foods and latex revealed positive tolatex, chestnut, walnut, pistachio nut,blackberry, tomato, zucchini and turnip(wheal diameter of 12, 13, 5, 4, 4, 5, 7 and5 mm; positive control 6 mm and negat-ive control 0 mm).The total serum IgE level was 34 IU/land the serum-speciﬁc IgE to latex3.2 KU/l (ImmunoCAPTM, Phadia,Uppsala, Sweden). As the sensitization toturnip and zucchini were not previouslydescribed in the latex–vegetable–fruitsyndrome, we decided to proceed withfurther investigation. The speciﬁc serumIgE to turnip and zucchini revealed 0.64and <0.35KU/l, respectively. Previousincubation of serum with turnip and latexnondiluted extracts resulted in an inhibi-tion of 99.3% and 93%, respectively, ofturnip ImmunoCAPs reaction. LatexImmunoCAP reaction was inhibited withboth zucchini and turnip extract, respec-tively (Fig. 1A). Speciﬁc IgE levels torHev b1 (Rk215), rHev b5 (Rk218) andrHev b6.01 (Rk219) were 0, 0.31 and2.9 KU/l, respectively. Inhibition study ofrHev b6.01 with nondiluted extracts ofturnip and zucchini revealed an inhibitionof 63% and 52.3%, respectively (Fig. 1B).Despite cross-reactivity between zuc-chini and latex had been previously des-cribed (3) with this study, we could provefor the ﬁrst time cross-reactivity betweenturnip and latex and identify Hev b6.01,the chitin-binding protein, as the proteinresponsible in this latex–fruit syndrome.Turnip and zucchini should be added tothe long list of plant-derived foods cross-reactive to latex and sensitization to thesevegetables must be assessed in patientswith latex anaphylaxis.*Servic¸o de ImunoalergologiaHospitais da Universidade de CoimbraApartado 90573001-301 CoimbraPortugalTel: +351 917205277Fax: +351 239836262E-mail: celsopereira@netcabo.ptAccepted for publication 8 December 2006Allergy 2007: 62:452–453 2007 The AuthorsJournal compilation  2007 BlackwellMunksgaardDOI: 10.1111/j.1398-9995.2006.01313.xReferences1. M’Raihi L, Charpin D, Pons A, BongrandP, Vervloet D. Cross-reactivity betweenlatex and banana. J Allergy ClinImmunology 1991;87:129–130.2. Blanco C, Carrillo T, Castillo R, Quiralte J,Cuevas M. Latex allergy: clinical featuresand cross-reactivity with fruits. Ann Allergy1994;73:309–314.3. Reindl J, Anliker MD, Karamloo F, ViethsS, Wu¨thrich B. Allergy caused by ingestionof zucchini (Cucurbita pepo):characterization of allergens and cross-reactivity to pollen and other foods.J Allergy Clin Immunology 2000;106:379–385.Effectiveness of omalizumabin monozygotic twin sisterswith severe allergic asthmaJ. Just*, F. Sahraoui, V. Le Gros, A. GrimfeldBetween 5% and 10% of childrenworldwide suﬀer from asthma (1). Thefamilial nature of asthma is well known;the risk for a ﬁrst cousin of an asthmaticpatient is multiplied by 2.5–3 comparedwith the generalpopulation (2).Studies of twinshave conﬁrmedthis genetic com-ponent ﬁndinghigher concordance of asthma amongmonozygotic (58.97%) than dizygotictwins (23.64%) (3). We report an excep-tional clinical situation of monozygotictwin sisters with severe allergic asthmawhere one was treated with a monoclonalanti-IgE antibody (omalizumab), and theother with a placebo in a randomized,double-blind, placebo-controlled study(4).Premature monozygotic twin sistersdeveloped bronchopulmonary dysplasiasecondary to hyaline membrane disease.Afterwards, the two sisters had similarrespiratory history; ﬁrst, asthma withexacerbations related to viral infectionsin infancy, then at the age of 6,developing respiratory allergies to var-ious aeroallergens with symptoms ofseasonal rhinitis and persistent atopicdermatitis. Despite treatment with highdoses of inhaled corticosteroids incombination with long-acting b2-mimet-ics and delayed-release theophylline,their asthma remained poorly con-trolled. Repeated severe exacerbations(>10 hospitalizations between 4 and 8)led to several stays in the mountains forclimatic treatment. In 1998 at the age of12, the twins were enrolled in a 32-weekrandomized, double-blind, placebo-con-trolled study (4). One received oma-lizumab and the other a placebo. Thetwin receiving omalizumab was able toreduce her long-term treatment withﬂuticasone to 500 lg/day, while theother required treatment with ﬂutica-sone at a dose of 1250 lg/day andregular courses of oral corticosteroidsdue to persistent exacerbations. Theywere both then treated with oma-lizumab during a 6-year extensionphase. During this time, there wasclinical improvement with the absenceof hospitalizations for severe attacks,disappearance of pollen-induced rhinitisand improved respiratory function(Fig. 1) under reduced long-term treat-ment with ﬂuticasone 500 lg/day andoccasional administration of oral corti-costeroids. The adult height of the twinwho ﬁrst received omalizumab was159 cm compared with 156 cm for theother.The eﬀectiveness of omalizumab inadolescents has previously been demon-strated in a pooled analysis showing thatthe relative risk of an adolescent agedbetween 12 and <18 presenting anasthma exacerbation when treated withomalizumab was 0.470 compared withthe control group (95% CI: 0.318–0.695;P ¼ 0.0002) (5). Our observation ofmonozygotic twins one treated withomalizumab and the other with a placebofor 32 weeks, then both with omalizumabfor 6 years, and living in the same envi-ronment, supports these ﬁndings andsuggests the eﬀectiveness of omalizumabon a speciﬁc phenotype of severe asthma.Omalizumab in twinsisters.ALLERGY Net453

Turnip and zucchini: new foods in the latex-fruit syndrome

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