HASEGAWA Matsuri

NAKAMURA Sakurako

OTANI Tomoko

SUGIHARA Shigetaka

Tokyo Women’s Medical University

A Case of Anaphylaxis due to Salmon RoeDiagnosed by Skin Prick Test著者名 OTANI Tomoko, HASEGAWA Matsuri, NAKAMURASakurako, SUGIHARA Shigetakajournal orpublication titleTokyo Women's Medical University Journalvolume 4page range 77-80year 2020-12-25URL http://hdl.handle.net/10470/00032749―77―Case ReportTWMUJ 4: 77-80, 2020A Case of Anaphylaxis due to Salmon Roe Diagnosed by Skin Prick TestTomoko Otani, Matsuri Hasegawa, Sakurako Nakamura, and Shigetaka SugiharaDepartment of Pediatrics, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan(Accepted November 22, 2019)(Advance Publication by J-STAGE January 29, 2020)In recent years, salmon roe allergies have become common among young children. Conventionally, the diagnosis of a salmonroe allergy has been confirmed by a positive specific immunoglobulin E (IgE) antibody test. We encountered a case of ana-phylaxis caused by salmon roe in a child aged 2 years and 10 months. The total amount of IgE antibody was low, thus, thesalmon roe-specific IgE antibody test was negative. However, the skin prick test showed positive results, and thus, the diag-nosis was confirmed. The skin prick test was found to be useful for confirming an anaphylaxis due to salmon roe in youngchildren with low specific IgE antibody levels.Key Words: food allergy, salmon roe allergy, skin prick test, specific IgE antibody testIntroductionIn Japan, ingestion of fish roe is a common culinary tra-dition. In particular, salmon roe is widely considered afavorite product in conveyor belt sushi. As it is used inmany dishes as a garnish, there are several opportunitiesfor children to eat it.An epidemiological survey in the Japanese PediatricGuidelines for Food Allergy (2016)１found that fish roewas the fifth most common cause of food allergies(3.7%). Moreover, as a food associated with new allergyonset, it was the second most common cause of onset by1 year of age (12.9%) and the first by 2-3 years of age(20.2%).A previous report suggested that the salmon roe-specific immunoglobulin E ( IgE ) is positive in mostcases of salmon roe allergy.２However, the subjects inthis report were around 6 years of age, and were differentfrom younger children with a high initial age. Further-more, the case of a 3-year-old boy with a salmon roe al-lergy who tested negative for the salmon roe-specific IgEhas also been reported. However, no prick test was per-formed.３The prick test is convenient, safe, and useful for con-firming the allergy diagnosis of infants with low specificIgE antibody levels. Here, we encountered the case of aboy aged 2 years and 10 months who experienced ana-phylaxis after eating chirashi sushi. He was diagnosedwith a salmon roe allergy using a prick test. We reportthis case alongside a literature review.Case ReportPatient: Boy aged 2years and 10 months.Corresponding Author: Tomoko Otani, Department of Pediatrics, Tokyo Women’s Medical University Medical Center East, 2-1-10,Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan. otani.tomoko@twmu.ac.jpdoi: 10.24488/twmuj.2019008CopyrightⒸ 2020 Society of Tokyo Women’s Medical University. This is an open access article distributed under the terms of CreativeCommons Attribution License (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided theoriginal source is properly credited.―78―Table　1　Blood test findings (at visit).WBC 11,700 /μL Alb 4.4 g/dL Neut. 60.1 % CRP 0.06 mg/dL Eos. 0.7 % AST 28 IU/L Baso. 0.4 % ALT 13 IU/L Mono. 6.4 % LDH 251 IU/L Lym. 32.4 % BUN 11.9 mg/dLRBC 448×104 /μL Creat. 0.24 mg/dL Hb. 11.6 g/dL Na 139 mEq/L Ht. 35.8 % K 3.6 mEq/LPlat. 32.7×104 /μL Cl 109 mEq/LTable　2　Results of specific IgE antibody tests.Total IgE antibody level   19.7 IU/mLSpecific IgE antibody levelCrab <0.01 UA/mL (class 0)Shrimp <0.01 UA/mL (class 0)Salmon <0.01 UA/mL (class 0)Salmon roe   0.22 UA/mL (class 0)Clam <0.01 UA/mL (class 0)Egg white <0.01 UA/mL (class 0)Egg yolk <0.01 UA/mL (class 0)Ovomucoid <0.01 UA/mL (class 0)Specific IgE antibody level, class 0=<0.34 UA/mL.Chief complaint: Facial edema, hoarseness.History of past illness: None noted.Family history: Parents had hay fever.History of present illness: At 18:15 on Hina MatsuriDay, immediately after eating 3-4 mouthfuls of home-made sushi, the patient exhibited sneezing and facialswelling with inspiratory wheezing. He visited the Holi-day Clinic at 19:25. Due to the severity of his symptomsand by recommendation of the doctor, his mother re-quested emergency care and he was transferred to our de-partment. Adrenaline (0.1 mg) was injected intramuscu-larly before the ambulance arrived. At 20:04, he was ad-mitted to our hospital.His acute status and findings at visit were as follows.The blood pressure was 138/68mmHg, heart rate was130/minute, oxygen saturation was 99% in room air, andbody temperature was 38.2℃ . Breath sound and heartsounds showed no abnormalities. His pharynx was noswelling or redness. Skin findings showed mild whealand