PRACA KAZUISTYCZNA

Ashok Shah, Kamal Gera Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India

Immediate reaction with mango Natychmiastowa reakcja nadwrażliwości na mango The authors declare no financial disclosure

Abstract Hypersensitivity to the fruit mango is extremely rare and can exhibit either as immediate or delayed reactions. Since 1939, only 22 patients (10 with immediate type I reactions and 12 with delayed) have been documented with to mango. History of atopy and geographical region may influence the type of reaction. Immediate reactions occured most often in patients with history of atopy, while delayed reactions developed in non-atopic individuals. Clustering of delayed hypersensitivity reports from Australia and imme- diate reactions from Europe has been documented. We report a 50-year-old man with immediate type I hypersensitivity to mango, who developed cough, wheezing dyspnoea, generalised itching and abdominal discomfort after ingestion of mango. Life threatening event can also happen making it imperative to diagnose on time, so as to prevent significant morbidity and potential mortality.

Key words: allergy, , bronchial asthma, contact , mango, urticaria Pneumonol. Alergol. Pol. 2014; 82: 445–453

Streszczenie Nadwrażliwość na owoce mango jest bardzo rzadkim zjawiskiem i może przebiegać zarówno jako reakcja natychmiastowa, jak i opóźniona. Od 1939 roku udokumentowano alergię na mango tylko u 22 pacjentów (u 10 z reakcjami typu natychmiastowego i u 12 z reakcją opóźnioną). Wydaje się, że wywiad atopowy oraz region geograficzny mogą wpływać na rodzaj reakcji. Na- tychmiastowe reakcje obserwowano najczęściej u pacjentów z wywiadem atopii, natomiast reakcje opóźnione byłych częstsze u pacjentów bez takiego wywiadu. Dane epidemiologiczne wskazują, że na terenie Australii dominuje nadwrażliwość z opóźnionym typem reakcji, w Europie zaś przeważają reakcje typu natychmiastowego. W pracy przedstawiono przypadek 50-letniego mężczyzny z nadwrażliwością typu I natychmiastowego na alergeny owocu mango, u którego po spożyciu mango wystąpił kaszel, świszczący oddech i duszność, uogólniony świąd skóry i dolegliwości brzuszne. Diagnostyka w takich sytuacjach powinna być przeprowadzona możliwie szybko, aby wdrożyć wtórną profilaktykę, uniknąć ekspozycji i zapobiegać stanom zagrażającym życiu w przebiegu nadwrażliwości.

Słowa kluczowe: allergy, anaphylaxis, bronchial asthma, contact dermatitis, mango, urticaria Pneumonol. Alergol. Pol. 2014; 82: 445–453

Introduction throughout the world and is the national fruit of the country. Despite being consumed in large The fruit mango (Mangifera indica), often quantities and in many forms in our country, hy- known as the ‘king of fruits’, belongs to the family persensitivity reactions to mango are extremely Anacardiacae. During the summer months, India rare. Hypersensitivity to the fruit mango can ma- produces nearly half of the mangoes cultivated nifest in two forms, immediate and delayed. To

Address for correspondence: Prof. Ashok Shah, MD FAMS, Department of Respiratory Medicine Vallabhbhai Patel Chest Institute University of Delhi, P.O. BOX 2101, Delhi-110 007, India, tel/fax: + 91-11- 2766 6549, e-mail: [email protected] DOI: 10.5603/PiAP.2014.0058 Praca wpłynęła do Redakcji: 6.02.2014 r. Copyright © 2014 PTChP ISSN 0867–7077

www.pneumonologia.viamedica.pl 445 Pneumonologia i Alergologia Polska 2014, tom 82, nr 5, strony 445–453 date, there are only 22 patients with documented of the paranasal sinuses showed bilateral maxil- hypersensitivity to mango. Of these 22 patients, lary, bilateral ethmoidal and left sphenoidal 10 [1–9] exhibited immediate hypersensitivity sinusitis. Pulmonary function testing showed while 12 [10–17] had delayed hypersensitivity a ratio of FEV1/FVC of 62% with a FVC of 3.99 L reactions. Of the 10 patients with immediate (126% of predicted), an FEV1 of 2.48 L (95% of hypersensitivity, two were reported from India predicted) but there was no significant increase

