Allergy and toxicodermia from shiitake mushrooms

Skin and respiratory symptoms developed within 2 months of exposure in a patient involved in the commercial production of shiitake mushrooms. A diagnosis of contact urticaria and allergic contact dermatitis from shiitake mushrooms was confirmed by prick and patch tests. The respiratory symptoms, their timing, the presence of precipitating IgG antibodies to shiitake spores and increased amounts of inflammatory cells and T lymphocytes in bronchoalveolar lavage indicated allergic alveolitis (mushroom worker's disease). A generalized exanthem developed in a second patient after eating raw shiitake mushrooms. Reactions to prick and patch tests with shiitake mushrooms were negative. The skin eruption in this patient corresponded to the previously reported shiitake-induced toxicodermia.     

P03Type‐I and ‐IV hypersensitivity to platinum salts

A 28‐year‐old female analytical chemist visited our patch test clinic with initially complaints of severe hand dermatitis. Later on she developed rhinitis, bronchial asthma and tightness of the chest. The complaints seemed work related: her condition improved during holidays and on sick leaves. She worked in a laboratory with several platinum salts and used different kinds of gloves (latex, nitril, etc.).
Methods:  Patch tests were performed with the European Standard series and prick tests with common inhalant allergens. Patch‐, prick‐ and open patch tests were carried out with various aqueous dilutions of platinum chloride (PtCl2).
Results:  Patch tests with 0.01–2% PtCl2 were positive on day 2, 3 and 6, and at 0.001% a follicular reaction was found. The prick‐test was already positive at the lowest concentration tested (0.001%). The open patch test, carried out retro‐auricular, showed a positive reaction at 1 and 2% PtCl2 after 20 min. Controls in healthy volunteers (n = 5) were all negative.
Discussion:  It is well known that platinum salts can cause type‐I hypersensitivity reactions like allergic rhinitis, conjunctivitis, bronchial asthma and urticaria, also referred to as platinosis. Contact dermatitis to platinum salts, however, is very rare. In our patch test clinic, 78 patients were tested between 1987 and 2001 with PtCl2 2%. Only 2 women showed a positive patch test for PtCl2. The patient presented here, stopped working with platinum salts and recovered from all complaints. We interpret our case as occupational type‐I and type‐IV hypersensitivity to platinum salts with mucosal and dermal manifestations.     

Occupational protein contact dermatitis from shiitake mushroom and demonstration of shiitake-specific immunoglobulin E

Shiitake are popular edible mushrooms all over the world, and eating raw shiitake may lead to relatively common 'shiitake dermatitis' or toxicodermia. Workers involved in shiitake cultivation and marketing have distinct occupational respiratory and skin diseases unrelated to 'shiitake dermatitis'. There are no previous reports of protein contact dermatitis (PCD) from shiitake, and there is only 1 report of shiitake-specific immunoglobulin (Ig) E. We report 2 shiitake growers who developed work-related eczematous eruption on their hands. Both of the patients had small prick test reactions to fresh shiitake, and specific IgE to shiitake was detected in their sera by immunospot. One of the patients had a large prick test reaction to dry shiitake and also a positive wheal reaction to fresh shiitake in an open application test. Neither of the patients had noticed any symptoms of contact urticaria at work. Both of the patients had immediate IgE-mediated allergy to shiitake, and the diagnosis of occupational PCD was made. There are no commercial in vitro tests for shiitake-specific IgE. Tests for immediate allergy are important when shiitake contact dermatitis is investigated.     

Allergic contact dermatitis from natural latex without contact urticaria

During the test decade, there have been many reports of immediate-type hypersensitivity to natural latex, resulting in contact urticaria, generalized allergic read ions such as urticaria and Quincke's edema, and asthmatic or anaphylactic reactions. Moreover, delayed-type hypersensitivity to rubber additives such as thiuram and carbamate derivatives is acknowledged to be the main cause of dermatitis in patients working with rubber gloves. We here report on a patient who developed severe dermatitis on his hands and forearms 3 months after he had started working with rubber gloves. Patch tests with rubber additives, skin prick tests and RAST to natural latex were negative. However, a delayed type of hypersensitivity to latex could be shown by a positive patch test. To our knowledge this is the 1st case reported of an isolated contact dermatitis from natural latex without contact urticaria to latex or hypersensitivity to rubber additives. We therefore propose that not only patch tests with rubber additives, hut also skin prick and patch tests with latex should be performed in contact dermatitis patients working with rubber gloves.     

