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Occupational Allergic Contact Dermatitis due to Multiple Tropical Plant Species
Images in Allergy Occupational Allergic Contact Dermatitis due to Multiple Tropical Plant Species Timothy J. Watts, MRCPa, Philip H. Li, MRes (Med), MRCPa,b, Iason Thomas, MRCPa, and Rubaiyat Haque, FRCPa London, United Kingdom; and Pokfulam, Hong Kong
A 25-year-old female horticulturist was assessed for a 10-month history of recurrent episodes of severe acute erythematous papulovesicular dermatitis affecting exposed areas of skin, occurring only after contact with various tropical plant species at her workplace. The eruptions typically developed around 48 hours after direct contact with plant leaves or stems at the exact sites of cutaneous exposure and lasted around 7 days before resolving. Multiple short courses of prednisolone were prescribed to treat the eruptions. She worked with tropical plants for 4 years before onset of her first reaction and reported minimal sunlight exposure around the time of eruptions. She became asymptomatic when she was temporarily transferred away from the tropical plant enclosure. She had no history of prior allergic disease. On physical examination, clustered erythematous papular lesions were noted on her left knee (Figure 1) and an erythematous vesiculobullous eruption was noted on her left wrist (Figure 2), which both developed 48 hours after contact with plants. The patient worked with multiple tropical plant species on a regular basis, making exact identification difficult; therefore, she brought samples of 12 labeled tropical plants that were handled around the time of her recurrent skin eruptions for testing. Patch testing was performed using IQ Ultra chambers with the British Standard Series and Plant Series (Chemotechnique Diagnostics, Vellinge, Sweden), and uniformly cut pieces of both fresh leaf and stem from the following 12 tropical plants: Mangifera indica, Abroma augustum, Hibiscus tiliaceus, Banisteriopsis caapi, Heliconia collinsiana, Philodendron radiatum, Allamanda cathartica, Stephanotis floribunda, Macadamia tetraphylla, Aechmea fasciata, Gigantochloa verticillata, and Acalypha hispida.
a
Department of Adult Allergy, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom b Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong No funding was received for this work. Conflicts of interest: R. Haque is on the Allergy Therapeutics board; and has received travel support from Allergy Therapeutics and ALK Abello. The rest of the authors declare that they have no relevant conflicts of interest. Received for publication March 15, 2017; revised April 2, 2017; accepted for publication April 20, 2017. Available online -Corresponding author: Timothy J. Watts, MRCP, Department of Adult Allergy, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, United Kingdom. E-mail: [email protected]. J Allergy Clin Immunol Pract 2017;-:---. 2213-2198 Ó 2017 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2017.04.026
FIGURE 1. Clustered erythematous papular lesions (left knee) 48 hours after direct contact with tropical plant(s).
Patch tests were read on day 2 (D2) and day 4 (D4) in accordance with the International Contact Dermatitis Research Group criteria. Patch testing to the British Standard Series and Plant Series was completely negative; however, there were strong positive reactions (erythema, papules, vesicles, infiltration) recorded at D4 (crescendo effect since D2) to M. indica (þþ), A. augustum (þþ), H. tiliaceus (þþ), and P. radiatum (þþþ) (Figure 3). Control subjects were also patch tested to the plants and the readings were negative. The patient was diagnosed with occupational allergic contact dermatitis due to M. indica (mango), A. augustum, H. tiliaceus, and P. radiatum based on the clinical features, history of frequent occupational exposure, and the strong positive patch test results. After returning to her work environment, she avoided exposure to these plants and used protective clothing that led to a complete resolution of her recurrent dermatitis. She also had no prior history of reacting to mango after oral consumption. 1
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FIGURE 2. Erythematous vesiculobullous eruption (left wrist) 48 hours after direct contact with tropical plant(s).
Allergic contact phytodermatitis is a delayed type IV cell-mediated hypersensitivity.1 Various plants and plant allergens have been identified over the years as causing allergic contact dermatitis.2 Unfortunately, this important condition is frequently underrecognized and accurate diagnosis, especially after simultaneous contact with multiple plants, remains challenging. Allergic contact dermatitis with sensitization to resorcinols in M. indica3 and Philodendron4 have been separately described. However, there has only been one other published report on Hibiscus contact allergy,5 and we describe the first case of A. augustum allergic contact dermatitis. Furthermore, polysensitization to these 4 tropical plant species has not been described previously. Multiple plant allergens could potentially be implicated. This report highlights the importance of a comprehensive and structured approach to investigating suspected plant dermatitis.
FIGURE 3. Positive patch test readings at Day 4. A: Mangifera indica (þþ), B: Abroma augustum (þþ), C: Hibiscus tiliaceus (þþ), D: Philodendron radiatum (þþþ). REFERENCES 1. Rietschel RL, Fowler JF, Fisher AA. Fisher’s Contact Dermatitis. 6th ed. Hamilton, Ontario, Canada: BC Decker Inc.; 2008. 2. Rozas-Muñoz E, Lepoittevin JP, Pujol RM, Giménez-Arnau A. Allergic contact dermatitis to plants: understanding the chemistry will help our diagnostic approach. Actas Dermosifiliogr 2012;103:456-77. 3. Kim AS, Christiansen SC. Mango: pulp fiction? Contact Dermatitis 2015;73:123-4. 4. Knight TE. Philodendron-induced dermatitis: report of cases and review of the literature. Cutis 1991;48:375-8. 5. Matsushita T, Aoyama K, Manda F, Ueda A, Yoshida M, Okamura J. Occupational dermatoses in farmers growing okra (Hibiscus esculentus L). Contact Dermatitis 1989;21:321-5.
