Elisabetta Damiani

Urticaria and angioedema to rubisco allergen in spinach and tomato

a t i a s l F t p r S A 23-year-old, nonatopic woman presented with severe angioedema of the lips and tongue associated with a choking sensation, which developed soon after the ingestion of spinach leaves. The acute reaction was successfully managed by intramuscular epinephrine and intravenous chlorpheniramine. History revealed previous episodes of urticaria and angioedema after the ingestion of raw and cooked spinach (Spinacia oleracea) and tomato (Solanum lycopersicum). Skin prick tests (SPTs) were performed with common airborne allergens and commercial extracts of several foods (Lofarma,Milan, Italy), using saline solution and histamine (10 mg/mL) as negative and positive controls, respectively. The SPTs produced positive results (defined as a wheal diameter greater than 3 mm over the negative control) to tomato, eliciting a wheal of 11 mm. Prick-byprick test results with raw and boiled spinach were positive, eliciting a wheal of 14 mm for the former and 12 mm for the latter. Proteinswere extracted by spinach leaves as previously described. The protein concentration, determined according to Bradford’s method, proved to be 2.04mg/mL for the spinach extract and 2.45 mg/mL for the tomato extract. The two extracts were stored at –20 C until required. The sodium dodecylsulfate–polyacrylamide gel electrophoresis (SDS-PAGE) (Nupage Bis Tris; Invitrogen,Milan, Italy) profile of spinach and tomato extracts, after staining with 0.1% Coomassie Brilliant Blue, revealed bands with a mass range of approximately 10 to 100 kDa for spinach and 6 to 60 kDa for tomato (Fig 1). The results of SPTs with the spinach extract at both 1:100 and 1:1,000 dilutions were positive, eliciting a wheal of 10 mm for the former and 9 mm for the latter. Ten healthy volunteers were skin prick tested with the same procedures with negative results. Specific IgE to spinach (7.29 kUA/L) and tomato (2.66 kUA/L) were detected by ImmunoCAP. Electrophoresis of tomato and spinach extracts was performed in a 10% polyacrylamide precast gel (Nupage Bis-Tris; Invitrogen) at 180mA for 1 hour. The gel was stained with Colloidal Blue Staining Kit (Invitrogen). Immunoblotting analysis (Quantity One Basic; BioRad, Milan, Italy) showed specific IgE reactivity to a band of approximately 15 kDa present in the spinach extract and to a band of approximately 6 kDa in the tomato extract (Fig 1). The proteomic profiling of such IgE-binding bands was performed to characterize the relevant allergenic proteins. The tryptic digests were obtained following a typical digestion protocol and analyzed by matrix-assisted laser desorption ionization time-offlight mass spectrometry. Protein identification was accomplished searching the Swiss-Prot database using Mascot (Matrix Science Ltd, London, England) database search engines. The 2 examined bands were identified as Rubisco (ribulose-1,5-bisphosphate carboxylase/oxygenase) (EC 4.1.1.39),with 11 identifiedpeptideswith a coverage of 44% for spinach and 10 identified peptides with a

Long-term treatment of refractory severe chronic urticaria by omalizumab: analysis of two cases

Omalizumab is a recombinant humanized monoclonal antibody raised against the Cɛ3 domain of human IgE, whose efficacy and safety in the treatment of moderate to severe asthma has been demonstrated [1–3]. Several other possible indications for this innovative drug have been considered, including severe idiopathic urticaria [4–6].

Non-allergic occupational asthma because of almond shell dust.