Systemic allergic contact dermatitis due to consumption of raw shiitake mushroom

Shiitake (Lentinus edodes) is a mushroom that is very popular in Asian cuisine. After ingestion of the raw fungus, dermatitis may occur in rare cases, and is commonly assumed to be a toxic reaction. We report a 52‐year‐old man who developed a generalized pruritic papulovesicular eruption 2 weeks after daily consumption of uncooked shiitake mushrooms. Prick‐to‐prick and scratch tests with uncooked mushrooms resulted in an eczematous reaction at 24 h that peaked at 72 h and persisted for 1 week. In contrast, no cutaneous reactions could be elicited in 20 healthy people. We conclude that our patient had systemic allergic contact dermatitis due to consumption of raw shiitake mushroom.     

P81Occupational hypersensitivity to platinum group elements

Objective: the increasing industrial use of platinum–group elements (PGEs), namely Ir, Pd, Pt and Rh and related hypersensitivity such as respiratory symptoms, urticaria and contact dermatitis, have led to a growing need to monitor selected populations of exposed workers. Our aim is to determine the prevalence and the clinical characteristics of hypersensitivity to the platinum‐group elements; the levels of PGE measured in indoor airborne particulate matter and in biological samples (serum, urine and hair) taken from of employees in a platinum refining and catalyst manufacture; to correlate environmental exposure role and platinum salts concentrations in biological samples in the onset of allergy.
Material and methods:  132 subjects variable exposed were informed about the purpose of this study and gave their consent. The examination consisted of a work exposure and medical questionnaire, physical examination, skin prick test to platinum salts and to other common allergens and patch test to platinum salts. Airborne PGEs was collected by personal and area samples. Biological samples (serum, urine and hair) were collected. Analitical procedure based on sector field inductively coupled plasma mass spectometry (SP‐ICP‐MS) for the analysis of airborne filter, serum, urine and hair was used. Results: positive prick test to platinum salts were found in 18 workers, 4 out 14 gave simultaneous positive reactions to Pt, Rh and Ir. 2 out 14 gave a positive reaction to Pt and Pd. Positive patch test reactions to Pt were found in 2 subjects, 1 out 2 gave positive reaction also to Pd
Conclusion:  the preliminary results of the investigation indicate that Pt‐salts are important allergens in catalyst industry and that the clinical manifestation involves both the respiratory system and the skin     

Facial dermatitis, contact urticaria, rhinoconjunctivitis, and asthma induced by potato.

BACKGROUND: Potato contains multiple heat-labile proteins which can induce immediate hypersensitivity reactions. Rhino-conjunctivitis, asthma, contact urticaria and protein contact dermatitis have been described in association with potato exposure. OBJECTIVE: A patient with possible airborne facial dermatitis to potato is described. RESULTS: A middle-aged atopic housewife with pre-existent atopic dermatitis suffered from rhino-conjunctivitis, asthma, and contact urticaria when pealing raw potatoes, but her main complaint was intense, treatment-resistant dermatitis of the face. The investigations showed a positive prick test, a positive patch test, and positive specific serum IgE to raw potato. Potato avoidance led not only to the resolution of the immediate symptoms, but also of the facial dermatitis, suggesting she had dermatitis due to this vegetable. CONCLUSIONS: Potato may induce contact dermatitis with positive immediate and delayed hypersensitivity tests.     