A 25-year-old female horticulturist was assessed for a 10-month history of recurrent episodes of severe acute erythematous papulovesicular dermatitis affecting exposed areas of skin, occurring only after contact with various tropical plant species at her workplace. The eruptions typically developed around 48 hours after direct contact with plant leaves or stems at the exact sites of cutaneous exposure and lasted around 7 days before resolving. Multiple short courses of prednisolone were prescribed to treat the eruptions. She worked with tropical plants for 4 years before onset of her first reaction and reported minimal sunlight exposure around the time of eruptions. She became asymptomatic when she was temporarily transferred away from the tropical plant enclosure. She had no history of prior allergic disease. On physical examination, clustered erythematous papular lesions were noted on her left knee (Figure 1) and an erythematous vesiculobullous eruption was noted on her left wrist (Figure 2), which both developed 48 hours after contact with plants. The patient worked with multiple tropical plant species on a regular basis, making exact identification difficult; therefore, she brought samples of 12 labeled tropical plants that were handled around the time of her recurrent skin eruptions for testing. Patch testing was performed using IQ Ultra chambers with the British Standard Series and Plant Series (Chemotechnique Diagnostics, Vellinge, Sweden), and uniformly cut pieces of both fresh leaf and stem from the following 12 tropical plants: Mangifera indica, Abroma augustum, Hibiscus tiliaceus, Banisteriopsis caapi, Heliconia collinsiana, Philodendron radiatum, Allamanda cathartica, Stephanotis floribunda, Macadamia tetraphylla, Aechmea fasciata, Gigantochloa verticillata, and Acalypha hispida.
a
Department of Adult Allergy, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom b Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong No funding was received for this work. Conflicts of interest: R. Haque is on the Allergy Therapeutics board; and has received travel support from Allergy Therapeutics and ALK Abello. The rest of the authors declare that they have no relevant conflicts of interest. Received for publication March 15, 2017; revised April 2, 2017; accepted for publication April 20, 2017. Available online -Corresponding author: Timothy J. Watts, MRCP, Department of Adult Allergy, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, United Kingdom. E-mail: [email protected]. J Allergy Clin Immunol Pract 2017;-:---. 2213-2198 Ó 2017 American Academy of Allergy, Asthma & Immunology http://dx.doi.org/10.1016/j.jaip.2017.04.026
FIGURE 1. Clustered erythematous papular lesions (left knee) 48 hours after direct contact with tropical plant(s).
Patch tests were read on day 2 (D2) and day 4 (D4) in accordance with the International Contact Dermatitis Research Group criteria. Patch testing to the British Standard Series and Plant Series was completely negative; however, there were strong positive reactions (erythema, papules, vesicles, infiltration) recorded at D4 (crescendo effect since D2) to M. indica (þþ), A. augustum (þþ), H. tiliaceus (þþ), and P. radiatum (þþþ) (Figure 3). Control subjects were also patch tested to the plants and the readings were negative. The patient was diagnosed with occupational allergic contact dermatitis due to M. indica (mango), A. augustum, H. tiliaceus, and P. radiatum based on the clinical features, history of frequent occupational exposure, and the strong positive patch test results. After returning to her work environment, she avoided exposure to these plants and used protective clothing that led to a complete resolution of her recurrent dermatitis. She also had no prior history of reacting to mango after oral consumption. 1
2
IMAGES IN ALLERGY
J ALLERGY CLIN IMMUNOL PRACT MONTH 2017
FIGURE 2. Erythematous vesiculobullous eruption (left wrist) 48 hours after direct contact with tropical plant(s).
Allergic contact phytodermatitis is a delayed type IV cell-mediated hypersensitivity.1 Various plants and plant allergens have been identified over the years as causing allergic contact dermatitis.2 Unfortunately, this important condition is frequently underrecognized and accurate diagnosis, especially after simultaneous contact with multiple plants, remains challenging. Allergic contact dermatitis with sensitization to resorcinols in M. indica3 and Philodendron4 have been separately described. However, there has only been one other published report on Hibiscus contact allergy,5 and we describe the first case of A. augustum allergic contact dermatitis. Furthermore, polysensitization to these 4 tropical plant species has not been described previously. Multiple plant allergens could potentially be implicated. This report highlights the importance of a comprehensive and structured approach to investigating suspected plant dermatitis.
FIGURE 3. Positive patch test readings at Day 4. A: Mangifera indica (þþ), B: Abroma augustum (þþ), C: Hibiscus tiliaceus (þþ), D: Philodendron radiatum (þþþ). REFERENCES 1. Rietschel RL, Fowler JF, Fisher AA. Fisher’s Contact Dermatitis. 6th ed. Hamilton, Ontario, Canada: BC Decker Inc.; 2008. 2. Rozas-Muñoz E, Lepoittevin JP, Pujol RM, Giménez-Arnau A. Allergic contact dermatitis to plants: understanding the chemistry will help our diagnostic approach. Actas Dermosifiliogr 2012;103:456-77. 3. Kim AS, Christiansen SC. Mango: pulp fiction? Contact Dermatitis 2015;73:123-4. 4. Knight TE. Philodendron-induced dermatitis: report of cases and review of the literature. Cutis 1991;48:375-8. 5. Matsushita T, Aoyama K, Manda F, Ueda A, Yoshida M, Okamura J. Occupational dermatoses in farmers growing okra (Hibiscus esculentus L). Contact Dermatitis 1989;21:321-5.