The almond is a species of Prunus (P. dulcis) belonging to Rosaceae family. The almond differs from other commonly consumed members of this family because its kernel is edible, while the outer pulp is hard and inedible. Allergic reactions to almond have been described, as well as the presence of allergens that are cross-reactive with other plant food allergens, such as peanut or lupine seed proteins, and with grass pollen profilin (1–3). Almond trees are widely distributed in temperate areas of Mediterranean countries, which are also actively involved in the commercial production of almonds. We present a case of occupational asthma developed in a subject chronically exposed to almond shell dust. The patient was a 37-year-old man, an ex-smoker without a personal or family history of atopy. In the last 3 years, he worked as a sheller of hulled almonds in a small almond processing industry. His working place consisted of a 600-m normally ventilated room with two shelling machines and two separators. Two years before, he noticed sneezing and nasal discharge a few hours after beginning his working activity. During the last year, he started to have dyspnea, dry cough, and wheezing which were more intense at the end of the work shift and at night. The patient was instead symptom-free during holidays and days off work. He denied any type of reaction after ingestion of foods, including almonds. Physical examination, laboratory tests and chest radiograph were normal. The almond shell without the hull was pulverized and stored at 4 C overnight. The proteins were extracted using Tris–Hcl pH 7.5 (1 : 5 w/v). Insoluble particles were removed by centrifugation at 15 000 g for 1 h at 4 C.Protein contents were determined according to Bradford (4), and found to be 2.04 mg/ml. The resulting extract was stored at )20 C until required. The extract was applied on 4– 12% polyacrylamide precast running gel and stained with 0.1% coomassie brilliant blue. The sodium dodecylsulfate–polyacrylamide gel electrophoresis profile of shell dust extract showed bands ranging from 11 to 14 kDa. Proteins were electrophoretically transferred to a nitro-cellulose membrane (5), which was saturated with 0.1 mol/l tris-buffered saline and 0.5% fat-free milk powder and incubated overnight at 4 C with patient serum. Bound specific IgE were detected by peroxidase-conjugated anti-human IgE antibodies from goat (1 : 1000 in saturation buffer) using the enhanced chemiluminescence kit for Western blotting. Immunoblotting analysis did not show IgE reactivity in the patient s serum to any band from 11 to 14 kDa. Skin prick tests (SPTs) with food commercial extracts (including those of almonds and other Rosaceae fruits) and diluted extract (1 : 1000, 1 : 100, 1 : 10) of the shell almond dust were performed, using saline solution and histamine (10 mg/ml) as negative and positive controls, respectively. Results of all SPTs were negative. Determinations of specific IgE to aeroallergens, including molds, and Rosaceae members also yielded negative results. Bronchial testing was performed during a symptom-free period, after 7 days without exposure to almond shell dust. Basal spirometry was normal. Methacholine bronchial challenge was positive [provocative dose producing a 20% fall in forced expiratory volume in 1 s (FEV1): 180 mcg). Specific inhalation challenge with almond shell dust at a concentration of 5 mg/m was performed in a challenge chamber according to standardized procedures (6). Serial FEV1 monitoring showed an immediate asthmatic response after 5 min which still persisted 24 h after the challenge. To the best of our knowledge, this is the first description of occupational asthma because of almond shell dust. Bronchial hyperreactivity was found to be induced by IgE-independent mechanisms.

Vicia faba Hypersensitivity and ASA Intolerance in a Farmer: A Case Report

The IgE-mediated allergic reactions to food are caused, generally, by ingestion. However, they can be rarely induced by exposure to airborne food particles through the handling or the cooking. Vicia faba is a vegetable which belongs to Legumes or Fabaceae family, Fabales order. Allergic reactions after ingestion of legumes and cases of asthma after exposure to the cooking vapors have been reported in the literature. A paper assessed the volatile substances (insect repellents) released by V. faba. The authors demonstrated that this plant produces several chemical substances, such as small quantities of methyl salicylate. We describe a case of occupational allergy, induced by handling during picking up of fresh broad beans, in a farmer with history of adverse reaction after eating the cooked and raw vegetable.

Allergy to red pitaya

zole has been referred (3) and it may be an option only for patients with positive SPT to all commercially available PPI forms but not the treatment of choice because alternative safe compounds of the PPI group could easily be identified (1, 5). Proton pump inhibitors are a rare cause of anaphylaxis, but healthcare professionals need to be aware of this possibility. The cross-reactivity at the whole group should not be assumed and a complete study should be carried out, whenever a drug of this group is indicated.

IgE-mediated reaction induced by arugula (Eruca sativa) ingestion compared with a spectrum of Brassicaceae proteins.

Eruca (E) sativa is an edible spontaneous or cultivated plant, native of the Mediterranean area.1 E sativa belongs to the Brassicaceae or Cruciferae family, which includes other vegetables such as cabbage, cauliflower, mustard, broccoli, turnip and radish.2,3 Arugula is a food of the Mediterranean diet and it is commonly used as a condiment in many dishes (pizza, pasta and salad), consumed raw or cooked.1 The Brassicaceae are able to determine sensitisation and IgE-mediated reactions. Rare cases of adverse reactions after arugula ingestion have been reported, such as contact or systemic manifestations.1,4,5 The aim of this paper is to report an allergic reaction after ingestion of fresh arugula leaves. The study was carried out to demonstrate the IgE-mediated mechanism of the reaction referred and to evaluate the co-sensitisation to other edible Brassicaceae, realizing their protein profile. A 32-year-old housewife reported urticaria to the trunk a few minutes after ingestion of pizza with raw arugula. History revealed allergic respiratory symptoms and no previous adverse reactions to foods. The reaction resolved with antihistamine treatment. The ingestion of other types of pizza did not generate problems. Skin prick test (SPTs) with commercial aeroallergen and food extracts (Stallergenes, Milan, Italy) were performed. Histamine and saline solution were used as positive and negative controls, respectively. The SPTs were positive to different aeroallergens (grass pollen, mugweed, Parietaria judaica, olive tree pollen, cypress, amaranth, cat dander and Alternaria alternata) and foods (peanut, potato and shrimp). The patient did not report food allergies; she ate foods with positive SPTs without reaction. In addition, prick by prick test with raw arugula was performed with positive result. The prick by prick tests with raw arugula were also performed in ten healthy controls and ten atopics, with negative results. The patient refused to undergo oral challenge test with

A mysterious case of gastroparesis: could the secret be found in a drink?

