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Anaphylaxis caused by linseed (flaxseed) intake
J ALLERGY CLIN IMMUNOL VOLUME 98, NUMBER 2
Long-term administration of corticosteroids may have different effects on lipid profiles than short-term therapy. In one study, patients taking a short-term tapering oral prednisone burst for treatment of rheumatic disease demonstrated significant increases in total cholesterol and HDL-C, 1 month later, but no changes in triglycerides or LDL-C. 5 The association of higher H D L - C levels in elderly CHS participants with asthma, independent of corticosteroid therapy, suggests that other mechanisms exist. We also found evidence for a dose-response relationship in elderly men: those with more severe asthma (more frequent attacks or more severe airway obstruction) had significantly higher H D L - C levels than those who were currently free of symptoms. A possible explanation is that some CHS participants with asthma had recently taken a short course of prednisone (raising HDL-C) but were not currently taking it at the time of their clinic visit when medication use was ascer-
A l o n s o et al.
469
tained. Another theory is that the increased work of breathing, which occurs because of bronchospasm in asthma, is a type of regular exercise that raises HDL-C. REFERENCES
1. Lasser EC, Berry C, Kortman K. Diminished atheroscierotic arterial calcifications in asthma: a possible role for elevated endogenous heparin-like material. Allergy 1987;42:549-52. 2. Fried LP, Borhani NO, Enright PL, et al. The Cardiovascular Health Study: design and rationale. Ann Epidemiol 1991;1:263-76. 3. Ettinger WH, Wahl PW, Kuller LH, et al. Lipoprotein lipids in older people: results from the Cardiovascular Health Study. Circulation 1992;86:858-69. 4. Mittlemark MB, Psaty BM, Rautaharju PM, et al. Prevalence of cardiovascular diseases among older adults: The Cardiovascular Health Study. Am J Epidemiol 1993;137: 311-7. 5. Ettinger WH, Klinefelter HF, Kwitervoitch PE. Effect of short-term, low-dose corticosteroids on plasma lipoprotein lipids. Atherosclerosis 1987;20:530-1.
Anaphylaxis caused by linseed (flaxseed) intake Lidia Alonso, MD, Maria Luisa Marcos, MD, Juan Guillermo Blanco, MD, Jose Antonio Navarro, MD, Sonsoles Juste, MD, Maria del Mar Garces, MD, Reyes Perez, MD, and Pedro Jaime Carretero, MD Burgos, Spain
Flax is a plant that belongs to the Linaceae family. It comes from Central Asia, and it has been cultivated for 5000 years. Egyptians, Hebrews, Greeks, and Romans used the seeds as food and the fibers to weave clothes, sails, and other items. Nowadays, linseed oil is extracted from this plant, and this oil is mainly used in the preparation of varnish, paint, linoleum, and soap. Linseed oil has recently been used as a laxative. 1 We report the case of a 40-year-old woman who had an anaphylactic reaction after the intake of linseed oil. From Secci6n Alergologfa, Hospital General Yagtie, Burgos, Spain. Reprint requests: Lidia Alonso, MD, Secci6n Alergologfa, Hospital General Yagfie, E-09005 Burgos, Spain. J Allergy Clin Immunol 1996;98:469-70 Copyright © 1996 by Mosby-Year Book, Inc. 0091-6749/96 $5.00 + 0 1/54/73138
Abbreviation used SDS-PAGE:
Sodium dodecylsulfate-polyacrylamide gel electrophoresis
CASE REPORT A 40-year-old woman with no personal or familial history of atopy took linseed oil as a laxative. Ten minutes after the intake of the first spoonful, she experienced ocular pruritus and weeping, followed by strong palmar pruritus and generalized urticaria, nausea, and vomiting. She was treated in the emergency department, and the symptoms were promptly reversed. Skin prick tests were done with a battery of commercially available allergens (Laboratory Ifidesa-Aristegui, Bilbao, Spain), which included: Dermatophagoides ptero-
470
Alonso
et al.