slight facial swelling.Inspection findings: The blood test results from thevisit were normal as shown in Table 1.Treatment course: When they got to the hospital, in-spiratory wheezing and hoarseness had reduced. The fa-cial swelling improved after inhalation of adrenaline anddexamethasone. Since the general condition was stable,hydrocortisone sodium succinate ( 100 mg ) and hy-droxyzine pamoate (10 mg) were intravenously adminis-tered at 20:59. Facial swelling and cough were observedand the patient was admitted to the hospital for follow-up. He was discharged the same day.Cause search : Before anaphylaxis development,homemade chirashi sushi had been consumed. The ingre-dients included rice, sushi vinegar, broiled egg, steamedshrimp, salmon roe, seaweed, crab, and grilled salmon.Clam soup was served to others in the room. Eggs werepreviously consumed, thus, shrimp, salmon roe, and crabwere considered suspicious.Table 2 shows the blood results of the specific IgE an-tibody tests performed by the capsulated hydrophilic car-rier polymer (CAP) method (Thermo Fisher Diagnostics)at the time of hospitalization. The total IgE antibodylevel was 19.7 IU/mL, an age-appropriate value. Crab,shrimp, salmon, salmon roe, clam, egg white, egg yolk,and ovomucoid were all class 0 negative.Two weeks later, a skin-prick test was performed. Ascratch solution manufactured by Torii Pharmaceutical,Tokyo, Japan, was used for the shrimp, crab, tuna, housedust, cedar, positive control, and negative control. Thesalmon roe test was administered using the prick by prickmethod in which raw salmon roe was stabbed directlywith a bifurcated needle. The salmon roe reaction re-sulted in wheal diameter of 7×10 mm and an erythemadiameter of 12×15 mm. The results were comparable tothe histamine diameter and were judged to be positive(Table 3 and Figure 1 ) . Shrimp and crabs that werenegative for both the prick test and the specific IgE anti-body tests were subsequently ingested and showed no ab-normalities. Therefore, this case was diagnosed as ana-phylaxis due to salmon roe.DiscussionThe positive rate of specific IgE antibody tests in patientswith a salmon roe allergy is relatively high.２Two pointswere considered as reasons why the specific IgE antibodytest was negative and the prick test was positive in thiscase. First, the patient was 2 years and 10 months old and―79―Figure　1　Photo of the reaction after the prick testpatient’s right forearm.salmon roetunanegative controlpositive controlTable　3　Result of skin prick tesr.Diameter ofwheal (mm) / erythema (mm)Salmon roe  7 × 10 / 12 × 15Shrimp 0 × 0 / 0 × 0Crab 0 × 0 / 0 × 0Tuna 0 × 0 / 0 × 0House dust 0 × 0 / 0 × 0Cedar 0 × 0 / 0 × 0Positive control solution 5 × 5 / 15 × 15Negative control solution 0 × 0 / 0 × 0The skin prick test was performed using a bifurcated needle.his total IgE antibody level was low (19.7 IU/mL). Thelevel of specific IgE antibody may not have been de-tected in the blood. Second, it may be possible that reac-tions with other antigens besides the salmon roe antigenoccurred in the specific IgE antibody test. The main anti-gen of salmon roe is β’-component (Onc k 5), a constitu-ent of the egg yolk protein precursor vitellogenin (Vg).About 10% of cases are considered to respond toLipovitellin and are not necessarily reactive to β’ -component.４The prick test checks for an immediate allergic reac-tion. It is highly appreciated in Western countries be-cause of its safety and simplicity. However, the lack ofreproducibility of the results is regarded as a problem. Inrecent years, this has been improved by using a bifur-cated needle. In addition, antigen solutions can containvasoactive substances causing unreliable results. This canbe clarified by using a positive control solution such asthe allergen scratch extract positive control drug (hista-mine di-hydrochloride) manufactured by Torii Pharma-ceutical, Tokyo, Japan.The prick test is considered to be more likely to causea positive local reaction in infants with low specific IgEantibody levels in their bloodstream. Egg allergy５andmilk allergy６studies also indicated that the prick test waspositive in early infancy when the specific IgE antibodytest was negative. Similar results were observed in astudy that checked allergies to peanuts and sesameseeds.７Furthermore, aging has been associated with in-creased detection of specific IgE antibodies in the circu-lating bloodstream.５，６It is speculated that the composition of the specific IgEantibody test antigen solution may be different from thatof the skin test antigen solution. Recently, skin prick testshave been reported to be more accurate than specific IgEantibody tests in the diagnosis of buckwheat allergy.８Also, at the Annual Meeting of the Pediatric Allergy andClinical Immunology held in November 2019, the useful-ness of the prick test for salmon roe allergy was an-nounced. The prick test showed 100% sensitivity, 100%specificity, 85% positive predictive value, and 100%negative predictive value for predicting salmon roe al-lergy and was reported to be superior to the specific IgEantibody test.