Exercise-induced anaphylaxis with an Ayurvedic drug as cofactor:A case report
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摘要
BACKGROUND The practice of Indian Ayurvedic medicine is spreading in Western countries and Shilajit is one of the most used drugs, for its antioxidant activities and immunomodulatory effects. Albeit Shilajit has showed a high degree of safety, it can act as cofactor of anaphylaxis, especially in condition at high risk, such as mast cell activation syndrome(MCAS). We reported this case to sensitize practitioners to investigate to the use of complementary and alternative medicine,in case of exercise-induced anaphylaxis(EIAn).CASE SUMMARY A 43-year-old woman, working as a dance teacher, developed urticaria after ingestion of rice, tuna and Shilajit, which did not respond to intramuscular corticosteroids. Subsequently, she developed dyspnoea and hypotension with loss of consciousness that arose 1 h after sexual activity. The patient did not refer personal history of atopy. Specific IgE for main food allergens resulted negative,with total IgE levels of 14 IU/L. Oral provocation test with Shilajit was not perfomed because the patient refused, but we performed prick-by-prick and patch test that resulted negative. Serum tryptase at the time of anaphylaxis was 20.6 μg/L that fell down to of 10.6 μg/L after therapy, but has remained at the high value after two days and during the follow-up. We performed an analysis of the c-KIT gene in peripheral blood, which was negative. We felt the diagnosis consistent with EIAn in a patient with a possible MCAS.CONCLUSION In Western countries the use of drugs from Ayurvedic medicine is more common than in the past. These substances can be cofactors of anaphylaxis in patients with risk factors.
BACKGROUND The practice of Indian Ayurvedic medicine is spreading in Western countries and Shilajit is one of the most used drugs, for its antioxidant activities and immunomodulatory effects. Albeit Shilajit has showed a high degree of safety, it can act as cofactor of anaphylaxis, especially in condition at high risk, such as mast cell activation syndrome(MCAS). We reported this case to sensitize practitioners to investigate to the use of complementary and alternative medicine,in case of exercise-induced anaphylaxis(EIAn).CASE SUMMARY A 43-year-old woman, working as a dance teacher, developed urticaria after ingestion of rice, tuna and Shilajit, which did not respond to intramuscular corticosteroids. Subsequently, she developed dyspnoea and hypotension with loss of consciousness that arose 1 h after sexual activity. The patient did not refer personal history of atopy. Specific IgE for main food allergens resulted negative,with total IgE levels of 14 IU/L. Oral provocation test with Shilajit was not perfomed because the patient refused, but we performed prick-by-prick and patch test that resulted negative. Serum tryptase at the time of anaphylaxis was 20.6 μg/L that fell down to of 10.6 μg/L after therapy, but has remained at the high value after two days and during the follow-up. We performed an analysis of the c-KIT gene in peripheral blood, which was negative. We felt the diagnosis consistent with EIAn in a patient with a possible MCAS.CONCLUSION In Western countries the use of drugs from Ayurvedic medicine is more common than in the past. These substances can be cofactors of anaphylaxis in patients with risk factors.
BACKGROUND The practice of Indian Ayurvedic medicine is spreading in Western countries and Shilajit is one of the most used drugs, for its antioxidant activities and immunomodulatory effects. Albeit Shilajit has showed a high degree of safety, it can act as cofactor of anaphylaxis, especially in condition at high risk, such as mast cell activation syndrome(MCAS). We reported this case to sensitize practitioners to investigate to the use of complementary and alternative medicine,in case of exercise-induced anaphylaxis(EIAn).CASE SUMMARY A 43-year-old woman, working as a dance teacher, developed urticaria after ingestion of rice, tuna and Shilajit, which did not respond to intramuscular corticosteroids. Subsequently, she developed dyspnoea and hypotension with loss of consciousness that arose 1 h after sexual activity. The patient did not refer personal history of atopy. Specific IgE for main food allergens resulted negative,with total IgE levels of 14 IU/L. Oral provocation test with Shilajit was not perfomed because the patient refused, but we performed prick-by-prick and patch test that resulted negative. Serum tryptase at the time of anaphylaxis was 20.6 μg/L that fell down to of 10.6 μg/L after therapy, but has remained at the high value after two days and during the follow-up. We performed an analysis of the c-KIT gene in peripheral blood, which was negative. We felt the diagnosis consistent with EIAn in a patient with a possible MCAS.CONCLUSION In Western countries the use of drugs from Ayurvedic medicine is more common than in the past. These substances can be cofactors of anaphylaxis in patients with risk factors.