nyssinus, D. farinae, Lepidoglyphus destructor, Glycyphagus domesticus, Aspergilhts furnigams, Penicillium notaturn, Alternaria tenuis, Cladosporium herbarum, grass pollen mix, animal allergens, feathers, cockroach, latex, and food. A linseed extract was prepared as follows: 5 gm of linseed was incubated in 50 ml of phosphate-buffered saline for 24 hours at 4 ° C with continuous stirring. After straining the extract through filter paper, the solution was passed through a Millipore filter (0.22 ~m; Millipore Corp., Bedford, Mass.). Skin prick tests were done with the antigenic preparation described previously. The positive control was histamine, 10 mg/ml, and the negative control was phosphate-buffered saline. Our extract was also tested in five atopic and five nonatopic patients. The total IgE antibody was determined by CAP System (Phadebas; Kabi Pharmacia, Uppsala, Sweden). The determination of specific IgE for linseed was performed by coating the allergen (2 rag/disk) to cellulose disks activated by CNBr. A Pharmacia-Trazer kit (Kabi Pharmacia) was used during the development process. We also performed sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of linseed extract by the Laemmli discontinuous method and SDSPAGE immunoblotting with the patient's serum and a nonallergic patient control serum. For ethical reasons, we did not perform the oral provocation with linseed. A skin test response to linseed extract was considered positive when a wheal with a diameter of 12 mm was produced. The positive control was 6 ram. There was no later reaction. None of the tested control subjects showed any skin reaction. Results were negative for the rest of the allergens tested. Total IgE antibody was 19 kU/L. Specific IgE antibody determination to linseed showed a value of 2.16 Phadebas RAST units/ml (grade 2 to the reference standard rate). The result of SDS-PAGE shows 15 visible bands between 58 kd and 13 kd. Immunoblot of SDS-PAGE was made with linseed extract and patient serum. It showed five allergens with molecular weights of 38, 35, 30, 22, and 20 kd.
DISCUSSION F l a x (Linum usitatissimum) is an i m p o r t a n t cause o f r e s p i r a t o r y disease. N o n - I g E - m e d i a t e d byssinosis, c a u s e d by i n h a l a t i o n of dust in the processing of flax, has b e e n d e s c r i b e d in flax workers, 2 as well as I g E - m e d i a t e d o c c u p a t i o n a l
J ALLERGY CLIN IMMUNOL AUGUST 1996
a s t h m a in the p r o c e s s i n g of linseed oil. 3 F t a x s e e d hypersensitivities w e r e d e s c r i b e d by two different a u t h o r s in the 1930s. 4- ~ L i n s e e d contains p o t e n t allergens. ~' E x p o s u r e to these allergens can occur t h r o u g h the oral r o u t e (e.g., linseed infusion: c o n s u m p t i o n o f b r e a d , b a k ery goods, or milk f r o m cows fed with flax flour: use o f c o u g h syrup o r laxatives) or t h r o u g h c o n t a c t with cattle feed o r dog food, hair lotion, s h a m p o o , depilatories, insulating materials, carpets, a n d s o m e linen clothes. 5 O u r p a t i e n t did not r e m e m b e r p r e v i o u s c o n t a c t with linseed, a l t h o u g h such c o n t a c t m a y have occ u r r e d b e c a u s e o f the n u m e r o u s sources o f exposure. A positive skin p r i c k test result a n d specific I g E a n t i b o d i e s indicate a type I hypersensitivity. In o u r patient, the 22 kd p r o t e i n s e e m s to be the i m p l i c a t e d allergen. In a d d i t i o n to psyllium, 7 linseed should also be c o n s i d e r e d a possible cause o f anaphylaxis f r o m laxatives. W e t h i n k new cases c o u l d arise b e c a u s e of the increasing use o f p r o d u c t s from h e a l t h f o o d shops. F l a x s e e d is also u s e d an s o m e m u l t i g r a i n breads and bakery products. We thank Ifidesa-Aristegui Laboratories for their collaboration in the realization of the in vitro study.
REFERENCES 1. Merier P. Seiler W. Stahelin H. Bulk-forming agents as laxatives in geriatric patients. Schweiz Med Wochenschr 1990::120:314-7. 2. Nowier M. EI-Sadik Y, El-Dakhakhny A, Osmar H. Dust exposure in manual flax processing in Egypt. Br J Ind Med 1975:32:147-52. 3. Bernstein D. Bernstein I, Occupational asthma. In: Middleton E Jr. Reed CE. Ellis EF, Adkinson NF Jr. Yungmger JW. editors. Allergy: principles and practice. 3rd edition, S1 Louis: CV Mosby Company, 1988:1197-218, 4. Black WC. Flax hypersensitiveness. JAMA 1930:94:1064. 5. Grant LR. A report of six cases of flaseed sensitization with review of the literature. J Allergy 1931;3:469-77. 6. William R. Kenneth P. Aerobiology and inhalant allergens, [n: Middleton E Jr. Reed CE. Ellis EF. Adkinson NF Jr. Yunginger JW. editors. Allergy: principles and practice. 3rd edition. St Louis: CV Mosby Company, 1988:312-72. 7. Suhonen R. Kantola F. Anaphylactic shock due to ingestion of psyllium laxative. Allergy 1983:38:363-5.
