Acaseofanaphylaxistopeppermint RoianBayat 1 andRozitaBoriciMazi 2 Abstract Background AnaphylaxisaformofIgEmediatedhypersensitivityariseswhenmastcellsandpossiblybasophils areprovokedtosecretemedi ID: 395279
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CASEREPORTOpenAccess Acaseofanaphylaxistopeppermint RoianBayat 1 andRozitaBorici-Mazi 2* Abstract Background: Anaphylaxis,aformofIgEmediatedhypersensitivity,ariseswhenmastcellsandpossiblybasophils areprovokedtosecretemediatorswithpotentvasoactiveandsmoothmusclecontractileactivitiesthatevokea systemicresponse.WereportacaseofIgEmediatedanaphylaxistopeppermint(Menthapiperita)inamaleshortly aftersuckingonacandy. A69yearoldmaledevelopedsuddenonsetoflipandtongueswelling,throattightnessand shortnessofbreathwithinfiveminutesofsuckingonapeppermintcandy.Hedeniedlightheadedness,weakness, nausea,vomiting,orurticaria.Hetook25mgofdiphenhydramine,buthissymptomsprogressedtoonsetof cough,wheezeanddifficultywithtalkingandswallowing.Hewasrushedtothenearestemergencydepartment, wherehewastreatedwithintramuscularepinephrine,antihistaminesandsteroids.Onhistory,hereportedrecent onsetofmouthitchinessandmildtongueandlipswellingafterusingColgatepepperminttoothpaste.Hedenied previoushistoryofasthma,allergicrhinitis,foodordrugallergies.Hispastmedicalhistorywasremarkablefor hypercholesterolemia,gastroesophagealrefluxandgout.Hewasonsimvastatin,omeprazole,aspirin,andwas carryingaself-injectableepinephrinedevice.Hemovedtocurrentresidencethreeyearsagoandcultivatedmint plantsinhisbackyard.Headmittedtodevelopnasalcongestion,coughandwheezewhengardening.Physical examinationwasunremarkableapartfromslightlyswollenpaleinferiorturbinates.Skinpricktest(SPT)wasstrongly positivetoaslurryofpeppermintcandyandfreshpeppermintleaf,withappropriatecontrols.Sametestsperformed onfivehealthyvolunteersyieldednegativeresults.Skintestingtocommoninhalantsincludingmoldsandmain allergenicfoodswaspositivetodustmites.Strictavoidanceofmintcontainingitemswasadvised.Upon reassessment,hehadremovedmintplantsfromhisgardenwhichledtoresolutionofsymptomswhengardening. IgEmediatedanaphylaxistopeppermintisrare.Thiscasedemonstratesasystemicreactiontoa commonlyconsumeditem,incapableoftriggeringanaphylaxisinthefarmajorityofthepopulation,yetcausinga severeepisodeforourpatient. Keywords: Anaphylaxis,Peppermint,Menthol,IgEmediated Background Foodallergyappearstobeincreasinginprevalenceand isestimatedtoaffect�2%ofpopulation[1].Morethan 170foodshavebeenidentifiedasbeingpotentiallyaller- genic,howeveraminorityofthesefoodscausethema- jorityofreactions[2].WereportacaseofIgEmediated anaphylaxistopeppermint(Menthapiperita)inamale shortlyaftersuckingonacandy. Casepresentation Apreviouslyhealthy69yearoldmalewasevaluatedinOut- patientAllergyClinic.Hereportedahistoryofsuddenon- setoflipandtongueswelling,throattightness,shortnessof breath,coughandwheezewithinfiveminutesofsucking onapeppermintcandy.Hetooktwotabletsofdiphen- hydramine25mgandhissymptomsprogressedtodifficulty withtalkingandswallowing.Hewasurgentlytransported epinephrineintramu scularly,parenteralantihistaminesand steroids.Hisvitalsremainedstablethroughouttheepisode andhedeniedanyurticariallesionsorgastrointestinal symptoms.Hissymptomsresolvedwithin3 4hours.On history,hereportedfreque ntconsumptionoffoodswith peppermintflavoursuchaschocolates,candies,icecream, *Correspondence: rb.mazi@queensu.ca 2 DepartmentofMedicineandPediatricsDivisionofAllergyandImmunology, Queen sUniversity,166BrockStreet,Kingston,ONK7L5G2,Canada Fulllistofauthorinformationisavailableattheendofthearticle ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY ©2014BayatandBorici-Mazi;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribu- tion,andreproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,un- lessotherwisestated. BayatandBorici-Mazi Allergy,Asthma&ClinicalImmunology 2014, 10 :6 http://www.aacijournal.com/content/10/1/6 aswellaspepperminttoothpaste,whichhehadtolerated well.However,afewweekspriortothisepisode,hehadde- velopedisolatedtongueandlipswellingwiththeuseof Colgatepepperminttoothpasteandhadavoideditsince,al- thoughhedidnotconsiderthepeppermintflavourtobe theculprit.Duringsummermonthsoftheprecedingthree years,hehadcultivatedpeppermintplantsinhisbackyard andadmittedtohavingexper iencednasalcongestion, coughandaslightwheezewhengardening.Hispastmed- icalhistorywasremarkableforgout,dyslipidemiaand gastroesophagealreflux.Hehadnopriorhistoryofatopy. Hismedicationsweresimvastatin,omeprazoleandaspirin. Skinpricktestingwasperformedtocommoninhalants andwaspositivetodustmites,butnegativetoothercom- moninhalants,includingeighttypesofmoulds.Skintest- ingwasnegativetocommerciallyavailablefoodallergens ofeggwhite,cow smilk,fish,shellfish,peanut,treenuts, wheat,soyandsesame.Skinpricktestingtoasalineslurry ofpeppermintcandydemonstratedawhealandflare withlargestdiametersof10mmand35mm(W10/F25), respectively(Figure1a).Prick-to-pricktestwithfresh peppermintleafprovidedbythepatientrevealedaskin testresponseofW25/F50(Figure1b).Bothpeppermint testswerenegativewhenappliedonfivehealthyvolun- teers.Patientandhealthyvolunteersdisplayedappropriate histamine(W3F25)andnegativecontrol(W0F0)skinre- sponses.Ourpatientwasadvisedtoavoidanytracesof peppermintandmentholandcarryanepinephrineautoin- jector.Heremovedthepeppermintplantsfromhisback- yardandreturnedtogardeningthefollowingsummer withoutexperiencinganysymptoms.Lateron,hehad anaccidentalexposuretolipbalmwithtracesof peppermintflavourcausingsolitarylipswellingthat respondedtooraldiphenhydramine. Discussion Wedescribethecaseofa69ymale,whoexperiencedsys- temicanaphylaxisaftersuckingonapeppermintcandy andhavereviewedtherelevantliterature.Mintplantsare membersofthegenusMentha,Lamiaceaefamilywhich alsoincludesotheraromaticplantssuchasthyme,ore- gano,basilandrosemary.InOntario,outdoormintplants pollinateinJuly-Augustperiod.Menthol(2-isopropyl-5- methylcyclohexanol)isthenaturallyoccurringactivein- gredientofpeppermintandiswidelyusedbecauseofits distinctiveflavour.Allergiccontactdermatitiscausedby TypeIVsensitivitytominthasbeenwelldescribed;how- everfirstreportofmentholinducedallergywaspublished in1964[3].A31yfemalepresentedwitha4dayhistory ofgeneralizedurticariawhichceasedimmediatelyafter stoppingallproductscontainingmentholandthe sensitizationwasconfirmedbypositiveimmediatecontact testtopeppermintoil.Casereportsofrhinitisandasthma symptomscausedbyexposuretopepperminttoothpaste Figure1 Skintestresponsestopeppermintallergenappliedonpatient sforearm.a) Pricktesttosalineslurryofpeppermintcandy b) Prick-to-pricktesttopeppermintleaf. BayatandBorici-Mazi Allergy,Asthma&ClinicalImmunology 2014, 10 :6Page2of3 http://www.aacijournal.com/content/10/1/6