A case of allergy to Silybum marianum ( milk thistle ) and Eragrostis tef ( teff )

A 29-year-old male presented at the Allergy Clinic (Allergy and Clinical Immunology Unit, Public Central Teaching Hospital in Warsaw) due to an episode of itching and burning in the mouth, tongue swelling, difficulty swallowing, feeling of anxiety, and rapid pulse, all of which developed several days earlier, within 5 min after ingesting teff flakes. Since the patient had been previously provided with an emergency kit, he immediately took 30 mg prednisone and 30 mg cetirizine orally. As his general condition improved rapidly, there was no need for adrenalin administration. The patient did not report to his doctor directly following the incident. The patient had already had a history of similar symptoms in the form of burning and itching in the mouth, albeit less severe, following ingestion of gluten-free bread from teff flour or containing teff. 8 months ago, in outpatient setting we diagnosed this patient with inhalant allergy to milk thistle. Four years prior to his presentation at our clinic, the patient started working at a production facility that manufactures healthy, organic foods, including gluten-free flours, food additives, and natural dietary supplements. During the first year of his employment there, he worked at a packaging station for dry, finely-ground fruit of milk thistle. At that time, he experienced no health issues. For the last 3 years, the patient has held an executive position and had no direct exposure to the packaging premises. However, he reported about a year’s history of rhinorrhea, sneezing, burning watery eyes, and wheezing whenever he came in contact with even minute amounts of milk thistle. The patient denied ever having consumed milk thistle in the form of infusions, teas, food additives, or pharmaceutical form (tablet) excipients. Milk thistle fruit is delivered to the plant already in a dry, finely ground form, which is not further processed, but only packaged on the premises. Milk thistle is delivered from an organic food farm in a defatted, ground form. The product has an appropriate quality certificate. For approximately 1 year the facility has been importing teff cereal from the Netherlands and manufacturing gluten-free flours and flakes. The facility has a product-quality certificate, containing information on the product’s sensory properties, storage conditions, physicochemical requirements, nutritional value, and allergens. The patient has not been diagnosed with celiac disease nor is on any special diet. However, as a co-owner of the facility, he samples all the foods products manufactured on the premises. It was during such routine sampling of teff-flour bread and flakes that the patient first noticed the symptoms listed above.

Past medical history revealed no major health issues and no current medication. His family history was negative for allergies. The patient denied hypertension, coronary artery disease, diabetes mellitus, and peptic ulcer disease. He reported periodic burning sensation in his mouth, heartburn, and dysphagia following ingestion of certain raw fruit and vegetables (apples, pears, plums, carrots, celery root). The patient had been stung twice by a wasp and developed considerable local reaction which, however, required no medical intervention. Nonetheless, 2 years prior to presentation, a wasp sting produced chest tightness and wheezing as well as localized edema and erythema. At that time, the patient was examined at an emergency room; however, he no longer has any medical records from the incident nor remembers what kind of treatment he received.

Physical examination revealed no apparent abnormalities. Otorhinolaryngological examination findings were as follows: Nose—no nasal septum deviation; pink, moist mucosa, slight hypertrophy of the inferior turbinates; no polyps or other growths; Pharynx—a normal tongue, with no coating; symmetrical palatal arches; palatal tonsils present in their anatomical location, no pathological discharge; clear posterior pharyngeal wall; Ears—bilateral otoscopy revealed no abnormalities; Larynx—normal appearance and function. Auscultation revealed normal breath sounds over both lung fields, no murmurs, and a regular heartbeat. The abdomen was soft, nontender. The skin was clear, with no evidence of exanthema.

Allergy diagnostics. Spirometry results were normal (FEV1 117% (5.14 L); FEV1/FVC 97%, 34th percentile, SR–0.42); rhinomanometry results were within normal limits. Skin prick testing (SPT) and skin tests with native alimentary allergens (from the foods brought by the patient) revealed high reactivity to the allergens of milk thistle (16/35) and teff flour (22/60), with the negative control score of 0/0, and histamine score of 3/5. Skin tests with Allergopharma allergens, sIgE (Table 1), and Faber test (Table 2) were also conducted. In order to verify the results of skin tests with native food allergens, the same tests with teff allergens were performed in 5 healthy volunteers and 5 volunteers diagnosed with an inhalant allergy to grasses, yielding negative results. Skin tests with native milk thistle allergens were also conducted in 5 healthy volunteers, yielding negative results.

Table 1 Allergy diagnostic assessments: skin-prick tests, skin (prick-by-prick) tests with native allergens, and allergen-specific IgE tests
Table 2 Serum IgE specific to allergenic molecules (M) and extracts (E)

Due to the presence of upper gastrointestinal (GI) symptoms (heartburn, acid regurgitation, foul taste in the mouth), the patient was referred to the Gastroenterology Department at Medical University of Warsaw to undergo diagnostic assessments for eosinophilic esophagitis. At the Gastroenterology Department the patient underwent gastroscopy with esophageal and gastric biopsy. Neither the gastroscopy nor microscopic examination of the biopsy samples revealed any upper GI tract abnormalities. Eosinophilic esophagitis was excluded. Since Helicobacter pylorii was detected, appropriate treatment was administered (500 mg metronidazole 3 times a day, 500 mg tetracycline 4 times a day, 120 mg bismuth oxide 4 times a day, 40 mg pantoprazoleonce a day). Following the course of treatment, the patient’s GI symptoms resolved completely. Currently, the patient remains under observation in an outpatient setting (at our clinic). The patient was recommended to carefully avoid any future contact with teff flour and milk thistle. Additionally, the patient received an emergency kit containing three 10-mg prednisone tablets, three cetirizine tablets, and a pre-filled syringe with adrenalin (EpiPen Senior). Moreover, the patient received thorough training on how and when to use the drugs from his emergency kit. Due to the patient’s diagnosis of wasp venom allergy (based on his medical history and serum specific IgE test results), he was also qualified to undergo venom immunotherapy (VIT), with the treatment scheduled to begin in September 2019.

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