Long-term administration of corticosteroids may have different effects on lipid profiles than short-term therapy. In one study, patients taking a short-term tapering oral prednisone burst for treatment of rheumatic disease demonstrated significant increases in total cholesterol and HDL-C, 1 month later, but no changes in triglycerides or LDL-C. 5 The association of higher H D L - C levels in elderly CHS participants with asthma, independent of corticosteroid therapy, suggests that other mechanisms exist. We also found evidence for a dose-response relationship in elderly men: those with more severe asthma (more frequent attacks or more severe airway obstruction) had significantly higher H D L - C levels than those who were currently free of symptoms. A possible explanation is that some CHS participants with asthma had recently taken a short course of prednisone (raising HDL-C) but were not currently taking it at the time of their clinic visit when medication use was ascer-
A l o n s o et al.
469
tained. Another theory is that the increased work of breathing, which occurs because of bronchospasm in asthma, is a type of regular exercise that raises HDL-C. REFERENCES
1. Lasser EC, Berry C, Kortman K. Diminished atheroscierotic arterial calcifications in asthma: a possible role for elevated endogenous heparin-like material. Allergy 1987;42:549-52. 2. Fried LP, Borhani NO, Enright PL, et al. The Cardiovascular Health Study: design and rationale. Ann Epidemiol 1991;1:263-76. 3. Ettinger WH, Wahl PW, Kuller LH, et al. Lipoprotein lipids in older people: results from the Cardiovascular Health Study. Circulation 1992;86:858-69. 4. Mittlemark MB, Psaty BM, Rautaharju PM, et al. Prevalence of cardiovascular diseases among older adults: The Cardiovascular Health Study. Am J Epidemiol 1993;137: 311-7. 5. Ettinger WH, Klinefelter HF, Kwitervoitch PE. Effect of short-term, low-dose corticosteroids on plasma lipoprotein lipids. Atherosclerosis 1987;20:530-1.
Anaphylaxis caused by linseed (flaxseed) intake Lidia Alonso, MD, Maria Luisa Marcos, MD, Juan Guillermo Blanco, MD, Jose Antonio Navarro, MD, Sonsoles Juste, MD, Maria del Mar Garces, MD, Reyes Perez, MD, and Pedro Jaime Carretero, MD Burgos, Spain
Flax is a plant that belongs to the Linaceae family. It comes from Central Asia, and it has been cultivated for 5000 years. Egyptians, Hebrews, Greeks, and Romans used the seeds as food and the fibers to weave clothes, sails, and other items. Nowadays, linseed oil is extracted from this plant, and this oil is mainly used in the preparation of varnish, paint, linoleum, and soap. Linseed oil has recently been used as a laxative. 1 We report the case of a 40-year-old woman who had an anaphylactic reaction after the intake of linseed oil. From Secci6n Alergologfa, Hospital General Yagtie, Burgos, Spain. Reprint requests: Lidia Alonso, MD, Secci6n Alergologfa, Hospital General Yagfie, E-09005 Burgos, Spain. J Allergy Clin Immunol 1996;98:469-70 Copyright © 1996 by Mosby-Year Book, Inc. 0091-6749/96 $5.00 + 0 1/54/73138
Abbreviation used SDS-PAGE:
Sodium dodecylsulfate-polyacrylamide gel electrophoresis
CASE REPORT A 40-year-old woman with no personal or familial history of atopy took linseed oil as a laxative. Ten minutes after the intake of the first spoonful, she experienced ocular pruritus and weeping, followed by strong palmar pruritus and generalized urticaria, nausea, and vomiting. She was treated in the emergency department, and the symptoms were promptly reversed. Skin prick tests were done with a battery of commercially available allergens (Laboratory Ifidesa-Aristegui, Bilbao, Spain), which included: Dermatophagoides ptero-
470
Alonso
et al.
