- Email: [email protected]
Goat's cheese anaphylaxis after cutaneous sensitization by moisturizer that contained goat's milk
Clinical Communications Goat’s cheese anaphylaxis after cutaneous sensitization by moisturizer that contained goat’s milk Astrid L. Voskamp, MSca,b, Celia M. Zubrinich, FRACPa, Jodie B. Abramovitch, BSc Honsa,b, Jennifer M. Rolland, PhDa,b, and Robyn E. O’Hehir, FRACP, PhDa,b Clinical Implication
We report anaphylaxis to goat’s cheese after cutaneous sensitization with a moisturizer that contained goat’s milk applied to eczematous skin, confirmed by specific in vitro basophil activation and inhibition serum IgE immunoblotting.
TO THE EDITOR: The current treatment for atopic eczema includes topical corticosteroid application during exacerbations and regular use of emollients and moisturizers to optimally hydrate affected areas. Many creams to treat dry skin and eczema are advertised as “natural” products, but they may contain potential food allergens. For example, ingredients could include goat’s milk, cow’s milk, coconut milk or oil, oats, and nut oil. Application of such food allergens to barrier-compromised skin could cause sensitization to the allergen, which leads to severe reactions when the food is subsequently ingested. A 55-year-old female medical research administrator developed a generalized allergic reaction, characterized by urticaria and rapidly evolving oral and upper airway angioedema, immediately after eating 2 mouthfuls of a salad at a restaurant. This resulted in emergency department attendance and administration of intramuscular adrenaline. The salad contained zucchini, goat’s cheese, broad beans, mustard, vinegar, olive oil, basil, and lemon zest. Her medical history was unremarkable, except for lifelong extensive atopic eczema and seasonal asthma. Direct questioning revealed that, 4 months before the anaphylactic episode, for several weeks, she had been frequently applying a skin moisturizer that contained goat’s milk. After an application resulted in acute erythema and itch, she subsequently ceased applying the product. Investigational serum-specific IgE was strongly positive for goat’s milk (65.7 kU/L) (ImmunoCAP; Phadia, Uppsala, Sweden) and negative for mustard. The remaining salad ingredients have subsequently been eaten without reaction, and she regularly consumes cow’s milk products. The patient confirmed ingestion of goat’s cheese without any adverse effects before the use of the moisturizer. We hypothesized that IgE-mediated sensitization occurred during application of the moisturizer that contained goat’s milk to inflamed, eczematous skin, which resulted in the generalized allergic reaction when the foodstuff was subsequently encountered orally. The basophil activation test is an in vitro test for functional IgE reactivity. The test assesses IgE-mediated basophil
FIGURE 1. Basophil activation test. Dose-dependent basophil activation induced by goat’s milk and moisturizing product used by the patient. C, Goat’s milk (mg/mL); -, cow’s milk (mg/mL); :, moisturizing product (mL); ; anti-IgE; A, fMLP; B, no antigen.
