- Email: [email protected]
Oral mite ingestion: Expect more than anaphylaxis
CORRESPONDENCE 505
J ALLERGY CLIN IMMUNOL VOLUME 132, NUMBER 2
being more expanded in our patient compared with the case described by Ramirez et al. Both cases1,4 suggest that some patients with EoE/EGID might benefit from immunotherapy with aeroallergens. This possibility is highly relevant in view of the severity of EoE/EGID and its restricted therapeutic possibilities.2,5 Controlled studies in patients with EoE/EGID and aeroallergen sensitivity should address this question and first could focus on patients also having respiratory symptoms with indications for immunotherapy. Liliane De Swert, MD From Pediatric Allergy, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium. E-mail: [email protected]. Disclosure of potential conflict of interest: L. De Swert declares that she has no relevant conflicts of interest.
REFERENCES 1. Ramirez RM, Jacobs RL. Eosinophilic esophagitis treated with immunotherapy to dust mites. J Allergy Clin Immunol 2013;132:503-4. 2. Rothenberg ME. Eosinophilic gastrointestinal disorders. J Allergy Clin Immunol 2004;113:11-28. 3. Fogg MI, Ruchelli E, Spergel JM. Pollen and eosinophilic esophagitis. J Allergy Clin Immunol 2003;112:796-7. 4. De Swert L, Veereman G, Bublin M, Breiteneder H, Dilissen E, Bosmans E, et al. Eosinophilic gastrointestinal disease suggestive of pathogenesis-related class 10 (PR-10) protein allergy resolved after immunotherapy. J Allergy Clin Immunol 2013;131:600-2. 5. Stone KD, Prussin C. Immunomodulatory therapy of eosinophil-associated gastrointestinal diseases. Clin Exp Allergy 2008;38:1858-65. Available online June 12, 2013. http://dx.doi.org/10.1016/j.jaci.2013.04.054
Oral mite ingestion: Expect more than anaphylaxis To the Editor: We read with great interest the article entitled ‘‘Anaphylaxis from ingestion of mites: pancake anaphylaxis.’’1 Because ingestion of mites is becoming a more globalized concern and not just limited to tropical climates, it should be taken into account that different clinical presentations can arise aside from anaphylaxis. In our experience we have observed that some subjects might present with only cutaneous symptoms (urticaria, facial angioedema, or both) or exacerbation of their previous respiratory disease (rhinitis, asthma, or both) immediately after the ingestion of mite-contaminated pancakes. In fact, we proved an organspecific response in patients with oral mite anaphylaxis (OMA) by means of a nasal provocation test to Thyreophagus entomophagus, the mite most frequently found in contaminated flours in our area of Spain. Interestingly, the patients with OMAs with underlying rhinitis and asthma had milder nasal responses (objectively measured by using acoustic rhinometry and a score of symptoms) in the nasal provocation test to T entomophagus compared with those with only rhinitis.2,3 The pathogenesis of OMA is another intriguing issue, and although Blanco et al4 showed 3 positive double-blind placebocontrolled challenge results with mite-contaminated flour, we were not able to reproduce those symptoms after double-blind placebo-controlled challenges with increasing doses of lyophilized mites in 5 patients with OMA. These observations suggest that the combination of heat, flour, and mites could lead to the development of certain undetermined products with the potential to induce severe reactions in specific subjects. It could also be
speculated that local digestive modifications of these constituents might play a role in triggering OMA because the clinical picture has been exclusively described after ingestion. Although COX-1 inhibitory activity by mite constituents has been postulated as a possible mechanism relating OMA and nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity (aspirin-exacerbated respiratory disease [AERD] or urticaria/ angioedema), only 50% of our 42 patients with OMA had AERD or urticaria/angioedema to NSAIDs,5,6 it should be noted that the latter does not always precede OMA (50% of 42 patients with OMA in our series). OMA can be considered a risk factor for AERD or urticaria/angioedema to NSAIDs, and it could be argued that a challenge with aspirin might be needed to exclude this diagnosis after an OMA episode. Finally, we agree with the authors that the increased incidence of this syndrome supports measures to increase early recognition, to heighten awareness of the need for injectable epinephrine, and to ensure that flour is kept refrigerated, an effective means of reducing the occurrence of OMA. Ruperto Gonz alez-P erez, MD, PhD Paloma Poza-Guedes, MD Vıctor Matheu, MD, PhD Inmaculada S anchez-Machın, MD From Servicio de Alergia, Hospital del Torax, HUNS La Candelaria, Santa Cruz de Tenerife, Spain. E-mail: [email protected]. Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest.