Contact urticaria from Emla cream

We report the first case of immediate-type hypersensitivity caused by Emla cream. A 55-year-old woman, after using Emla cream, went on to develop urticaria. An open test was positive to Emla cream. Patch tests and prick tests were performed with Emla cream, the components of Emla cream (lidocaine, prilocaine and castor oil) and other local anaesthetics. The patch test with lidocaine and the prick test with Emla cream were both positive. An intradermal test and subcutaneous administration of 3 anaesthetics that had negative patch tests and prick tests were performed and well tolerated, allowing their use. In the literature, anaphylactic reactions to lidocaine injections, delayed-type hypersensitivity after lidocaine subcutaneous injections and contact dermatitis from Emla cream have all been described. This first case of contact urticaria from Emla cream was due to lidocaine and did not show any cross-reaction with other local anaesthetics.     

Urticarial reaction following the inhalation of nicotine in tobacco smoke

We report a patient with recurrent generalized itching and urticaria due to inhalation of nicotine in tobacco smoke. A skin prick test with nicotine base (1 : 10 w/v) was negative but an intradermal test with nicotine base (1 : 100 w/v) was strongly positive. Intradermal tests with nicotine base (1 : 100 w/v) performed on 10 healthy controls were negative. A provocation test with a nicotine patch showed the same symptoms and signs including generalized itching, weals and flares, and mild dyspnoea, which occurred when he was exposed to tobacco smoke. Nicotine in tobacco smoke can act as an inhalant allergen and induce urticaria in hypersensitive persons.     

Occupational allergic contact dermatitis from champignon and Polish mushroom

Capsicum peppers are widespread both in and out the kitchen. "Human hand" is a contact dermatitis resulting from the direct handling of peppers. Capsaicin also is found in topical agents for treatment of postherpetic neuralgia, diabetic neuropathy and arthritis. The oleoresin of capsicum is considered a powerfull irritant capable to induce irritant contact dermatitis and non‐immunological contact urticaria. A 81 year‐old man with a severe itchy macular and papular rash induced by Capsidol® initially located over the shoulder and sudden spread over the thorax is presented. A dense dermal mononuclear cell infiltrate and spongiosis suggested the diagnosis of contact dermatitis. Negative open tests and a positive patch test reaction (++ 96 hours) using the trade cream Capsidol®(capsaicin 5%) led us to contact with the Pharmaceutical Company Viñas. They provided us the components of the cream: capsaicin, isopropyl myristate, estearic acid (DERVACID 3148), propylene glycol, glycerin monomyristate (ESTOL3650GMM), AMPHISOL K, Cetyl alcohol (NACOL 16–85), benzyl alcohol, diazolidinyl urea (GERMALL II), p‐hydroxybenzoate–methylsodium (NIPAGIN M sódic), p‐hydroxybenzoate propyl (NIPASOL M). Capsaicin in benzyl alcohol at 0,075% was open tested with negative results. Only patch test with capsaicin was positive (++) at 48/96 hours and the excipient components at the appropiate concentrations were all negative. Patch test biopsy showed an eczematous pattern. Twenty controls showed negative results. This case is probably an allergic reaction but shows how still remains difficult to distinguish among allergic and irritative cutaneous reactions.     

Specific immunoglobulin E in patients with immediate persulfate hypersensitivity

Persulfate salts may cause contact urticaria, allergic and irritant contact dermatitis, rhinitis and asthma. The mechanism of the immediate reactions has been unclear. Positive prick test, skin application and nasal and bronchial provocations identify immediate allergy. There is only 1 previous report of specific binding of immunoglobulin E (IgE) to ammonium persulfate demonstrated by radioallergosorbent test (RAST). In the present study, fresh 2% ammonium and potassium persulfate solutions were used for prick testing. Patients with positive prick tests were further evaluated with open skin application, immunospot and RAST. Prick testing with persulfate salts was performed in a total of 138 patients. 7 patients had a positive reaction to at least 1 persulfate salt. 6 of the patients had had skin symptoms, urticaria, eczema or angioedema, because of contact with hair bleaches. Open application on healthy skin was performed in 4 patients, and 3 out of them had urticarial reactions. The sera of 5 patients were investigated with immunospot and RAST. On immunospot, specific binding of IgE to human serum albumin (HSA)-conjugated ammonium and potassium persulfate was found in 2 patients. 1 immunospot-positive patient also had a positive RAST to ammonium persulfate-HSA conjugate. The mechanism of immediate hypersensitivity to persulfates thus seems to be IgE-mediated at least in some patients.     