[6, 9]. The mango is known to cross in FEV1 after inhalation of 400 micrograms of react with Artemisia , birch pollen, poison salbutamol. This was suggestive of an obs- ivy, carrot, celery, pistachio nut, banana, tomato tructive pattern with mild airflow limitation. and papaya [8]. Paucity of the literature on the Neither was there any significant reversibility subject prompted this report of the 50-year-old nor did the peak flow diary reveal any circadian man with immediate hypersensitivity reaction variation. in the form of wheezing dyspnoea, generalised Skin prick testing with the battery of stan- itching and abdominal discomfort after ingestion dard aeroallergens demonstrated immediate hy- of fresh mango. persensitivity to weeds (Ageratum, Amaranthus spinosus, Argemone, Artemisia, Gynandropsis Case report and Parthenium). Prick to prick testing from a fresh ripe mango was done along with a negative A 50-year-old male office worker, a never- control (buffered normal saline [1 × 1 mm]) and smoker, was referred to our Institute for evalu- a positive control ( [6 × 6 mm]). This ation of hypersensitivity to the fruit mango. He elicited an immediate type I hypersensitivity re- had wheezing dyspnoea and cough for 10 years action to the mango extract (14 × 10 mm). which initially were episodic but had recently A week later, the patient agreed to ingest become troublesome. These complaints were a small slice of fresh mango under observation in preceded by nasal symptoms which had commen- the emergency room. After an informed consent ced about 15 years ago in the form of paroxysmal was taken, he was examined prior to ingestion of sneezing, rhinorrhoea and nasal itching. Nasal mango and spirometry and peak flow rates were blockage and post nasal drip too occurred off and also recorded. Oxygen saturation at room air was on. All respiratory symptoms aggravated during 98%. Within 5 minutes of ingestion of mango, change of season and whenever he ingested man- he complained of itching in the oral cavity. Ge- go during the mango season. This also caused neralised itching and abdominal discomfort too skin allergy which manifested as itching and commenced which peaked after 1 hour. This was . Symptomatic treatment and avoidance of followed by a bout of coughing, audible wheezing mangoes for past 10 years had partially controlled dyspnoea and throat irritation. Polyphonic rhon- his symptoms. chi were audible over all lung fields. The peak Physical examination revealed a middle aged flow rate fell from 4.10 L/min to 2.92 L/min, man in no acute distress.There was no pallor, icte- a decrease of 1180 mL (28%). The spO2 fell to 93% rus, clubbing, cyanosis or pedal oedema. Oxygen at room air and FEV1 fell from 3.3 L to 2.67 L. saturation at room air was 98%. Diaphragmatic These manifestations subsided within half an excursion was equal on both sides. On ausculta- hour after injectable adrenaline, pheniramine tion, vesicular breath sounds along with bilateral and dexamethasone along with nebulisation with polyphonic expiratory rhonchi were audible over salbutamol, ipratropium and budesonide. After all lung fields. Nasal mucosa was erythematous. 2 hours of mango ingestion, he vomited mango Complete blood counts revealed a total leu- remnants (Table 1). cocyte count of 9900 cells per cubic millimeter A diagnosis of bronchial asthma and allergic with an eosinophil count of 10.8%. Absolute eosi- along with immediate hypersensitivity nophil count was 1000 cells per cubic millimeter. to the fruit mango was made and the patient was Serum total Ig E value was 358 kUA/L (reference strongly advised not to ingest mango in any form. range < 64.00). Specific IgE against mango was He was also initiated on a combination of inhaled 1.38 kUA/L (Immunocap [100] system) suggesting budesonide and formoterol along with mometa- presence of moderate levels of mango specific an- sone nasal spray. This was done as soon as the tibodies. Renal as well as hepatic functions were diagnosis was established. With this, the patient within normal limits. The chest radiograph reve- experienced significant relief and his symptoms aled no abnormalities but a non-contrast CT scan were minimised on maintenance therapy.