activation in response to stimulation with allergen by detection of CD63 on the basophil surface by using flow cytometry.1 Results of this test have previously shown high correlation with clinical symptoms.2 We performed a basophil activation test by using the whole blood of the patient stimulated with both goat’s milk (Greer Laboratories, Lenoir, NC) and her moisturizing product. The moisturizer was diluted at a 1:2 ratio in PBS solution (Life Technologies, Grand Island, NY) before use. As a control, we also tested cow’s skimmed milk protein. Dosedependent basophil activation to both the goat’s milk extract and the moisturizing product were confirmed, but no activation was found with cow’s skimmed milk (Figure 1). Basophils from a nonallergic donor also were assessed and failed to respond to any of the antigens (data not shown). Positive controls included the bacterial peptide formyl-methionyl-leucyl-phenylalanine (fMLP) and anti-IgE antibody induced activation. We also performed serum IgE immunoblotting to the moisturizer and the goat’s milk. The concentration of goat’s milk within the moisturizing product was calculated to be approximately 0.44 mg/mL based on the equivalent levels of basophil activation achieved with a known concentration of goat’s milk (Figure 1). Antigen preparations (3 mg/lane) were resolved by 4% to 12% gradient SDS-PAGE under reducing conditions and then were transferred to nitrocellulose and probed with the patient’s serum at a 1:20 dilution. IgE immunoblotting revealed serum IgE binding to components in both the moisturizing product and goat’s milk (Figure 2, A, lane 2, and Figure 2, B, respectively), consistent with the ImmunoCAP and basophil activation test results. To verify our hypothesis that the initial sensitization developed through use of the moisturizing product, we performed IgE inhibition immunoblotting.3 For this, before probing the nitrocellulose, the patient’s serum was incubated with increasing concentrations of goat’s milk, moisturizing product, or control protein keyhole limpet hemocyanin (KLH) 629
630
CLINICAL COMMUNICATIONS
J ALLERGY CLIN IMMUNOL PRACT SEPTEMBER/OCTOBER 2014
FIGURE 2. Inhibition IgE immunoblotting. A, Inhibition of patient serum IgE binding to moisturizing product with 10-fold dilutions of inhibiting extract. Lane 1, nonallergic control serum; lane 2, no inhibitor; lanes 3-6, 0.1-100 mg/mL goat’s milk; lanes 7-10, 0.1100 mg/mL moisturizing product; lanes 11-13, 1-100 mg/mL KLH. B, Patient serum IgE reactivity to goat’s milk. C, Inhibition of ryegrass allergic patient serum IgE reactivity to ryegrass. Lane 1, No serum; lane 2, no inhibitor; lanes 3 and 4, 10,100 mg/mL ryegrass; lanes 5-8, 0.1-100 mg/mL goat’s milk.
for 1 hour. IgE binding to the moisturizing product (lane 2) is shown in Figure 2, which is completely inhibited by preincubation with goat’s milk (lanes 3-6) as well as the moisturizing product (lanes 7-10), which confirms that the IgE target protein within the moisturizing product contains B-cell epitopes present in goat’s milk. Controls for the IgE inhibition immunoblotting included KLH (lane 11-13), which did not cause any nonspecific inhibition of IgE binding to the moisturizing product, and a ryegrass (Greer Laboratories) immunoblot with serum from a ryegrass allergic donor in which no nonspecific inhibition of IgE binding occurred with goat’s milk (Figure 2, C). Together, these results support the conclusion that an allergic response was induced by the moisturizing product, and this response could be attributed to the goat’s milk proteins within the product. The immunoblot results show strong IgE reactivity to proteins with a molecular weight between 20 and 28 kDa within the moisturizing product, which may correspond with goat b-casein (approximately 27 kDa) and g-casein (22 kDa) and which differs from typical cow’s milk allergy, in which a-casein and whey proteins (eg, blactoglobulin) are the dominant allergens,4 which likely explains the lack of cross-reactivity with cow’s milk in this case. When combined, the clinical history and in vitro immunologic data clearly support the route of sensitization as being through topical application of the allergen to inflamed and compromised skin with subsequent anaphylaxis to the ingested allergen. This route of sensitization has been suggested in clinical studies of the development of wheat, oat, peanut, and goat’s milk allergies5-8 with speculation in several of these studies that the suspected sensitizing product consisted of soaps and oils used to alleviate the symptoms of eczema. Murine studies demonstrate systemic sensitization after cutaneous allergen exposure.9 Our data provide, to our knowledge, the first direct evidence of an immunologic response of a patient to the suspected causative agent involved in the development of the allergy. We remind clinicians and patients that skin care