REFERENCES 1. Sanchez-Borges M, Suarez Chacon R, Capriles-Hulett A, Caballero-Fonseca F, Fernandez-Caldas E. Anaphylaxis from ingestion of mites: pancake anaphylaxis. J Allergy Clin Immunol 2013;131:31-5. 2. Sanchez-Machın I, Gonzalez-P Poza R, Iglesias-Souto J, Iraola V, Matheu V. Asthma and rhinitis by storage mites. Allergy 2011;66:1615-6. 3. Sanchez-Machın I, Glez-Paloma Poza R, Iglesias-Souto J, Iraola V, Matheu V. Oral mite anaphylaxis. Allergy 2010;65:1345-7. 4. Blanco C, Quiralte J, Castillo R, Delgado J, Arteaga C, Barber D, et al. Anaphylaxis after ingestion of wheat flour contaminated with mites. J Allergy Clin Immunol 1997;99:308-13. 5. Sanchez-Borges M, Capriles-Hulett A, Capriles-Behrens E, Fernandez-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens. Cutis 1997;59:311-4. 6. Sanchez-Borges M, Fernandez-Caldas E, Capriles-Hulett A, Caballero-Fonseca F. Mite-induced inflammation: more than allergy. Allergy Rhinol (Providence) 2012; 3:1-5. Available online June 15, 2013. http://dx.doi.org/10.1016/j.jaci.2013.03.053
Reply To the Editor: We would like to thank Gonzalez-Perez et al1 for their insightful observations on our article.2 We concur with them that ingestion of foods contaminated with mites can induce not only severe episodes of anaphylaxis but also milder clinical pictures, such as urticaria, angioedema, rhinorrhea, nasal congestion, conjunctivitis, or gastrointestinal symptoms, which might not fulfill the currently accepted criteria for the diagnosis of anaphylaxis.3 Concerning the pathogenesis of oral mite anaphylaxis (OMA), very little information is available, and additional research is needed to obtain a better understanding of the mechanisms leading to the acute and often severe clinical manifestations observed in this subset of atopic subjects.
J ALLERGY CLIN IMMUNOL VOLUME 132, NUMBER 2
being more expanded in our patient compared with the case described by Ramirez et al. Both cases1,4 suggest that some patients with EoE/EGID might benefit from immunotherapy with aeroallergens. This possibility is highly relevant in view of the severity of EoE/EGID and its restricted therapeutic possibilities.2,5 Controlled studies in patients with EoE/EGID and aeroallergen sensitivity should address this question and first could focus on patients also having respiratory symptoms with indications for immunotherapy. Liliane De Swert, MD From Pediatric Allergy, Department of Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium. E-mail: [email protected]. Disclosure of potential conflict of interest: L. De Swert declares that she has no relevant conflicts of interest.
REFERENCES 1. Ramirez RM, Jacobs RL. Eosinophilic esophagitis treated with immunotherapy to dust mites. J Allergy Clin Immunol 2013;132:503-4. 2. Rothenberg ME. Eosinophilic gastrointestinal disorders. J Allergy Clin Immunol 2004;113:11-28. 3. Fogg MI, Ruchelli E, Spergel JM. Pollen and eosinophilic esophagitis. J Allergy Clin Immunol 2003;112:796-7. 4. De Swert L, Veereman G, Bublin M, Breiteneder H, Dilissen E, Bosmans E, et al. Eosinophilic gastrointestinal disease suggestive of pathogenesis-related class 10 (PR-10) protein allergy resolved after immunotherapy. J Allergy Clin Immunol 2013;131:600-2. 5. Stone KD, Prussin C. Immunomodulatory therapy of eosinophil-associated gastrointestinal diseases. Clin Exp Allergy 2008;38:1858-65. Available online June 12, 2013. http://dx.doi.org/10.1016/j.jaci.2013.04.054
Oral mite ingestion: Expect more than anaphylaxis To the Editor: We read with great interest the article entitled ‘‘Anaphylaxis from ingestion of mites: pancake anaphylaxis.’’1 Because ingestion of mites is becoming a more globalized concern and not just limited to tropical climates, it should be taken into account that different clinical presentations can arise aside from anaphylaxis. In our experience we have observed that some subjects might present with only cutaneous symptoms (urticaria, facial angioedema, or both) or exacerbation of their previous respiratory disease (rhinitis, asthma, or both) immediately after the ingestion of mite-contaminated pancakes. In fact, we proved an organspecific response in patients with oral mite anaphylaxis (OMA) by means of a nasal provocation test to