446 www.pneumonologia.viamedica.pl Ashok Shah, Kamal Gera, Mango allergy

Table 1. Mango ingestion provocation test

Time Clinical profile spO2 PFR (L/min) FEV1 (L) Pre-mango ingestion No symptoms with normal vesicular breathing 98% 410 3.3 5 minutes Itching in oral cavity 98% 420 – 15 minutes Generalised itching and abdominal discomfort 98% 410 – 30 minutes Increasing generalised itching and abdominal discomfort 98% 410 – 45 minutes Further aggravation of generalised itching and abdominal discomfort 97% 400 –

60 minutes Generalised itching and abdominal discomfort accompanied by throat 95% 290 – irritation, bout of coughing, audible wheezing dyspnoea and polyphonic rhonchi 70 minutes Aggravation of all symptoms including generalised itching and abdominal 93% 200 2.67 discomfort, throat irritation, coughing, wheezing dyspnoea, polyphonic rhonchi Post-treatment 15 ↓ itching, ↓cough and wheezing dyspnoea, ↓ rhonchi 96% 320 – minutes Post-treatment 30 ↓cough and wheezing dyspnoea, ↓ rhonchi 96% 360 – minutes Post-treatment 60 Vomiting containing mango remnants, no cough, wheezing dyspnoea or 98% 400 – minutes rhonchi

Discussion patient too, a case of immediate hypersensitivity type I reaction to mango, experienced bout of Mango is native to southern Asia and has coughing, wheezing dyspnoea, throat irritation been cultivated in the Indian subcontinent for within 1 hour of mango ingestion. thousands of years. It is consumed in various Of the ten patients documented with imme- forms both during the season as well as off se- diate reaction to mango, erythema developed in ason. During season, it is partaken in form of three [3–4, 7], angioedema in five [2, 4, 6–8], respi- fresh fruits, shakes and ice creams while during ratory distress/dyspnea in nine [1–9] and anaphy- off season, it is cherished as pickles, jams and laxis in two patients [2, 3], one of whom had juices. Immediate hypersensitivity can manifest a life threatening anaphylactic shock [2]. Symp- as anaphylaxis, angioedema, erythema, urticaria, toms in most of these patients occurred almost wheezing dyspnoea while delayed reaction as immediately [3–9], while in two patients, symp- contact dermatitis, oral allergy syndrome and toms commenced in around 30 minutes [1, 2]. periorbital oedema [18]. History of atopy, also present in our patient, was A recent review [18] presented 22 patients available in eight others [1, 2, 4, 5, 7–9]. with documented hypersensitivity to the fruit Skin prick tests and immunoassays of serum mango, 10 of whom had immediate hypersen- food specific IgE levels can detect the allergen sitivity, while 12 presented with delayed hy- specific IgE. These tests are only supportive and persensitivity reactions with predominant skin can aid in the diagnosis but it is imperative that manifestations. The first report of an allergic it be performed in light of an appropriate clinical reaction to mango was a description of delay- history. In IgE mediated , the wheal ed hypersensitivity manifestation from USA size correlates with the likelihood of clinical al- in 1939 by Zakon [10]. The report described lergy. However, wheal size can be highly variable a young female who developed acute vesicular as it depends on age, diurnal variation and site dermatitis involving lips and circumoral area, on the body where SPT is performed. The indi- 24 hours after ingestion of mango. The first case vidual’s skin reactivity as well as the SPT device of immediate hypersensitivity too was reported and reagents used also play a role [19]. from USA by Kahn [1] in 1942. The patient deve- The ICON statement on “Food Allergy” [19] loped hoarseness, dyspnoea and wheezing within issued jointly by the American Academy of Aller- 30 minutes of mango ingestion. These symptoms gy, Asthma and ; European Academy were relieved with injectable epinephrine. Our of Allergy and Clinical Immunology; World Al-