９The advantage of the prick test is that even low anti-body levels can cause a reaction that can be detected inyounger children. It is simple, less invasive than othertests, and very safe. In addition, the determination time isas short as 15 minutes and the results can be understoodimmediately. Furthermore, if the prick by prick test usesfood itself, many antigens such as fruits, vegetables, andseafood can be tested. Moreover, allergens that are notincluded in the specific IgE test options can be tested thisway.A disadvantage of the test is that it uses a qualitativereaction that cannot be quantified. Furthermore, the aller-gen extract contains a vasoactive substance and may pro-duce a false positive result. This can be improved bycomparison with a positive control solution. In addition,taking antihistamines may cause false negative resultsand they should be discontinued 3 days prior to testing.In addition, the test cannot be performed if the condition―80―of the subject’s skin is bad. The gold standard for diag-nosing food allergies is the oral food challenge test.However, the prick test is safer because the risk is highwhen testing food orally in patients exhibiting anaphy-laxis.In the case reported, the patient was diagnosed with asalmon roe allergy. However, other fish roes also containβ’ -component ( Onc k 5 ) as a common antigen andsalmon roe has cross-antigenicity with pollock, herring,capelin, and some other fish.１０，１１In this case, it may benecessary to conduct a specific IgE antibody test or pricktest to examine the risk of ingesting other fish roe.Salmon roe allergy accounts for a significant propor-tion of fish roe allergies and is ranked first in the new on-set of allergies in infants. There are several cases in in-fants where specific IgE antibody tests show negative re-sults. In these cases, the prick test as a diagnosticmethod, is more accurate and safer.ConclusionWe reported a case of anaphylaxis in a young boy causedby the ingestion of salmon roe which was diagnosed by askin prick test. In younger children with low antibodylevels, a prick test that can yield results is useful whenthe specific IgE antibody test is not positive.Conflicts of Interest: The authors declare that they haveno conflict of interest.Disclaimer : Shigetaka Sugihara is one of the AssociateEditors of Tokyo Women’s Medical University Journal andon the journal’s Editorial Board. He was not involved in theeditorial evaluation or decision to accept this article for publi-cation at all.References1．Ebisawa M, Itoh K, Fujisawa T: Epidemiology/naturalhistory. In Japanese Pediatric Guideline for Food Allergy2016, pp36―38, Kyowa-kikaku, Tokyo (2016) (in Japa-nese)2．Yanagida N, Minoura T, Takahashi K et al: Salmon roe-specific serum IgE predicts oral salmon roe food chal-lenge test results. Pediatric Allergy Immunol 27 (3 ) :324―327, 20163．Takamasu T, Fujitsuka M, Okamoto Y et al: 3-year-oldboy with immediate salom roe allergy whose specific an-tibody was class 0. Jpn J Pediatr Allergy Clin Immunol26: 569, 2012 (in Japanese abstract)4．Shimizu Y, Kishimura H, Kanno G et al: Molecular andimmunological characterization of β’-component(Onc k5), a major IgE-binding protein in chum salmon roe. IntImmunol 26 (3): 139―147, 20135．Ogata M, Sukuya A, Sugizaki C et al: Usefulness of skinprick test using Bifurcated needle for the diagnosis offood allergy among infantile atopic dermatitis: 1st Re-port, In the case of egg allergy. Jpn J Allergology 57 (7):843―852, 2008 (in Japanese)6．Ogata M, Sukuya A, Sugizaki C et al: Usefulness of skinprick test using Bifurcated needle for the diagnosis offood allergy among infantile atopic dermatitis: Secondreport, In the case of cow’s milk allergy. Jpn J Allergol-ogy 59 (7): 839―846, 2010 (in Japanese)7．Peters RL, Allen KJ, Dharmage SC et al: Skin prick testresponses and allergen-specific IgE levels as predictorsof peanut, egg, and sesame allergy in infants. J AllergyClin Immunol 132 (4): 874―880, 20138．Yanagida N, Sato S, Takahashi K et al: Skin prick test ismore useful than specific IgE for diagnosis of buckwheatallergy: A retrospective cross-sectional study. AllergolInt 67 (1): 67―71, 20189．Sakai S, Atsushi M, Kitamura M et al: Usefulness ofskin prick test in diagnosis of salmon roe allergy. Jpn JPediatr Allergy Clin Immunol 33: 542, 201910．Kondo Y, Kakami M, Koyama H et al: IgE cross-reactivity between fish roe (salmon, herring and pollock)and chicken egg in patients anaphylactic to salmon roe.Allergol Int 54 (2): 317―323, 200511．Makita E, Yanagida N, Sato S et al: Increased ratio ofpollack roe-specific IgE levels is associated with a posi-tive reaction to cooked Pollock roe oral food challenge.Allergol Int 67 (3): 364―370, 2018

A Case of Anaphylaxis due to Salmon Roe Diagnosed by Skin Prick Test

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A Case of Anaphylaxis due to Salmon Roe Diagnosed by Skin Prick Test

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