Gaspar, A

Paiva, M

Piedade, S

Repositório do Centro Hospitalar de Lisboa Central, EPE

allergic rhinitis. Am J Rhinol 2006;20:641–647.3. Katelaris CH. Allergic rhinitis and asthma:epidemiological evidence for the link. ClinExp Allergy Rev 2003;3:5–8.4. Bousquet J, Khaltaev N, Cruz AA,Denburg J, Fokkens WJ, Togias A et al.Allergic Rhinitis and its Impact on Asthma(ARIA) 2008 Update (in collaboration withthe World Health Organization, GA2LENand AllerGen). Allergy 2008;63(Suppl. 86):8–160.5. Cirillo I, Pistorio A, Tosca MA, Ciprandi G.Impact of allergic rhinitis on asthma: effectson bronchial hyperreactivity. Allergy2009;64:439–444.Toothpaste-inducedanaphylaxis causedby mint (Mentha)allergyM. Paiva, S. Piedade, Aˆ. Gaspar*Keywords: allergy; anaphylaxis; menthol;mint; toothpaste.To our knowledge, the present report isthe ﬁrst description of an IgE-mediatedanaphylaxis to mint (Mentha piperita)related to the use of toothpaste.We present a clinical case of a46-year-oldwoman, nona-topic and with-out relevantpast medicalhistory, referredto our Immu-noallergy out-patient clinicfor suspected nonsteroidal anti-inﬂam-matory (NSAIDs) hypersensitivity. Thepatient had a ﬁrst episode of anaphy-laxis, characterized by generalizedurticaria and laryngeal oedema, 30 minafter oral intake of metamizol 575 mg(Nolotil, Boehringer Ingelheim,Ingelheim, Germany), in June 2008.She was treated in the emergency roomwith i.m. epinephrine and i.v. corticoste-roid and H1 antihistamine, withregression of the symptoms, and wasdischarge with indication to avoidmetamizol and other NSAIDs. She hadthree more anaphylactic episodes, after12 h, 3 and 5 days, respectively. Thepatient reported a relationship betweenthese episodes and the use of toothpaste(Colgate, Colgate-Palmolive, NewYork, NY, USA, and Sensodyne Pro-Esmalte, GlaxoSmithKline, London,UK).At the Immunoallergy Department, achallenge test was performed with Senso-dyne Pro-Esmalte toothpaste use,being strongly positive and characterizedby immediate (< 5 min) facial urticaria,abdominal colic and bronchospasm,requiring immediate treatment with i.m.epinephrine. The patient performed skinprick tests (SPT) that were positive toall tested toothpastes (includingColgate and Sensodyne Pro-Esmalte).Consulting the toothpaste’s laboratoriesfor further information about the tooth-paste’s ingredients, menthol was foundto be the common ‘ﬂavour’ probablyrelated to the reactions. The patientperformed SPT with 100% peppermintoil that was strongly positive (48 mmmean diameter wheal) and accompaniedby symptoms of rhinitis and conjunctivi-tis. The same skin test was negative in10 adult atopic controls. Mint-speciﬁcIgE measurements by two differentmethods (UniCAP, Phadia, Uppsala,Sweden; and Immulite2000, SiemensHealthcare Diagnostics, Deerﬁeld, IL,USA) were negative. SPT and challengetest with a menthol-free toothpaste(Elmex menthol-free, GABA Interna-tional, Therwil, Switzerland) were bothnegative. Regardless indication foravoidance of metamizol, 4 monthsafter the ﬁrst reaction, the patient had anew anaphylactic episode, with loss ofconsciousness, after administration ofi.v. metamizol prescribed for severepain. The patient performed SPTwith metamizol i.v. solution, at aconcentration of 0.4 g/ml, which waspositive (9 mm mean diameter wheal).CAST, (Bu¨hlmann, Scho¨nenbuch,Switzerland) to metamizol was negative.Single-blind placebo-controlled oralchallenges were performed withetoricoxibe, meloxicam, ibuprofen anddiclofenac, being all negative.There are few reports of IgE-medi-ated allergy to toothpaste, being mintor its cyclic alcohol derivative menthol,the usual responsible. The ﬁrst imme-diate reaction was described in 1964 ina woman with recurrent urticaria afterexposure to