BACKGROUND Gastroparesis is a disorder characterized by delayed gastric emptying of a meal in the absence of a mechanical gastric outlet obstruction. Idiopathic gastroparesis is at least as common as diabetic gastroparesis in most case series, and the true prevalence of gastroparesis is unknown. RESULTS We report here an interesting case of idiopathic gastroparesis characterized by sudden onset in a female patient. The diagnosis was confirmed by ultrasonographic study of gastric emptying and electrogastrography, by gastric endoscopy/histology, and finally by allergy tests. The disorder was found to be due to a rare cause, namely an allergic predisposition. In fact, our patient, who demonstrated an allergy to gold salts, had drunk a glass of a liqueur containing gold flakes and developed an eosinophilic aggregation in the gastric mucosa observed at gastric endoscopy/histology. The symptoms disappeared after steroid administration. CONCLUSION Our experience suggests that gastric histology and close enquiry into any history of allergy may be useful diagnostic tools in cases of idiopathic gastroparesis.

Adverse reaction after ingestion of raw and boiled Octopus vulgaris.

to digest chitin (insects) and cellulose (vegetables) and could utilize only the more readily assimilable part of food, such as molds (4). Previous papers measuring HDM allergens on wall surface provided low levels first because HDM presumably did not belong to the Dermatophagoides genus, second because the dwellings were not selected on the basis of mold infestation. Storage mites do have an allergenic potency, quite different from the one of Dermatophagoides genus (5) so that their occurrence cannot be assessed using Der p 1 or Der f 1 monoclonal antibodies, nor using guanine excretion quantification. Allergens from storage mites, together with those from Dermatophagoides genus and molds, glucans, endotoxins, mycotoxins and microbial volatile organic compounds constitute a large array of aero-contaminants which could also play a role in triggering inflammatory symptoms in individuals living in unhealthy dwellings.

Allergy to Muscari comosum bulb

orthopedic surgery to rectify the orthopedic ailment and within 11 months he had a patch test. The test used 30% of commercialized cefadroxil powder in white petrolatum and water. Pure white petrolatum and water served as a placebo. The test spot was taped-strapped 10 times prior to occluding the test materials for 48 h. The same test was performed on five healthy volunteers who had not had any prior exposure to cefadroxil and one healthy nonallergic volunteer with known prior exposure to cefadroxil. Test results on the patient showed strong positive reaction on hours 48, 72 and 96, either for cefadroxil in white petrolatum and in water. Both of the placebos were negative. The results on all of the six controls were negative. DRESS syndrome is an idiosyncratic severe adverse drug reaction that begins acutely in the first two months after initiation of the offending drug. The diagnostic criteria encompasses: (1) cutaneous eruption; (2) absolute eosinophilia (‡1500/ll) with or without atypical lymphocytes; and (3) systemic involvement (lymphadenopathy ‡2 cm, AST ‡2· normal, interstitial nephritis, interstitial pneumonitis, or carditis). Diagnosis is confirmed if three criteria are present (1, 2). Most commonly drugs are antiepileptic and sulfonamides. Less common offending drugs are allopurinol, gold salt, sorbinil, minocycline, zalcitabine, calcium channel blockers, ranitidine, thalidomide, or mexilatine (1, 2). Nonimmediate type hypersensitivity reaction or a defect in ability to detoxify the toxic metabolic product is considered to be the pathogenesis of DRESS syndrome (1–3). Patch test is the safest skin test to prove nonimmediate type drug hypersensitivity, which should be performed between 6 weeks and 6 months after complete convalescence from the drug reaction (4). To avoid the relapse of severe drug reaction, such as in DRESS syndrome case, 1–10% of commercialized form of the drug, either in white petrolatum or in water is recommended (4, 5). Tape-stripping eight to 12 times can be performed to increase percutaneous drug penetration and avoid false negative (6). The patient underwent the test 14 months after complete convalescence; to avoid a false-negative result, 30% of commercialized cefadroxil was used, and the spot was tape-strapped 10 times. Six months later, no relapse was observed. As far as we know, this is the first case of DRESS syndrome from cefadroxil confirmed by positive patch test.