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CORRESPONDENCES
Year : 2020  |  Volume : 65  |  Issue : 6  |  Page : 550-552
Oral allergy syndrome associated with eggplant particles manifesting as lichenoid reaction– A sequential diagnostic workout and long-term follow up


1 Department of Oral Medicine and Radiology, KIMS Dental College and Hospital, NH.216, Chaitanya Health City, Amalapuram, Andhra Pradesh, India
2 Department of Biochemistry, Mahatma Gandhi Medical College and Research Institute, SBV University, Pondicherry, India
3 Department of Dermatology Venereology and Leprology, Mahatma Gandhi Medical College and Research Institute, SBV University, Pondicherry, India
4 Department of Oral Medicine and Radiology, Indira Gandhi Institute of Dental Sciences, SBV University, Pondicherry, India

Date of Web Publication23-Oct-2020

Correspondence Address:
Santosh Palla
Department of Oral Medicine and Radiology, KIMS Dental College and Hospital, NH.216, Chaitanya Health City, Amalapuram, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_13_19

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How to cite this article:
Palla S, Srinivasan AR, Subramanian K, Shekar V. Oral allergy syndrome associated with eggplant particles manifesting as lichenoid reaction– A sequential diagnostic workout and long-term follow up. Indian J Dermatol 2020;65:550-2

How to cite this URL:
Palla S, Srinivasan AR, Subramanian K, Shekar V. Oral allergy syndrome associated with eggplant particles manifesting as lichenoid reaction– A sequential diagnostic workout and long-term follow up. Indian J Dermatol [serial online] 2020 [cited 2020 Nov 29];65:550-2. Available from: https://www.e-ijd.org/text.asp?2020/65/6/550/298897




Sir,

We would like to report a case of oral allergy syndrome, in a 25 year old male patient, who presented with complaints of burning sensation of the mouth and tongue since 4 weeks, associated with difficulty in taking food. He gave history of recurring oral ulcers for 3 years and usage of oral gel (identified as 0.1% Triamcinolone acetonide) which gave temporary relief. History of drug allergy was non-contributory. Patient reported previous 2 episodes of skin rashes and an episode of oral burning sensation after consumption of eggplant based diet. On examination, the right buccal mucosa showed an erythematous lesion with 2-3 central white spots, having irregular greyish borders. The lesion was extremely tender on palpation [Figure 1]. A provisional diagnosis of oral lichenoid reaction was considered based on history and unilateral occurrence of lesion. Erosive lichen planus, pemphigus vulgaris and oral allergy syndrome were kept as differential diagnoses. A Nikolsky's sign elicited during examination was negative. A biopsy was taken and histology showed features of parakeratinized epithelium with loss of attachment (ulceration), acanthosis in some areas of spinous layer, sharp rete pegs, basal cell degeneration and lymphocyte aggregates in upper dermis. The histopathology was suggestive of oral lichen planus [Figure 2]a and [Figure 2]b. Patient was treated with topical clobetasol propionate 0.05% cream three times/day and application of 2% benzocaine gel before taking food for 2 weeks. Symptomatic relief was achieved along with some regression of oral lesion [Figure 3]. A further diagnostic workout was planned to confirm the association of eggplant as reported in the history. A skin prick test (SPT) was performed with 4 different extracts of eggplant prepared as per reported standards.[1] They were labeled as – fruit berry (P1), pulp (P2), cooked slices (P3) and peel (P4). A wheel of diameter 3.5 mm, 3.0 mm, 3.5 mm and 6.5 mm were noted for P1, P2, P3 and P4 respectively without any flare [Figure 4] as opposed to 5.5 mm and 1.5 mm for positive and negative controls respectively. Thus, P4 (peel) was considered for specific allergen detection by enzyme-linked immunosorbant assay (ELISA), performed as per standard protocol.[1] The results were positive and showed presence of IgE reactive bands (25 kD-65 kD). The ELISA had demonstrated 6 types of IgE specific allergy causative particles (27 kD, 36 kD, 38 kD, 46 kD, 56 kD, 60 kD and 65 kD) clearly demarcated as opposed to control. The oral food challenge (provocation test) was planned at a later stage, to establish causal association of specific vegetables. Oral cetirizine 10 mg was advised as needed for any future oral lesion.
Figure 1: Initial lesion on right buccal mucosa