ought to be bland, and we advocate avoidance of agents capable of sensitization, especially foods. a
Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia b Department of Immunology, Monash University, Melbourne, Australia Supported by The Alfred Research Trusts. Conflicts of interest: All authors have declared they have received research support from the Alfred Research Trusts. Received for publication April 28, 2014; accepted for publication April 29, 2014. Available online June 13, 2014. Corresponding author: Robyn E. O’Hehir, FRACP, PhD, Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne 3004, Victoria, Australia. E-mail: [email protected]. 2213-2198/$36.00 Ó 2014 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2014.04.012 REFERENCES 1. Drew AC, Eusebius NP, Kenins L, de Silva HD, Suphioglu C, Rolland JM, et al. Hypoallergenic variants of the major latex allergen Hev b 6.01 retaining human T lymphocyte reactivity. J Immunol 2004;173:5872-9. 2. McGowan EC, Saini S. Update on the performance and application of basophil activation tests. Curr Allergy Asthma Rep 2013;13:101-9. 3. Abramovitch JB, Kamath S, Varese N, Zubrinich C, Lopata AL, O’Hehir RE, et al. IgE reactivity of blue swimmer crab (Portunus pelagicus) tropomyosin, Por p 1, and other allergens; cross-reactivity with black tiger prawn and effects of heating. PLoS One 2013;8:e67487. 4. Umpierrez A, Quirce S, Maranon F, Cuesta J, Garcia-Villamuza Y, Lahoz C, et al. Allergy to goat and sheep cheese with good tolerance to cow cheese. Clin Exp Allergy 1999;29:1064-8. 5. Chinuki Y, Morita E. Wheat-dependent exercise-induced anaphylaxis sensitized with hydrolyzed wheat protein in soap. Allergol Int 2012;61:529-37. 6. Boussault P, Leaute-Labreze C, Saubusse E, Maurice-Tison S, Perromat M, Roul S, et al. Oat sensitization in children with atopic dermatitis: prevalence, risks and associated factors. Allergy 2007;62:1251-6. 7. Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy in childhood. N Engl J Med 2003;348:977-85. 8. Mullins RJ. Allergy to topical and oral goat products. Med J Aust 2012;197:148-9. 9. Dunkin D, Berin MC, Mayer L. Allergic sensitization can be induced via multiple physiologic routes in an adjuvant-dependent manner. J Allergy Clin Immunol 2011;128:1251-1258 e2.
We report anaphylaxis to goat’s cheese after cutaneous sensitization with a moisturizer that contained goat’s milk applied to eczematous skin, confirmed by specific in vitro basophil activation and inhibition serum IgE immunoblotting.
TO THE EDITOR: The current treatment for atopic eczema includes topical corticosteroid application during exacerbations and regular use of emollients and moisturizers to optimally hydrate affected areas. Many creams to treat dry skin and eczema are advertised as “natural” products, but they may contain potential food allergens. For example, ingredients could include goat’s milk, cow’s milk, coconut milk or oil, oats, and nut oil. Application of such food allergens to barrier-compromised skin could cause sensitization to the allergen, which leads to severe reactions when the food is subsequently ingested. A 55-year-old female medical research administrator developed a generalized allergic reaction, characterized by urticaria and rapidly evolving oral and upper airway angioedema, immediately after eating 2 mouthfuls of a salad at a restaurant. This resulted in emergency department attendance and administration of intramuscular adrenaline. The salad contained zucchini, goat’s cheese, broad beans, mustard, vinegar, olive oil, basil, and lemon zest. Her medical history was unremarkable, except for lifelong extensive atopic eczema and seasonal asthma. Direct questioning revealed that, 4 months before the anaphylactic episode, for several weeks, she had been frequently applying a skin moisturizer that contained goat’s milk. After an application resulted in acute erythema and itch, she subsequently ceased applying the product. Investigational serum-specific IgE was strongly positive for goat’s milk (65.7 kU/L) (ImmunoCAP; Phadia, Uppsala, Sweden) and negative for mustard. The remaining salad ingredients have subsequently been eaten without reaction, and she regularly consumes cow’s milk products. The patient confirmed ingestion of goat’s cheese without any adverse effects before the use of the moisturizer. We hypothesized that IgE-mediated sensitization occurred during application of the moisturizer that contained goat’s milk to inflamed, eczematous skin, which resulted in the generalized allergic reaction when the foodstuff was subsequently encountered orally. The basophil activation test is an in vitro test for functional IgE reactivity. The test assesses IgE-mediated basophil
FIGURE 1. Basophil activation test. Dose-dependent basophil activation induced by goat’s milk and moisturizing product used by the patient. C, Goat’s milk (mg/mL); -, cow’s milk (mg/mL); :, moisturizing product (mL); ; anti-IgE; A, fMLP; B, no antigen.