www.pneumonologia.viamedica.pl 447 Pneumonologia i Alergologia Polska 2014, tom 82, nr 5, strony 445–453 lergy Organization; and the American College of Mango antigen also cross-reacts with arte- Allergy, Asthma & Immunology has stressed the misia pollen, birch pollen, poison ivy, mugwort, need for studies to define the diagnostic accuracy celery, carrot, pistachio nut, tomato, papaya and of 95% positive predictive value wheal sizes for banana [10]. Mostly, Bet v1, Bet v6, and Art v1 different foods, ages, diseases, and populations. related lead to cross-reactions between Information regarding the skin allergy test to mango and other plants and fruits [7]. A study has mango was available in eight of the ten patients documented that the common epitopes are sha- with immediate hypersensitivity to mango and red by allergens from mango fruit and allergens was positive in all [2, 4, 5, 6–9]. Our patient too from birch pollen, mugwort pollen, celery, and had a skin prick test positive to mango extract. carrot [22]. Mango allergy was also seen in indi- Food specific IgE is also often used for esta- viduals with latex hypersensitivity [7, 23]. The blishing the diagnosis of food allergy but has the possible explanation is that multiple antigens can same status as skin prick testing [19]. Specific IgE bind to an IgE at corresponding sites, against mango was evaluated in six patients [4–8], thus mediating an immune response. Allergens, but was positive in only three [5, 6, 8]. In our termed as profilins, responsible for cross reac- patient too, specific IgE against mango antigens tivities between botanically unrelated was detected in moderate levels. The possible and fruits can account for this phenomenon [22]. explanation behind the under detection of specific However, this has yet to be proved conclusively. IgE may be the unstability of the corresponding The first case of delayed hypersensitivity to allergens, which remain undetected and also the mango was reported in 1939 in USA. Subsequent current IgE detection system appears to lack some reports are from Asia, Australia and North Ameri- of the specific mango allergens [18]. Combining ca. Amongst the twelve such patients documented skin prick testing results with serum food specific in the literature so far [10–17], urticaria was pre- IgE may be of value in diagnosing food allergy [20]. sent in eight [10–13, 15], oral allergy syndrome in Wheal size with skin prick testing and serum food two [1, 17] and periorbital edema in two [13, 15]. specific IgE levels correspond with the plausibility Three of these patients [10, 13, 15] developed the of clinical allergy but it must be highlighted that symptoms after mango ingestion, while in the they do not correlate with or predict the severity remaining nine patients, the reaction occurred of allergic reaction to a food [19]. after contact with mango skin or bark of mango Although, the double-blind, placebo-con- tree [11, 12, 14, 16, 17]. Duration of onset of symp- trolled food challenge (DBPCFC) remains the toms was variable and ranged from 4 hours [11] gold standard for the diagnosis of food allergy, it to 7 days [12]. Patch testing, done in ten patients is less frequently performed as it requires time, [11, 13–17], was positive in all. Cross reactivity huge resources and appropriate set-up. In clinical was not reported in any patient nor was there any practice, single blind or open food challenges information regarding specific IgE antibody aga- are generally performed, though DBPCFC is the inst mango antigen in any of the twelve patients. most specific test to confirm food allergy. There is Delayed hypersensitivity reaction to mango a risk of immediate allergy and anaphylaxis, so it is cell mediated and was seen mainly in form of is essential that food challenge should always be contact dermatitis, oral allergy syndrome and performed in a well equipped facility under medi- periorbital oedema. Direct contact with the mango cal supervision with appropriate medications and or tree itself and ingestion too, can lead to a cell resources available for emergency management of mediated reaction. Sensitising substances present anaphylaxis [19]. in the skin, bark, pericarp as well as the mango Immediate hypersensitivity is a classical IgE pulp up to five millimeters below the skin include mediated reaction and usually occurs in individu- uroshiol, cardol, limonene and B-pinene [18]. als who are previously sensitised to mango anti- Since 8 of the 10 patients with immediate gens [5]. Sensitisation may occur by prior mango type I hypersensitivity reactions had a history of ingestion or by intake of other fruits belonging atopy, it appears that atopy may be a risk factor to Anacardiaceae family. Even unrecognisable for a type I reaction with mango. In contrast, in forms such as fruit punch can also sensitise the patients with delayed manifestations, history of patient [2]. Allergenicity of mango nectar persists atopy was seen in only one of 12 documented even after heating, enzymatic degradation and patients, suggesting that delayed hypersensitivity mechanically caused tissue degradation as evi- occurs in non-atopic subjects. denced by allergic reaction to canned or packaged Further, geographical region may influence mango [21]. the type of reaction. There are five reports of

