Anamnesis: The not yet two-year-old boy sat on his mother’s lap during a car ride and was given a sweet to suck. Within minutes, massive swelling of the face and lips, urticaria of the throat, and difficulty swallowing and signs of laryngeal edema with inspiratory stridor occurred. On admission to the emergency department, he was found to have an edematous face with crusted contours, swollen and red lips, and massive edema of the pharynx and larynx.
Blood pressure was 100/60 mmHg, pulse 98/min. After administration of intravenous therapy with steroids and antihistamines, the boy remained hospitalized for monitoring and was discharged the other day in good general condition after symptoms resolved.
For further clarification of the cause, a consultation was arranged at the allergy ward of the Dermatology Clinic of the University Hospital Zurich.
Allergological clarification
The family history revealed no evidence of atopic diseases; the father’s profession was baker/pastry chef and the boy regularly spent time in the bakery. For the past year, the boy had been suffering from intermittent respiratory problems.
On clinical examination at this time, the auscultation findings of the lungs were unremarkable, the cheeks were red and infiltrated, and there were discrete eczematous efflorescences on the backs of the hands and wrists, corresponding to atopic eczema (Fig. 1).
In vitro allergy diagnostics performed at the initial consultation revealed an elevated total IgE level to 575 U/ml (norm to 50 U/ml) and RAST elevation of specific IgE to house dust mite (Dermatophagoides pteronyssinus), cat epithelium and wheat flour of class 3 each and of class 2 each to gluten and rye flour.
The candy that was sucked was a “10 mogul”… (Fig.2). After inquiry, the confectionery company told us the exact composition: Sugar, glucose syrup, vegetable fat, citric acid, glyceryl stearate monoester (GMS), raspberry flavoring, strawberry red (E 124), lecithin and Hyfoama 88. Our suspicions were directed at the food coloring E 124, but we asked the company to send us samples of the various ingredients. Performing the prick-to-prick tests with all ingredients of the candy yielded a result that was surprising to us: only powdered Hyfoama 88 showed a clear wheal comparable to the histamine control (Fig. 3).
The boy’s serum together with the Hyfoama sample (kindly provided by the manufacturer PPF International, The Netherlands) was sent to Prof. S.G.O. Johansson (Karolinska Institute, Department of Clinical Immunology, Stockholm), who prepared a RAST disc. Specific IgE determination yielded a positive result of RAST class 3.
The prospectus of the Hyfoama 88 product states that it is a soluble protein powder made from wheat gluten protein after exposure to calcium hydroxide. This results in a mixture of gluten polypeptides.
Diagnosis
- Acute Quincke’s edema in IgE-mediated allergy to the gluten polypeptide hyfoama;
- Respiratory allergy to dust mites, cat epithelium and flours;
- Neurodermatitis atopica.
Comment
The boy, with no family history of atopy, apparently became sensitized to flours by inhalation while in his parents’ bakery and to dust mites and cat epithelium at home. The asthmatic complaints, which recurred intercurrently from the first year of life, were apparently not associated with allergy. Until the acute event, symptoms of food allergy had never been observed before, even after eating breads, cereals, or other baked goods. Hyfoama 88 provided by the manufacturing company is a cream-colored, soluble, tasteless vegetable protein powder, which is formed from wheat gluten protein after exposure to calcium hydroxide. It thus consists of a mixture of gluten polypeptides. With these characteristics, Hyfoama as a dietary protein belongs to the group of emulsifiers, stabilizers and thickeners. According to EC directives, these products are not considered additives. Hyfoama is widely used in bakery products and in the confectionery industry, e.g. as an ingredient in nougat, caramel, frappés, gummy bears, bars or strawberries with icing. On the corresponding packages Hyfoama is declared as wheat protein. Prior to our case report at that time, no allergic reactions had been described in either manufacturers or consumers [1]. In a recent search on Google, our case study is cited again and again, but new cases were not described. However, it is likely that latent sensitization to Hyfoama is also present in a proportion of those sensitized to wheat and gluten IgE. Prof. Johansson found at that time by RAST testing that two-thirds of those sensitized to gluten also had positive results against Hyfoama.
The question arises as to the triggering epitope in Hyfoama. Now, it is known that in ingestive wheat allergy in children or in wheat flour-related effort-induced anaphylaxis, the major allergen in wheat flour is rTri-α19-omega-5-gliadin, and thus RAST f416 is considered a pathognomonic marker of ingestive wheat flour allergy [2,3]. In baker’s asthma, the major allergens of wheat are the α-amylase/trypsin inhibitors with molecular weights of 15-17 kDa, which are found in all three protein fractions of raw and cooked wheat. IgE sensitization to a dimeric wheat α-amylase inhibitor (Tri α28) was observed most frequently [4]. The α-amylase added to flours is also an important trigger of baker’s asthma [5].
Literature:
- Varga EM, Wüthrich B: Acute Quincke’s edema in a two-year-old boy after consumption of a lozenge in type I allergy to the gluten polypeptide Hyfoama 88. Allergology 1995; 18: 331-333.
- Wüthrich B: What is your diagnosis? (Quiz). Food-induced exertion-induced anaphylaxis in cases of severe sensitization to cereal proteins, especially rTri α19-omega-5-gliadin. DERMATOLOGIE PRAXIS 2013; 1: 25 and 32-33.
- Wüthrich B: What do pizza, Guetzli and a turkey with garnish have in common? DERMATOLOGIE PRAXIS 2014; 24(2): 26-27.
- Sander I, Raulf-Heimsoth M: Tracking down causes of baker’s asthma. IPA Journal 2011; 2 : 20-21. www.ipa.ruhr-uni-bochum.de/pdf/IPA_Journal_11_02_Baecker.pdf.
- Wüthrich B, Baur X: Baking agents, especially α-amylase, as occupational inhalant allergens in the bakery industry. Schweiz Med Wochenschr 1990; 120: 446-450.
DERMATOLOGIE PRAXIS 2016; 26(2): 34-36
DERMATOLOGIE PRAXIS 2018 Special Edition (Anniversary Issue), Prof. Brunello Wüthrich