Occupational contact urticaria and protein contact dermatitis

Irritant dermatitis and eczema are the most prevalent occupational skin diseases. Less common are immediate contact reactions such as contact urticaria and protein contact dermatitis. Occupational contact urticaria can be subdivided into two categories, immunological and non immunological. However, some agents can induce these two types of reactions. Contact urticaria to natural rubber latex is particularly frequent among health care personnel, but contact urticaria to a wide variety of other substances occurs in many other occupations. Among those at risk are cooks, bakers, butchers, restaurant personnel, veterinarians, hairdressers, florists, gardeners, and forestry workers. Protein contact dermatitis in some of these occupations is caused principally by proteins of animal or plant origin, especially among individuals with a history of atopic dermatitis. Diagnosis requires careful interrogation, clinical examination and skin tests (open tests and prick tests with immediate lecture) to identify a particular contact allergen.     

P70Photoallergical contact dermatitis from diclophenac: cross reaction to aceclophenac

Introduction:  Cutaneous adverse reactions from topical or systemic administration of non‐steroidal anti‐inflammatory drugs (NSAID) are frequently described. New cases of adverse reactions from NSAIDs are reported, but the most frequently involved are drugs as ketoprofen or piroxicam. We report a case of photoallergical contact dermatitis from diclophenac with possible cross reaction to aceclophenac.
Material and methods:  A 63‐year‐old‐man, allergic to penicillin, developed eczematous lesions on hands and face, after applying a medicament containing diclophenac. Patch test and photopatch test (5 J/cm²) were performed with a photoallergen battery (Chemotechnique diagnosticsÒ), a NSAIDs battery (Aristegui lab.Ò) and aceclophenac 1%, 5% and 10% in pet. Readings were done at 48 and 96 hours in epicutaneous test and at 24 and 72 hours in photoallergic study, following the ICDRG criteria.
Results:  The results of photoallergic study were as follows: diclophenac 1%, 5% and 10% in pet. and aceclophenac 10% in pet. positive at 24 and 72 hours. The remaining compounds of the NSAIDs battery were negative.
Conclusions:  Diclophenac is a NAIDs derived from aryl alcanoic acid group used both topically and systemically in Spain. Some adverse reactions have been reported as exanthema, urticaria, eczema or Steven‐Johnson's syndrome. We have found only two cases reported as photosensitization from diclophenac. In one of them, the clinical lesion was described as a granuloma annular‐like and photoallergic study was negative. We report a photocontact dermatitis from diclophenac with positive photopatch test. Photopatch test positive to aceclophenac may be explained as a cross reaction among group.     

Peroral Challenge Tests with Food Additives in Urticaria and Atopic Dermatitis

Double-blind, placebo controlled challenge tests with benzoic acid butylhydroxytoluene, butylhydroxyanisole, beta-carotene, beta-8-apo-carotenal, and sodium metabisulfite were made in 44 cases of chronic urticaria, 91 cases of atopic dermatitis, and 123 cases of contact dermatitis, as a comparison group. Positive reactions were seen in four patients, two of whom had urticaria, one atopic dermatitis, and one contact dermatitis. Two of these reactions were caused by the placebo, one in a patient with urticaria and the other in a contact dermatitis patient. For one patient who reacted to the placebo and one who reacted to benzoic acid, the challenges were repeated with positive results in both instances. In nine patients, equivocal test results were produced with all the active substances and the placebo, but in all nine cases, retesting 4 days later produced negative results. This suggests that common food additives are seldom if ever of significance as precipitating factors in chronic urticaria or atopic dermatitis.     