nyssinus, D. farinae, Lepidoglyphus destructor, Glycyphagus domesticus, Aspergilhts furnigams, Penicillium notaturn, Alternaria tenuis, Cladosporium herbarum, grass pollen mix, animal allergens, feathers, cockroach, latex, and food. A linseed extract was prepared as follows: 5 gm of linseed was incubated in 50 ml of phosphate-buffered saline for 24 hours at 4 ° C with continuous stirring. After straining the extract through filter paper, the solution was passed through a Millipore filter (0.22 ~m; Millipore Corp., Bedford, Mass.). Skin prick tests were done with the antigenic preparation described previously. The positive control was histamine, 10 mg/ml, and the negative control was phosphate-buffered saline. Our extract was also tested in five atopic and five nonatopic patients. The total IgE antibody was determined by CAP System (Phadebas; Kabi Pharmacia, Uppsala, Sweden). The determination of specific IgE for linseed was performed by coating the allergen (2 rag/disk) to cellulose disks activated by CNBr. A Pharmacia-Trazer kit (Kabi Pharmacia) was used during the development process. We also performed sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of linseed extract by the Laemmli discontinuous method and SDSPAGE immunoblotting with the patient's serum and a nonallergic patient control serum. For ethical reasons, we did not perform the oral provocation with linseed. A skin test response to linseed extract was considered positive when a wheal with a diameter of 12 mm was produced. The positive control was 6 ram. There was no later reaction. None of the tested control subjects showed any skin reaction. Results were negative for the rest of the allergens tested. Total IgE antibody was 19 kU/L. Specific IgE antibody determination to linseed showed a value of 2.16 Phadebas RAST units/ml (grade 2 to the reference standard rate). The result of SDS-PAGE shows 15 visible bands between 58 kd and 13 kd. Immunoblot of SDS-PAGE was made with linseed extract and patient serum. It showed five allergens with molecular weights of 38, 35, 30, 22, and 20 kd.
DISCUSSION F l a x (Linum usitatissimum) is an i m p o r t a n t cause o f r e s p i r a t o r y disease. N o n - I g E - m e d i a t e d byssinosis, c a u s e d by i n h a l a t i o n of dust in the processing of flax, has b e e n d e s c r i b e d in flax workers, 2 as well as I g E - m e d i a t e d o c c u p a t i o n a l
J ALLERGY CLIN IMMUNOL AUGUST 1996
a s t h m a in the p r o c e s s i n g of linseed oil. 3 F t a x s e e d hypersensitivities w e r e d e s c r i b e d by two different a u t h o r s in the 1930s. 4- ~ L i n s e e d contains p o t e n t allergens. ~' E x p o s u r e to these allergens can occur t h r o u g h the oral r o u t e (e.g., linseed infusion: c o n s u m p t i o n o f b r e a d , b a k ery goods, or milk f r o m cows fed with flax flour: use o f c o u g h syrup o r laxatives) or t h r o u g h c o n t a c t with cattle feed o r dog food, hair lotion, s h a m p o o , depilatories, insulating materials, carpets, a n d s o m e linen clothes. 5 O u r p a t i e n t did not r e m e m b e r p r e v i o u s c o n t a c t with linseed, a l t h o u g h such c o n t a c t m a y have occ u r r e d b e c a u s e o f the n u m e r o u s sources o f exposure. A positive skin p r i c k test result a n d specific I g E a n t i b o d i e s indicate a type I hypersensitivity. In o u r patient, the 22 kd p r o t e i n s e e m s to be the i m p l i c a t e d allergen. In a d d i t i o n to psyllium, 7 linseed should also be c o n s i d e r e d a possible cause o f anaphylaxis f r o m laxatives. W e t h i n k new cases c o u l d arise b e c a u s e of the increasing use o f p r o d u c t s from h e a l t h f o o d shops. F l a x s e e d is also u s e d an s o m e m u l t i g r a i n breads and bakery products. We thank Ifidesa-Aristegui Laboratories for their collaboration in the realization of the in vitro study.
REFERENCES 1. Merier P. Seiler W. Stahelin H. Bulk-forming agents as laxatives in geriatric patients. Schweiz Med Wochenschr 1990::120:314-7. 2. Nowier M. EI-Sadik Y, El-Dakhakhny A, Osmar H. Dust exposure in manual flax processing in Egypt. Br J Ind Med 1975:32:147-52. 3. Bernstein D. Bernstein I, Occupational asthma. In: Middleton E Jr. Reed CE. Ellis EF, Adkinson NF Jr. Yungmger JW. editors. Allergy: principles and practice. 3rd edition, S1 Louis: CV Mosby Company, 1988:1197-218, 4. Black WC. Flax hypersensitiveness. JAMA 1930:94:1064. 5. Grant LR. A report of six cases of flaseed sensitization with review of the literature. J Allergy 1931;3:469-77. 6. William R. Kenneth P. Aerobiology and inhalant allergens, [n: Middleton E Jr. Reed CE. Ellis EF. Adkinson NF Jr. Yunginger JW. editors. Allergy: principles and practice. 3rd edition. St Louis: CV Mosby Company, 1988:312-72. 7. Suhonen R. Kantola F. Anaphylactic shock due to ingestion of psyllium laxative. Allergy 1983:38:363-5.