引文
1 Muraro A,Roberts G,Worm M,BilòMB,Brockow K,Fernández Rivas M,Santos AF,Zolkipli ZQ,Bellou A,Beyer K,Bindslev-Jensen C,Cardona V,Clark AT,Demoly P,Dubois AE,DunnGalvin A,Eigenmann P,Halken S,Harada L,Lack G,Jutel M,Niggemann B,Ru?ff F,Timmermans F,VliegBoerstra BJ,Werfel T,Dhami S,Panesar S,Akdis CA,Sheikh A;EAACI Food Allergy and Anaphylaxis Guidelines Group.Anaphylaxis:guidelines from the European Academy of Allergy and Clinical Immunology.Allergy 2014;69:1026-1045[PMID:24909803 DOI:10.1111/all.12437]
2 Ansley L,Bonini M,Delgado L,Del Giacco S,Du Toit G,Khaitov M,Kurowski M,Hull JH,Moreira A,Robson-Ansley PJ.Pathophysiological mechanisms of exercise-induced anaphylaxis:an EAACI position statement.Allergy 2015;70:1212-1221[PMID:26100553 DOI:10.1111/all.12677]
3 Onnes MC,Tanno LK,Elberink JN.Mast Cell Clonal Disorders:Classification,Diagnosis and Management.Curr Treat Options Allergy 2016;3:453-464[PMID:27942432 DOI:10.1007/s40521-016-0103-3]
4 Wilson E,Rajamanickam GV,Dubey GP,Klose P,Musial F,Saha FJ,Rampp T,Michalsen A,Dobos GJ.Review on shilajit used in traditional Indian medicine.J Ethnopharmacol 2011;136:1-9[PMID:21530631 DOI:10.1016/j.jep.2011.04.033]
5 Alvarez-Twose I,González-de-Olano D,Sánchez-Mu?oz L,Matito A,Jara-Acevedo M,Teodosio C,García-Montero A,Morgado JM,Orfao A,Escribano L.Validation of the REMA score for predicting mast cell clonality and systemic mastocytosis in patients with systemic mast cell activation symptoms.Int Arch Allergy Immunol 2012;157:275-280[PMID:22042301 DOI:10.1159/000329856]
6 Motojima H,O Villareal M,Han J,Isoda H.Microarray analysis of immediate-type allergy in KU812cells in response to fulvic acid.Cytotechnology 2011;63:181-190[PMID:21331654 DOI:10.1007/s10616-010-9333-6]
7 Agarwal SP,Khanna R,Karmarkar R,Anwer MK,Khar RK.Shilajit:a review.Phytother Res 2007;21:401-405[PMID:17295385 DOI:10.1002/ptr.2100]
8 Bielory L.Complementary and Alternative Medicine in Allergy-Immunology:More Information is Needed.J Allergy Clin Immunol Pract 2018;6:99-100[PMID:29310770 DOI:10.1016/j.jaip.2017.09.024]
9 Akin C.Mast cell activation syndromes presenting as anaphylaxis.Immunol Allergy Clin North Am 2015;35:277-285[PMID:25841551 DOI:10.1016/j.iac.2015.01.010]
10 Nwaru BI,Dhami S,Sheikh A.Idiopathic Anaphylaxis.Curr Treat Options Allergy 2017;4:312-319[PMID:28890861 DOI:10.1007/s40521-017-0136-2]
11 Kristensen T,Vestergaard H,M?ller MB.Improved detection of the KIT D816V mutation in patients with systemic mastocytosis using a quantitative and highly sensitive real-time qPCR assay.J Mol Diagn2011;13:180-188[PMID:21354053 DOI:10.1016/j.jmoldx.2010.10.004]