Clinical features of shiitake dermatitis: a systematic review

Shiitake dermatitis is a rare cutaneous reaction to lentinan, a polysaccharide component in the cell walls of shiitake mushrooms (Lentinula edodes). Herein, we systematically review the case report and case series English‐language literature on shiitake dermatitis, which refers to a total of 50 patients (38 males, 12 females; mean age: 44.58 years). The majority of cases occurred after the consumption of raw mushrooms, whereas 22% of cases were caused by the eating of lightly or undercooked mushrooms. The most common clinical presentations, localized symptoms, and systemic findings include linear flagellated dermatitis (98%), pruritus (78%), and fever, diarrhea, and mucosal ulcers, respectively. The diagnosis of this entity continues to be based on clinical findings as laboratory abnormalities, and the findings of skin biopsies and patch/prick tests are nonspecific and inconsistent. The condition is self‐limiting, resolving in approximately 12.5 d without treatment. Based on the included case reports, it appears that medical treatment may slightly shorten the course of disease (to 9–11 d, varying by therapy) but should be considered on an individual patient basis. However, the treatment of symptoms, reassurance, and the avoidance of re‐exposure are sufficient treatment recommendations for this condition.     

Shiitake dermatitis

Shiitake Dermatitis is a skin eruption that resembles whiplash marks and occurs after consumption of raw shiitake mushrooms. It is caused by a toxic reaction to lentinan, a thermolabil polysaccharide which decomposes upon heating. We report the second case of this dermatitis in Brazil. A 25-year-old man presented with linearly arranged erythematous, pruritic papules on the trunk and limbs, after ingestion of a salad containing raw shiitake mushrooms. The eruption was self-limited, resolving within 10 days of onset. The recognition of this entity gains importance due to the increased consumption of shiitake mushrooms in occidental countries.     

FS09.5Patch testing with allopurinol and oxypurinol in drug eruptions

The rapidly increasing frequency of contact allergy to methyldibromo glutaronitrile (MDBGN) is of concern. This study investigates the allergic response elicited in pre‐sensitised individuals from exposure to a leave‐on product preserved with 50 or 100 ppm MDBGN.
Material and methods:  Eighteen volunteers with contact allergy to MDBGN and 10 healthy controls were exposed to repeated open allication tests (ROAT) with two moisturisers with a high and a low lipid content, respectively, both containing MDBGN in a concentration of 50 ppm. The ROATs were performed on the left and the right side of the neck for 14 days, or until a positive reaction was seen. If a positive reaction did not develop within the first 14 days the application with analogous moisturisers containing 100 ppm MDBGN continued for further 14 days.
Results:  Eleven (61.1%) developed dermatitis on the test area, and 10 (55.5%) developed a positive reaction to 50 ppm moisturiser. Reactions to the low‐ moisturiser were the most frequent. the controls all had negative ROATs.
Conclusion:  A concentration of 50 ppm MDBGN in a leave‐on product was found to elicit an allergic reaction in more than half of sensitised individuals when applied on the neck.     

Berufsbedingtes Kontaktekzem und Asthma bronchiale bei ungewöhnlicher allergischer Reaktion vom Spättyp auf Hydroxychloroquin

We report the case of a a 60 year-old worker in the pharmaceutical industry who suffered from recurring contact dermatitis. Initially the contact dermatitis was limited to the hands; later on it became generalized. The patient had been working on a drug filling line in a pharmaceutical plant for more than 20 years. Eight years after starting this job he had developed allergic hand dermatitis to 2,6-diaminopyridine (patch test positive); this healed upon cessation of exposure. Ten years later he again developed hand dermatitis which progressed to generalized dermatitis and conjunctivitis. Under systemic and local therapy with corticosteroids and cessation of work, it healed nearly completely. Four months after returning to work, the patient experienced a first episode of severe asthma and generalized dermatitis with conjunctivitis following exposure to hydroxychloroquine the day before. The asthma and dermatitis improved after systemic corticosteroid therapy and stopping work. His condition continued to fluctuate, when though the patient was transferred at work and now wore rubber gloves. Eight months later he again developed a generalized dermatitis. Patch testing revealed delayed-type sensitizations to hydroxychloroquine (tested in concentrations of 0. 1%, 0.5%, 1% and 2%). Equivalent tests in five healthy volunteers were negative. The patch test reactions were pustular, while a biopsy was interpreted as a multiform contact dermatitis reaction. Bronchial exposure with hydroxychloroquine dust produced a delayed bronchial obstruction over the next 20 hours, which progressed to fever and generalized erythema (hematogenous contact dermatitis). After removing exposure to 2,6-diaminopyridine and hydroxychloroquine, the patient went on to develop a contact dermatitis to latex (patch test positive). However, skin prick tests with latex and patch tests with rubber additiva were negative. Hydroxychloroquine is well known to cause drug reactions. To our knowledge, contact dermatitis to this substance has not yet been reported. It is noteworthy that the patch test reactions were pustular and of multiform morphology and that bronchial exposure to the allergen resulted in asthma and a generalized drug reaction. Pathogenetically the asthmatic reaction seems to be on a delayed-type mechanism as is also seen with ampicillin, cobalt and nickel induced asthma.     