448 www.pneumonologia.viamedica.pl Ashok Shah, Kamal Gera, Mango allergy - NA NA NA NA NA Symptoms after mango vocation test ingestion pro NA NA NA NA NA mango Specific IgE against - NA NA NA NA NA vity Cross reacti mango extract Positive Positive Positive Positive to mango Positive to Positive Patch testing Patch - NA NA NA NA NA go extract SPT to man - NA NA NA NA with ment Treat topical steroids received treatment Prolonged Prolonged 6 days 4 days 4 hours 5 hours Time of onset of 12 hours symptoms - - titis) bullae sicular plaques (contact ingestion dermatitis) dermatitis) on arms (contact dermatitis) arms, legs, neck and abdomen lesions on lower legs, urticarial acute eczematous plaques with on forearms (contact dermatitis) over arms and abdomen (contact urticarial plaques (contact derma Intensely pruritic linear papulo-ve Itchy palpable, pruritic lesions over Pruritic confluent urticaria on neck, Pruritic Widespread acute eczematous and Intensely pruritic confluent urticaria Presenting symptoms after mango Presenting No No No No No History of atopy ------tion sensitivity sensitivity sensitivity sensitivity sensitivity Type of reac Type Delayed hyper Delayed hyper Delayed hyper Delayed hyper Delayed hyper - Yes Yes Yes Yes Yes ting the fruit Geographical region cultiva - [11] [11] [16] [11] rence 21, female, 31, female, 42, female, 27, female, Australia [11] Country, Refe Country, 1995, Australia 1995, Australia 2008, Australia 1995, Australia 36, male, 1995, Age, Sex, Year, Age, Sex, Year, Table 2. Documented reports of hypersensitivity to mango from Australia Table IgE — immunoglobulin E; NA — not available; SPT skin prick test

www.pneumonologia.viamedica.pl 449 Pneumonologia i Alergologia Polska 2014, tom 82, nr 5, strony 445–453 - NA NA NA NA NA Symptoms after mango vocation test ingestion pro - RAST fic IgE Speci mango against Positive by RAST Negative Negative Negative Raised by Raised - - NA and ragweed and pistachio Positive for mu Positive Positive to Arte Positive gwort, pistachio Positive for latex Positive Cross reactivity mesia pollen and house dust mites Positive for ginger Positive NA NA NA Patch Patch testing extract Not done Not done to mango SPT to mango extract Positive Positive Positive Positive Positive

NA NA received Treatment Treatment corticosteroids corticosteroids inj. hydrocortisone and Inj. epinephrine and Inj. epinephrine and Time of onset of symptoms 20 minutes 10 minutes Immediately Immediately < 10 minutes - - - - hands dyspnoea syndrome) mango ingestion lergy, cough, dyspnoea lergy, Periorbital edema, facial Periorbital noea, dysphagia, anxiety ratory distress (oral allergy erythema, diffuse urticaria, Facial angioedema, hoarse Facial Rhino–conjunctivitis, oral al Sneezing, rhinorrhoea, dysp Sneezing, Presenting symptoms after Presenting ness, pruritis of palms, respi Urticaria, swelling of face and - - sent atopy Positive Positive Positive sitization Received History of Positive, latex Positive, sensitivity pre immunotherapy for mugwort sen ------tion persensitivity persensitivity persensitivity persensitivity persensitivity Type of reac Type Immediate hy Immediate hy Immediate hy Immediate hy Immediate hy - No No No Yes Yes the fruit cal region cultivating Geographi - - - - [8] [5] ny [7] ny [7] rence 24, male, 32, male, try, Refe try, Age, Sex, 39, female, 45, female, 46, female, Year, Coun Year, 2009, Spain 1999, Spain 1988, UK [4] 2008, Germa 2008, Germa Table 3. Documented reports of hypersensitivity from Europe Table IgE — immunoglobulin E; NA — not available; RAST radio allergo sorbet assay; SPT skin prick test