different menthol-contain-ing products that was reproducible ina challenge with a menthol solution(1). In 1990, Spurlock et al. (2)described a patient with asthmatriggered by menthol-containing tooth-paste. Since then some other caseswere published referring to immediatehypersensitivity to mint or menthol,with different clinical presentationincluding urticaria, rhinitis andasthma (3–5). After performingchallenges with menthol-containingtoothpaste, Kawane found a signiﬁcantdecrease in FEV1. The same test wasperformed in four patients with asthmabut no menthol induced symptoms andthe result was negative to all. Chal-lenges were negative with menthol-freetoothpaste (3).This is a rare case, with anIgE-mediated anaphylaxis to mint(Mentha piperita) and also an IgE-mediated anaphylaxis to metamizol, apyrazolone drug, often associated withIgE-mediated reactions (6), withtolerance to other NSAIDs. A self-injectable epinephrine device has beenprescribed, as well as avoidance ofmetamizol, daily use of menthol-freetoothpaste and strictly avoidance ofmint and menthol-containing products.This case emphasizes the importanceof being aware about any possibleallergen, even those presumablyinnocent.*Immunoallergy DepartmentDona Estefaˆnia HospitalRua Jacinta Marto1169-045 LisbonPortugalTel.: +351 213126653Fax: +351 213126654E-mail: angela.gaspar@sapo.ptAccepted for publication 16 December 2009Allergy 2010: 65:1201–1202ª 2010 John Wiley & Sons A/SDOI: 10.1111/j.1398-9995.2010.02329.xReferences1. Papa CM, Shelley WB. Menthol hypersensi-tivity. JAMA 1964;189:546–548.We report a rarecase of IgE-mediatedanaphylaxis afterexposure totoothpaste.ALLERGY NetAllergy 65 (2010) 1196–1204 ª 2010 John Wiley & Sons A/S 12012. Spurlock BW, Dailey TM. Shortness of(fresh) breath-toothpaste-induced bronchospasm. N Engl J Med 1990;323:1845–1846.3. Kawane H. Menthol and aspirin inducedasthma. Respir Med 1996;90:247.4. Andersson M, Hindse´n M. Rhinitis becauseof toothpaste and other menthol-containingproducts. Allergy 2007;62:336–337.5. Marlowe KF. Urticaria and asthma exacerba-tion after ingestion of menthol-containinglozenges. Am J Health Syst Pharm2003;60:1657–1659.6. Himly M, Jahn-Schmid B, PittertschatscherK, Bohle B, Grubmayr K, Ferreira F et al.IgE-mediated immediate type-hypersensitivityto the pyrazolone drug propyphenazone.J Allergy Clin Immunol 2003;111:882–888.Anaphylaxis toRaphanus nigerN. Sousa, Aˆ. Gaspar, M. Morais-Almeida*Keywords: allergy; anaphylaxis; foodsupplement; radish; Raphanus niger.Immunoglobulin E (IgE) mediated foodallergy to members of the Brassicaceaefamily is uncommon. The ﬁrst case wasdescribed in 1980 by Panconesi et al. (1)and was attributed to mustard in apizza. Since then, several mustard allergycases have been reported (2, 3), beingallergic to othercrucifers isexceedinglyrare, namely tothe Raphanusgender. To ourknowledge,only two casesof possibleallergic reactions to Raphanus have beenreported, one patient with contact der-matitis (4) and another one with acuteurticaria (5).Nowadays, adverse events relatedwith dietary supplements intake areincreasingly reported, but the majorityof the consumers are not aware of thepotential dangers of these natural healthproducts (6).The authors report the case of a56-year-old female patient, with ahistory of nonatopic asthma and allergicrhinitis since childhood. The patientinitiated generalized urticaria, facialangioedema, and severe bronchospasm(O2 saturation in room air = 88%),10 min after the ingestion of a 15 mlampoule of Hepatocomplex (BiocolLaborato´rios, Alcoita˜o, Portugal), afood supplement used for weight loss.She was medicated in the emergencyroom with i.m. adrenalin, as well as i.v.corticosteroid and H1 anti-histamine,with regression of the