Results of evaluating health care workers with prick and patch testing.

BACKGROUND: Health care workers are exposed to many agents that can cause irritant or allergic contact dermatitis. Recently, much attention has been focused on latex sensitivity, which commonly causes contact urticaria. Most studies have examined the conditions of irritant or allergic contact dermatitis and contact urticaria independently. Therefore, we have little information about the possible occurrence of these conditions in the context of combined assessment including both prick and patch testing. OBJECTIVE: To determine the prevalence of irritant and allergic contact dermatitis and contact urticaria in a group of health care workers presenting with skin problems. METHODS: Retrospective review of health care workers assessed by both prick and patch testing in an occupational health clinic. RESULTS: The diagnoses included 61% with irritant contact dermatitis, 31% with allergic contact dermatitis, and 27% with contact urticaria to latex. Eleven percent had both allergic contact dermatitis related to thiuram and contact urticaria to latex. Ninety five percent were deemed to be work-related. CONCLUSION: Health care workers presenting with skin complaints should be assessed with both prick and patch testing.     

Positive atopy patch test reaction to Malassezia furfur in atopic dermatitis correlates with a T helper 2-like peripheral blood mononuclear cells response

The yeast Malassezia furfur belongs to the normal cutaneous flora, but is also a triggering allergen that can contribute to atopic dermatitis. To illuminate the effect of circulating allergen-specific T cells in atopic dermatitis, the peripheral mononuclear cell response was correlated with the in vivo skin prick test and atopy patch test reactivity to M. furfur. None of 16 healthy controls showed any positive in vivo reaction. The 40 atopic dermatitis patients, of whom 18 had serum IgE reactivity to M. furfur, were subdivided according to their in vivo reaction to M. furfur extract into three groups: skin prick test positive/atopy patch test positive (n = 12), skin prick test positive/atopy patch test negative (n = 12), and skin prick test negative/atopy patch test negative (n = 16). The skin prick test positive/atopy patch test positive and the skin prick test positive/atopy patch test negative groups had a significantly higher peripheral mononuclear cell stimulation index than the healthy controls. Interestingly, the stimulation index values in the skin prick test positive/atopy patch test positive group were significantly higher than in the skin prick test positive/atopy patch test negative group. In the M. furfur skin prick test positive atopic dermatitis patients (n = 24) a correlation was found between stimulation index and the M. furfur atopy patch test reactions, but not between stimulation index and M. furfur-specific serum IgE levels. Skin prick test positive and/or atopy patch test positive reactions to the recombinant M. furfur allergens rMal f 1, rMal f 5, and rMal f 6 were observed in 7, 14, and 16 of the 40 atopic dermatitis patients, respectively. Further, there was a correlation between production of the T helper 2-related cytokines interleukins 4, 5, and 13 and stimulation index to M. furfur extract, but not between the T helper 1-related interferon-gamma and stimulation index to M. furfur extract. Our data strongly suggest a relationship between circulating specific T cells with a T helper 2-like cytokine profile and positive atopy patch test reactions.