450 www.pneumonologia.viamedica.pl Ashok Shah, Kamal Gera, Mango allergy - - - NA NA NA NA min later irritation, wheezing hour later dyspnoea, Immediate bout of co Symptoms ml. (28%) 1 ml. (9%) 30 noea, throat PFR of 1180 after mango irritation. Fall irritation. Fall cough. Fall in cough. Fall in PFR of 490 ughing, dysp ughing, vocation test itching, throat itching, Oropharyngeal ingestion pro - NA NA NA NA mango system Specific cap [100] ELISA and Positive by Positive SDS–PAGE (moderate) 1.38 kUA/L IgE against by Immuno - - NA NA NA uroshiol Ageratum, Positive for Positive Positive for Positive Parthenium Anacardium Amaranthus Gynandropsis, Positive for In Positive Spinosus, Arge apple, Anethum, Cross reactivity dian dill, cashew mone, Artemisia, mango extract Not done Not done Not done to mango Positive to Positive to Positive Positive to Positive Patch testing Patch mango extract mango extract NA NA NA SPT to mango extract Positive Positive Positive ------NA NA nes mine pium niramine with oral received tamol and tisone and tisone and Treatment Treatment with salbu and ipratro inj. phenira antihistami after 5 days ipratropium, Nebulization Nebulisation prednisolone S/S subsided inj. hydrocor Inj. hydrocor and chlorphe and with albuterol with - NA NA nutes 1 day Time of onset of < 10 mi symptoms 15 minutes 10 minutes - - - - distress dermatitis) mango ingestion allergy syndrome) ea, paroxysmal cough irritation, itching and ery formation around lips (oral Oropharyngeal itching, an Oropharyngeal itching, periorbital edema (contact Patchy pruritic erythema of Patchy smal cough, throat irritation smal cough, throat irritation History of mango dermatitis present (contact dermatitis) Eczematous and blister thema over body, abdominal thema over body, Presenting symptoms after Presenting Wheezing dyspnoea, paroxy Oropharyngeal itching, throat Oropharyngeal itching, gioedema of face, respiratory the face, and extremities with discomfort, wheezing dyspno No No No atopy Positive Positive Negative History of -

hyper- hyper- hyper- hyper- hyper- hyper- action Delayed Delayed Delayed sensitivity sensitivity sensitivity sensitivity sensitivity sensitivity Immediate Immediate Immediate Type of re Type - No No Yes Yes Yes Yes fruit region cul tivating the Geographical - [17] [15] NA (2 pa Age, Sex, *50, male, Japan [14] Reference 46, female, 43, female, 27, female, 42, female, 2013, India 2009, Korea tients), 2004, 2011, India [9] 2007, India [6] Year, Country, Country, Year, 2008, Thailand Table 4. Documented reports of hypersensitivity to mango from Asia Table PAGE — sodium dodecyl sulphate polyacrylamide gel electrophoresis; SPT skin prick test immunosorbent assay; IgE — immunoglobulin E; *current report; ELISA — enzyme linked NA not available; PFR peak flow rate; SDS