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Figure 2: (a) Histopathology shows acanthosis, basal cell degeneration and band-like infiltrate (H and E, x40) (b) showing ulceration at places (H and E, x100)

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Figure 3: Regressed lesions on right buccal mucosa

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Figure 4: Results of SPT with 4 components of eggplant

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Patient was asked to stop eggplant consumption for 6-months; on review was asymptomatic and had stopped medication. An oral provocation test was performed after 8 months of initial diagnosis, with eggplant samples. The preparation of unpeeled pieces of eggplants cooked as per SPT protocol (P2 about 35 g) was considered for testing. The provocation testing was done with increments of 1/10th of dose (3.5 g per 10 minutes) and evaluated for any notable symptom. Patient developed skin rashes after 10 minutes of initial dose and burning sensation of mouth and throat. Also, detectable oral erythema was noted after 20 minutes, but not specific to previous site. The test was ceased after 7 g of eggplant sample was ingested after 25 minutes. The final diagnosis of “oral allergy syndrome associated with eggplant peel particles” was confirmed considering SPT, ELISA, and oral challenge test. The provoked lesions were managed with intramuscular epinephrine at the dose of 0.01 mL/kg of 1:1000 dilutions and oral cetirizine 10 mg was given for a week to avoid any further episode. He was warned regarding other thick peel solanaceous fruits (Solanum tuberosum or potatoes from same family of solanaceae ). The patient was asymptomatic on 1 year follow up.

Oral allergy syndrome (OAS) is an allergic reaction in the oral cavity occurring after consumption of food inclusive of fruits, nuts and vegetables. Patients with allergic rhinitis, asthma or pollen allergy are at predisposition for this syndrome.[2] Pollen sensitization followed by symptoms (cross-reactions between food and inhaled allergens) in mucosal or skin sites is known pattern for the syndrome, thus, named as “pollen-food allergy syndrome,” “pollen-food syndrome,” and “pollen-associated food allergy syndrome”.[3] It is a type 1 hypersensitivity reaction occurring in the oral mucosa, lips, tongue, and throat.[2],[3]

Eggplant (Solanum melongena or commonly as aubergine or brinjal) is a fruit of commonly cultivated perennial herb. It is a vegetable cooked both in peeled and unpeeled forms in India. Allergic reactions to eggplant are common and reported due to cross-reactivity with proteins of tomato or initially inhaled pollen (Parietaria and tomato).[4] A previous report on an Indian survey of 600 adults showed a prevalence of 11% for eggplant allergy.[4] Among the members of the Solanaceae family, the tomatoes (Lycopersicon esculentum ), potatoes (Solanum tuberosum ), bell peppers (Capsicum frutescens ) form important part of cultivation, apart from the eggplant. Allergic reactions to profilin (Lyc e 1) and patatin (Sol t 1) in tomato and potato respectively are documented in 3 cases in southern India.[4] Tomato juice-induced dyspnea, swelling of oral and nasal mucosa and congestion of bulbar conjunctiva was reported in a case.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Harish Babu BN, Venkatesh YP. Clinico-immunological analysis of eggplant (Solanum melongena ) allergy indicates preponderance of allergens in the peel. World Allergy Organ J 2009;2:192-200.  Back to cited text no. 1
    
2.
Kashyap RR, Kashyap RS. Oral allergy syndrome: An update for stomatologists. J Allergy (Cairo) 2015;2015:543928.  Back to cited text no. 2
    
3.
Kelava N, Lugović-Mihić L, Duvancić T, Romić R, Situm M. Oral allergy syndrome—the need of a multidisciplinary approach. Acta Clinica Croatica 2014;53:210-9.  Back to cited text no. 3
    
4.
Pramod SN, Venkatesh YP. Allergy to eggplant (Solanum melongena). J Allergy Clin Immunol 2004;113:171-3.  Back to cited text no. 4
    
5.
Kawamoto H, Yamagata M, Nakashima H, Kambe M, Kuraoka T. A case of tomato juice-induced oral allergy syndrome in which dyspnea onset occurred during the season of Japanese cedar pollen dispersion. Nihon Kokyuki Gakkai Zasshi 2003;41:397-401.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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