activation in response to stimulation with allergen by detection of CD63 on the basophil surface by using flow cytometry.1 Results of this test have previously shown high correlation with clinical symptoms.2 We performed a basophil activation test by using the whole blood of the patient stimulated with both goat’s milk (Greer Laboratories, Lenoir, NC) and her moisturizing product. The moisturizer was diluted at a 1:2 ratio in PBS solution (Life Technologies, Grand Island, NY) before use. As a control, we also tested cow’s skimmed milk protein. Dosedependent basophil activation to both the goat’s milk extract and the moisturizing product were confirmed, but no activation was found with cow’s skimmed milk (Figure 1). Basophils from a nonallergic donor also were assessed and failed to respond to any of the antigens (data not shown). Positive controls included the bacterial peptide formyl-methionyl-leucyl-phenylalanine (fMLP) and anti-IgE antibody induced activation. We also performed serum IgE immunoblotting to the moisturizer and the goat’s milk. The concentration of goat’s milk within the moisturizing product was calculated to be approximately 0.44 mg/mL based on the equivalent levels of basophil activation achieved with a known concentration of goat’s milk (Figure 1). Antigen preparations (3 mg/lane) were resolved by 4% to 12% gradient SDS-PAGE under reducing conditions and then were transferred to nitrocellulose and probed with the patient’s serum at a 1:20 dilution. IgE immunoblotting revealed serum IgE binding to components in both the moisturizing product and goat’s milk (Figure 2, A, lane 2, and Figure 2, B, respectively), consistent with the ImmunoCAP and basophil activation test results. To verify our hypothesis that the initial sensitization developed through use of the moisturizing product, we performed IgE inhibition immunoblotting.3 For this, before probing the nitrocellulose, the patient’s serum was incubated with increasing concentrations of goat’s milk, moisturizing product, or control protein keyhole limpet hemocyanin (KLH) 629
630
CLINICAL COMMUNICATIONS
J ALLERGY CLIN IMMUNOL PRACT SEPTEMBER/OCTOBER 2014
FIGURE 2. Inhibition IgE immunoblotting. A, Inhibition of patient serum IgE binding to moisturizing product with 10-fold dilutions of inhibiting extract. Lane 1, nonallergic control serum; lane 2, no inhibitor; lanes 3-6, 0.1-100 mg/mL goat’s milk; lanes 7-10, 0.1100 mg/mL moisturizing product; lanes 11-13, 1-100 mg/mL KLH. B, Patient serum IgE reactivity to goat’s milk. C, Inhibition of ryegrass allergic patient serum IgE reactivity to ryegrass. Lane 1, No serum; lane 2, no inhibitor; lanes 3 and 4, 10,100 mg/mL ryegrass; lanes 5-8, 0.1-100 mg/mL goat’s milk.