www.pneumonologia.viamedica.pl 451 Pneumonologia i Alergologia Polska 2014, tom 82, nr 5, strony 445–453 - NA NA NA NA NA Symptoms hoarseness after mango symptoms of Rapidly acute Rapidly and wheezing vocation test ingestion pro - NA NA NA NA NA NA fic IgE Speci mango against - - NA NA NA NA NA tivity almond, termelon Positive to Positive wheat, wa house dust, Cross reac - NA NA NA NA NA phenol mango Positive to Positive skin, nickel skin, nickel formaldehyde mango extract and p–tert butyl Patch testing to Patch NA NA NA NA NA SPT to mango passive extract transfer Positive Positive reaction - - - - - NA cream received cortisone Treatment Treatment cal steroids fluocinonide thasone and Inj. dexame S/S subsided Resolved after Resolved and inj. hydro after few days ids and topical a week’s treat inj. epinephrine with oral stero Inj. epinephrine Inj. epinephrine ment with topi 2 days 7 days 24 hours 30 minutes 10 minutes 30 minutes of symptoms Time of onset ------breathing ingestion and shock dermatitis) lar lesions in Patchy pruritic Patchy Papular lesions Papular tightness, noisy of eyelids, chest erythema of face, of face and extre allergy syndrome) periorbital edema. circumoral region, upper extremities. tous rash (contact Itching of eyes, la Presenting symp Presenting Hoarseness, dysp extended to chest, toms after mango Itching and vesicu crimation, swelling erythema, swelling Gasping for breath, noea and wheezing mities, hypotension neck and arms with (contact dermatitis) swelling of lips (oral Pruritic and eczema Pruritic No NA atopy Positive Positive oak and Negative to poison poison ivy History of Sensitivity - -

tion hyper- hyper- hyper- hyper- hyper- Delayed Delayed sensitivity sensitivity sensitivity sensitivity sensitivity sensitivity Immediate Immediate Immediate Type of reac Type Delayed hyper - No No No No No No fruit region cul tivating the Geographical - rence USA [2] USA [12] 24, female, 22, female, 29, female, NA, female, 1967, USA [3] 1942, USA [1] Country, Refe Country, 2004, USA [13] 1939, USA [10] 27, male, 1998, 32, male, 1965, Age, Sex, Year, Age, Sex, Year, IgE — immunoglobulin E; NA — not available; SPT skin prick test Table 5. Documented reports of hypersensitivity to mango from North America North of hypersensitivity to mango from 5. Documented reports Table