symptoms. Noother food was ingested in the previoushours. There was also no strenuousexercise after the ingestion. The patienthad taken this food supplement previ-ously with no adverse reaction.Skin prick test with Hepatocomplexwas performed. Not only was the skintest positive (5-mm mean diameterwheal), but it was accompanied by drycough that promptly reverted withinhaled salbutamol. The composition ofthis food supplement was analyzed toﬁnd the culprit foodstuff. It containedrosemary (Rosmarinus ofﬁcinalis),artichoke (Cynara cardunculus), andblack radish (Raphanus niger), as well assorbitol, glycerin, lecithin, choline,arginine, vitamin E, and several oligo-elements. Prick-prick tests with the ﬁrstthree fresh foodstuffs were performedand were clearly positive for the blackradish (10.5-mm mean diameter wheal);the remainders were negative; thepatient also had a positive prick-pricktest (5-mm mean diameter wheal) toradish (Raphanus sativus). The sameskin tests were negative in 10 adult ato-pic controls. The patient has no recol-lection of purposely eating any type ofradish. Ingestion of other members ofthe Brassicaceae family did not elicitsymptoms, namely mustard, broccoli,and cabbages. Avoidance of the Raph-anus gender has been indicated, as wellas an adrenaline auto-injector wasprescribed for possible hidden allergens,taking into account the severe nature ofthe reaction.To our knowledge, this reportconstitutes the ﬁrst anaphylacticIgE-mediated reaction to foodstuff ofthe Raphanus gender. Our patientpresented a positive skin test with theraw Raphanus niger, as well as Raph-anus sativus, a closely related species.An irritant effect can be ruled out,because the same skin test was negativein 10 atopic controls. Although alsosuggestive of an IgE-mediated reaction,in the report of Sayed et al. (5), theydid not perform skin prick or prick-prick tests and only had a late modera-tely positive scratch test at 40 min.Oral provocation test is formallycontra-indicated in our case, given theclear cut history of severe anaphylaxisand positive skin test. Allergy to otherconstituents of the food supplementwas ruled out. Considering the exten-sive use of herbal and food supple-ments, a comprehensive risk-beneﬁtanalysis including a surveillance systemfor monitoring the adverse healtheffects of these products is essential,allowing the identiﬁcation of unpredict-able adverse reactions, namely allergic,which are potentially severe (6).*Immunoallergy DepartmentCUF-Descobertas HospitalRua Ma´rio Botas1998-018 LisboaPortugalTel.: +351 917232267Fax: +351 210025220E-mail: mmoraisalmeida@netcabo.ptAccepted for publication 16 December 2009Allergy 2010: 65:1202ª 2010 John Wiley & Sons A/SDOI: 10.1111/j.1398-9995.2010.02330.xReferences1. Panconesi E, Sertoli A, Fabbri P, Giorgini S,Spallanzini P. Anaphylactic shock frommustard after ingestion of pizza. ContactDerm 1980;6:294–295.2. Rance´ F, Kanny G, Dutau G, Moneret-Vautrin DA. Food hypersensitivity inchildren: clinical aspects and distribution ofallergens. Pediatr Allergy Immunol1999;10:33–38.3. Rance´ F. Mustard allergy as a new foodallergy. Allergy 2003;58:287–288.4. Mitchell JC, Jordan WP. Allergic contact der-matitis from the radish, Raphanus sativus. BrJ Dermatol 1974;91:183–189.5. Sayed F, Manzur F, Marguery MC, BayleP, Bazex J. Urticarial manifestations dueto Raphanus niger. Contact Derm 1995;32:241.6. Ernst E. Herbal medicines: balancing beneﬁtsand risks. Novartis Found Symp 2007;282:154–167.This is the firstdescription ofanaphylaxis tofoodstuff of theRaphanus gender.ALLERGY Net1202 Allergy 65 (2010) 1196–1204 ª 2010 John Wiley & Sons A/S

Toothpaste-Induced Anaphylaxis Caused by Mint (Mentha) Allergy

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