for 1 hour. IgE binding to the moisturizing product (lane 2) is shown in Figure 2, which is completely inhibited by preincubation with goat’s milk (lanes 3-6) as well as the moisturizing product (lanes 7-10), which confirms that the IgE target protein within the moisturizing product contains B-cell epitopes present in goat’s milk. Controls for the IgE inhibition immunoblotting included KLH (lane 11-13), which did not cause any nonspecific inhibition of IgE binding to the moisturizing product, and a ryegrass (Greer Laboratories) immunoblot with serum from a ryegrass allergic donor in which no nonspecific inhibition of IgE binding occurred with goat’s milk (Figure 2, C). Together, these results support the conclusion that an allergic response was induced by the moisturizing product, and this response could be attributed to the goat’s milk proteins within the product. The immunoblot results show strong IgE reactivity to proteins with a molecular weight between 20 and 28 kDa within the moisturizing product, which may correspond with goat b-casein (approximately 27 kDa) and g-casein (22 kDa) and which differs from typical cow’s milk allergy, in which a-casein and whey proteins (eg, blactoglobulin) are the dominant allergens,4 which likely explains the lack of cross-reactivity with cow’s milk in this case. When combined, the clinical history and in vitro immunologic data clearly support the route of sensitization as being through topical application of the allergen to inflamed and compromised skin with subsequent anaphylaxis to the ingested allergen. This route of sensitization has been suggested in clinical studies of the development of wheat, oat, peanut, and goat’s milk allergies5-8 with speculation in several of these studies that the suspected sensitizing product consisted of soaps and oils used to alleviate the symptoms of eczema. Murine studies demonstrate systemic sensitization after cutaneous allergen exposure.9 Our data provide, to our knowledge, the first direct evidence of an immunologic response of a patient to the suspected causative agent involved in the development of the allergy. We remind clinicians and patients that skin care
ought to be bland, and we advocate avoidance of agents capable of sensitization, especially foods. a
Department of Allergy, Immunology and Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Australia b Department of Immunology, Monash University, Melbourne, Australia Supported by The Alfred Research Trusts. Conflicts of interest: All authors have declared they have received research support from the Alfred Research Trusts. Received for publication April 28, 2014; accepted for publication April 29, 2014. Available online June 13, 2014. Corresponding author: Robyn E. O’Hehir, FRACP, PhD, Department of Allergy, Immunology and Respiratory Medicine, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne 3004, Victoria, Australia. E-mail: [email protected]. 2213-2198/$36.00 Ó 2014 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2014.04.012 REFERENCES 1. Drew AC, Eusebius NP, Kenins L, de Silva HD, Suphioglu C, Rolland JM, et al. Hypoallergenic variants of the major latex allergen Hev b 6.01 retaining human T lymphocyte reactivity. J Immunol 2004;173:5872-9. 2. McGowan EC, Saini S. Update on the performance and application of basophil activation tests. Curr Allergy Asthma Rep 2013;13:101-9. 3. Abramovitch JB, Kamath S, Varese N, Zubrinich C, Lopata AL, O’Hehir RE, et al. IgE reactivity of blue swimmer crab (Portunus pelagicus) tropomyosin, Por p 1, and other allergens; cross-reactivity with black tiger prawn and effects of heating. PLoS One 2013;8:e67487. 4. Umpierrez A, Quirce S, Maranon F, Cuesta J, Garcia-Villamuza Y, Lahoz C, et al. Allergy to goat and sheep cheese with good tolerance to cow cheese. Clin Exp Allergy 1999;29:1064-8. 5. Chinuki Y, Morita E. Wheat-dependent exercise-induced anaphylaxis sensitized with hydrolyzed wheat protein in soap. Allergol Int 2012;61:529-37. 6. Boussault P, Leaute-Labreze C, Saubusse E, Maurice-Tison S, Perromat M, Roul S, et al. Oat sensitization in children with atopic dermatitis: prevalence, risks and associated factors. Allergy 2007;62:1251-6. 7. Lack G, Fox D, Northstone K, Golding J. Factors associated with the development of peanut allergy in childhood. N Engl J Med 2003;348:977-85. 8. Mullins RJ. Allergy to topical and oral goat products. Med J Aust 2012;197:148-9. 9. Dunkin D, Berin MC, Mayer L. Allergic sensitization can be induced via multiple physiologic routes in an adjuvant-dependent manner. J Allergy Clin Immunol 2011;128:1251-1258 e2.