452 www.pneumonologia.viamedica.pl Ashok Shah, Kamal Gera, Mango allergy hypersensitivity to mango from Australia, all of References whom presented with delayed hypersensitivity 1. Kahn I.S. Fruit sensitivity. Southern Med. J. 1942; 35: 858–859. reaction and none had history of atopy. All these 2. Rubin J.M., Shapiro J., Muehlbauer P., Grolnick M. Shock reac- five patients had negative skin prick test for man- tion following ingestion of mango. JAMA 1965; 193: 397–398. 3. Dang R.W., Bell D.B. Anaphylactic reaction to the ingestion of go while patch testing was positive in all [11, 16] mango. Case report. Hawaii Med. J. 1967; 27: 149–150. (Table 2). On the other hand, all five patients 4. Miell J., Papouchado M., Marshall A.J. Anaphylactic reaction documented from Europe had immediate type I after eating a mango. BMJ 1988; 297: 1639–1640. 5. Duque S., Fernandez-Pellon L., Rodriguez F. Mango allergy in hypersensitivity reactions and history of atopy a latex sensitised patient. Allergy 1999; 54: 1004–1005. was present in all. All these five patients also had 6. Hegde V.L., Venkatesh Y.P. Anaphylaxis following ingestion of mango fruit. J. Investig. Allergol. Clin. Immunol. 2007; 17: a positive skin prick test for mango [4, 5, 7, 8] 341–344. (Table 3). Of the six patients documented from 7. Renner R., Hipler C., Treudler R., Harth W., Sub A., Simon J.C. Asia, two were immediate from India while four Identification of a 27 kDa protein in patients with anaphylactic reactions to mango. J. Investig. Allergol. Clin. Immunol. 2008; presented with delayed hypersensitivity (two 18: 476–481. from Japan, one from Thailand and one from Ko- 8. Silva R., Lopes C., Castro E., Ferraz de Oliviera J., Bartolome B., rea) [14, 15, 17]. There are no reports of delayed Castel-Branco M.G. Anaphylaxis to mango fruit and cross-reac- tivity with Artemisia vulgaris pollen. J. Investig. Allergol. Clin. hypersensitivity reaction from India (Table 4). Of Immunol. 2009; 19: 414–422. the six patients documented from North America, 9. Sareen R., Gupta A., Shah A. Immediate hypersensitivity to mango manifesting as asthma exacerbation. J. Bras. Pneumol. all from USA, three each presented with immedia- 2011; 37: 135–138. te and delayed hypersensitivity (Table 5). 10. Zakon S.J. Contact dermatitis due to mango. JAMA 1939; 113: Both in vitro and the in vivo tests were perfor- 1808. 11. Calvert M.L., Robertson I., Samaratunga H. Mango dermati- med in our patient to confirm the mango allergy. tis: allergic contact dermatitis to Mangifera indica. Australas Skin test with extract showed wheal and flare J. Dermatol. 1996; 37: 59–60. reaction of more than histamine (positive control) 12. Tucker M.O., Swan C.R. The mango-poison ivy connection. New Eng J. Med. 1998; 339: 235. indicating IgE against mango allergen bound to 13. Weinstein S., Tehrani S.B., Cohen D.E. Allergic contact dermati- the mast cells were degranulated by the allergen tis to mango flesh. Int. J. Dermatol. 2004; 43: 195–196. extract. Similarly, Immuncocap results indicated 14. Oka K., Saito F., Yasuhara T., Sugimoto A. A study of cross- -reactions between mango contact allergens and uroshiol. Con- the free IgE in serum of patient. In the study, tact Dermatitis 2004; 51: 292–296. skin prick testing was done with weeds to find 15. Wiwanitkit V. Mango dermatitis. Indian. J. Dermatol. 2008; 53: 158. out whether food-specific IgE were 16. Thoo C.H., Freeman S. Hypersensitivity reaction to the inge- cross-reacting in nature or not. Therefore, an oral stion of mango flesh. Australas. J. Dermatol. 2008; 49: 116–119. mango challenge was performed to confirm food 17. Lee D., Seo J.K., Lee H.J., Kang J.H., Sung H.S., Hwang S.W. A case of allergic contact dermatitis. Korean J. Dermatol. 2009; allergy. These data proved that our patient had 47: 612–614. immediate hypersensitivity to mango. 18. Sareen R., Shah A. Hypersensitivity manifestations to the fruit Our report highlights the fact that hyper- mango. Asia Pac. Allergy 2011; 1: 43–49. 19. Burks A.W., Tang M., Sicherer S. et al. ICON: Food allergy. sensitivity manifestations to mango can include J. Allergy Clin. Immunol. 2012; 129: 906–920. both immediate and delayed reactions. Immediate 20. Fiocchi A., Brozek J., Schunemann H. et al. World Allergy Or- reaction can also result in life threatening events. ganization (WAO) Diagnosis and Rationale for Action against Cow’s (DRACMA) Guidelines. Pediatr. Allergy If not diagnosed on time, allergic reactions to Immunol. 2010; 21 (suppl 21): 1–125. the fruit can lead to significant morbidity and 21. Saraswat A., Kumar B. Anaphylactic reaction to apple, banana possible mortality. and lychee: what is common between botanically disparate plant families? Int. J. Dermatol. 2005; 44: 996–998. 22. Paschke A., Kinder H., Zunker K. et al. Characterisation of cross Conflict of interest -reacting allergens in mango fruit. Allergy 2001; 56: 237–242. 23. Brehler R., Theissen U., Mohr C., Luger T. ‘Latex-fruit syndro- me’: frequency of cross-reacting IgE antibodies. Allergy 1997; The authors declare no conflict of interest. 52: 404–410.

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