Thyreophagus entomophagus, the mite most frequently found in contaminated flours in our area of Spain. Interestingly, the patients with OMAs with underlying rhinitis and asthma had milder nasal responses (objectively measured by using acoustic rhinometry and a score of symptoms) in the nasal provocation test to T entomophagus compared with those with only rhinitis.2,3 The pathogenesis of OMA is another intriguing issue, and although Blanco et al4 showed 3 positive double-blind placebocontrolled challenge results with mite-contaminated flour, we were not able to reproduce those symptoms after double-blind placebo-controlled challenges with increasing doses of lyophilized mites in 5 patients with OMA. These observations suggest that the combination of heat, flour, and mites could lead to the development of certain undetermined products with the potential to induce severe reactions in specific subjects. It could also be
speculated that local digestive modifications of these constituents might play a role in triggering OMA because the clinical picture has been exclusively described after ingestion. Although COX-1 inhibitory activity by mite constituents has been postulated as a possible mechanism relating OMA and nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity (aspirin-exacerbated respiratory disease [AERD] or urticaria/ angioedema), only 50% of our 42 patients with OMA had AERD or urticaria/angioedema to NSAIDs,5,6 it should be noted that the latter does not always precede OMA (50% of 42 patients with OMA in our series). OMA can be considered a risk factor for AERD or urticaria/angioedema to NSAIDs, and it could be argued that a challenge with aspirin might be needed to exclude this diagnosis after an OMA episode. Finally, we agree with the authors that the increased incidence of this syndrome supports measures to increase early recognition, to heighten awareness of the need for injectable epinephrine, and to ensure that flour is kept refrigerated, an effective means of reducing the occurrence of OMA. Ruperto Gonz alez-P erez, MD, PhD Paloma Poza-Guedes, MD Vıctor Matheu, MD, PhD Inmaculada S anchez-Machın, MD From Servicio de Alergia, Hospital del Torax, HUNS La Candelaria, Santa Cruz de Tenerife, Spain. E-mail: [email protected]. Disclosure of potential conflict of interest: The authors declare that they have no relevant conflicts of interest.
REFERENCES 1. Sanchez-Borges M, Suarez Chacon R, Capriles-Hulett A, Caballero-Fonseca F, Fernandez-Caldas E. Anaphylaxis from ingestion of mites: pancake anaphylaxis. J Allergy Clin Immunol 2013;131:31-5. 2. Sanchez-Machın I, Gonzalez-P Poza R, Iglesias-Souto J, Iraola V, Matheu V. Asthma and rhinitis by storage mites. Allergy 2011;66:1615-6. 3. Sanchez-Machın I, Glez-Paloma Poza R, Iglesias-Souto J, Iraola V, Matheu V. Oral mite anaphylaxis. Allergy 2010;65:1345-7. 4. Blanco C, Quiralte J, Castillo R, Delgado J, Arteaga C, Barber D, et al. Anaphylaxis after ingestion of wheat flour contaminated with mites. J Allergy Clin Immunol 1997;99:308-13. 5. Sanchez-Borges M, Capriles-Hulett A, Capriles-Behrens E, Fernandez-Caldas E. A new triad: sensitivity to aspirin, allergic rhinitis, and severe allergic reaction to ingested aeroallergens. Cutis 1997;59:311-4. 6. Sanchez-Borges M, Fernandez-Caldas E, Capriles-Hulett A, Caballero-Fonseca F. Mite-induced inflammation: more than allergy. Allergy Rhinol (Providence) 2012; 3:1-5. Available online June 15, 2013. http://dx.doi.org/10.1016/j.jaci.2013.03.053
Reply To the Editor: We would like to thank Gonzalez-Perez et al1 for their insightful observations on our article.2 We concur with them that ingestion of foods contaminated with mites can induce not only severe episodes of anaphylaxis but also milder clinical pictures, such as urticaria, angioedema, rhinorrhea, nasal congestion, conjunctivitis, or gastrointestinal symptoms, which might not fulfill the currently accepted criteria for the diagnosis of anaphylaxis.3 Concerning the pathogenesis of oral mite anaphylaxis (OMA), very little information is available, and additional research is needed to obtain a better understanding of the mechanisms leading to the acute and often severe clinical manifestations observed in this subset of atopic subjects.