12 Mu?oz-Cano R,Pascal M,Araujo G,Goikoetxea MJ,Valero AL,Picado C,Bartra J.Mechanisms,Cofactors,and Augmenting Factors Involved in Anaphylaxis.Front Immunol 2017;8:1193[PMID:29018449 DOI:10.3389/fimmu.2017.01193]
2 Ansley L,Bonini M,Delgado L,Del Giacco S,Du Toit G,Khaitov M,Kurowski M,Hull JH,Moreira A,Robson-Ansley PJ.Pathophysiological mechanisms of exercise-induced anaphylaxis:an EAACI position statement.Allergy 2015;70:1212-1221[PMID:26100553 DOI:10.1111/all.12677]
3 Onnes MC,Tanno LK,Elberink JN.Mast Cell Clonal Disorders:Classification,Diagnosis and Management.Curr Treat Options Allergy 2016;3:453-464[PMID:27942432 DOI:10.1007/s40521-016-0103-3]
4 Wilson E,Rajamanickam GV,Dubey GP,Klose P,Musial F,Saha FJ,Rampp T,Michalsen A,Dobos GJ.Review on shilajit used in traditional Indian medicine.J Ethnopharmacol 2011;136:1-9[PMID:21530631 DOI:10.1016/j.jep.2011.04.033]
5 Alvarez-Twose I,González-de-Olano D,Sánchez-Mu?oz L,Matito A,Jara-Acevedo M,Teodosio C,García-Montero A,Morgado JM,Orfao A,Escribano L.Validation of the REMA score for predicting mast cell clonality and systemic mastocytosis in patients with systemic mast cell activation symptoms.Int Arch Allergy Immunol 2012;157:275-280[PMID:22042301 DOI:10.1159/000329856]
6 Motojima H,O Villareal M,Han J,Isoda H.Microarray analysis of immediate-type allergy in KU812cells in response to fulvic acid.Cytotechnology 2011;63:181-190[PMID:21331654 DOI:10.1007/s10616-010-9333-6]
7 Agarwal SP,Khanna R,Karmarkar R,Anwer MK,Khar RK.Shilajit:a review.Phytother Res 2007;21:401-405[PMID:17295385 DOI:10.1002/ptr.2100]
8 Bielory L.Complementary and Alternative Medicine in Allergy-Immunology:More Information is Needed.J Allergy Clin Immunol Pract 2018;6:99-100[PMID:29310770 DOI:10.1016/j.jaip.2017.09.024]
9 Akin C.Mast cell activation syndromes presenting as anaphylaxis.Immunol Allergy Clin North Am 2015;35:277-285[PMID:25841551 DOI:10.1016/j.iac.2015.01.010]
10 Nwaru BI,Dhami S,Sheikh A.Idiopathic Anaphylaxis.Curr Treat Options Allergy 2017;4:312-319[PMID:28890861 DOI:10.1007/s40521-017-0136-2]
11 Kristensen T,Vestergaard H,M?ller MB.Improved detection of the KIT D816V mutation in patients with systemic mastocytosis using a quantitative and highly sensitive real-time qPCR assay.J Mol Diagn2011;13:180-188[PMID:21354053 DOI:10.1016/j.jmoldx.2010.10.004]
12 Mu?oz-Cano R,Pascal M,Araujo G,Goikoetxea MJ,Valero AL,Picado C,Bartra J.Mechanisms,Cofactors,and Augmenting Factors Involved in Anaphylaxis.Front Immunol 2017;8:1193[PMID:29018449 DOI:10.3389/fimmu.2017.01193]