Contact Dermatitis Contact Points NEUTROPHILIC FIXED FOOD ERUPTION WATONET AL. Anew entity: the neutrophilic fixed food eruption Julie Waton, Barthelemy Splingard and Annick Barbaud Dermatology Department, University Hospital of Nancy, Batiment des specialites m edicales, Brabois Hospital, CHU, 54500 Vandoeuvre les Nancy, France doi:10.1111/j.1600-0536.2010.01845.x Key words: contact dermatitis; fixed food eruption; food allergy; neutrophilic f ixed drug eruption; neutrophilic fixed food eruption; work-related dermatitis. We describe the first case of work-related contact and systemic fixed food eruption with a neutrophilic perivascular infiltrate, which we propose to call neutrophilic fixed food eruption. Case Report A 26-year-old male, a cook in a restaurant, was referred for a recurrent, work-related, fixed eruption caused by contact with or ingestion of freshwater fish and Correspondence: Professor Annick Barbaud, Dermatology Department, University Hospital of Nancy, Brabois Hospital, 6 rue du Morvan, 54500 Vandoeuvr e les Nancy, France. Tel: +33(0)383157145; Fax: +33(3)383157011. E-mail:
[email protected] Conflicts of interest: The authors have declared no conflicts. seafood. He had developed several erythematous, welldemarcated, bullous plaques on his forearms. His longterm treatment had not been modified for more than 6years. His professional activity was disrupted because of these fixed eruption outbreaks. For the previous 4years, as soon as he handled or ate fish, bullous lesions (Fig. 1) appeared on his forearms, recurring on the same five sites and healing with residual scars. Allergological Test Patch tests were performed with Finn Chambers® on Scanpor® (Epitest Ltd oy, Tuusula, Finland), both on the scarred lesions of the forearm and also on the back, with all of the drugs and suspected foods taken by the patient, with commercial extracts (Allerbio®-ALK © 2011 John Wiley & Sons A/S Contact Dermatitis, 65,43 58 Contact Dermatitis Contact Points NEUTROPHILIC FIXED FOOD ERUPTION WATONETAL. Fig. 1.Clinical features of the neutrophilic fixed food eruption. Fig. 2.Biopsy sample from a positive patch test with tuna at 24hr, showinga polymorphous neutrophil infiltrate. Laboratory, Courbevoie, France, or Stallerg `enes® SA, (IgE) antibody test was per formed with the ImmunoCap Antony, France), or with fresh food, and read at 20min, 250 (Pharmacia Diagnosti cs, Saint Quentin en Yvelines, on D2 and D4. France) analytical system. Prick tests were performed on normal skin on the forearm, with commercial extracts or fresh food (prick-to-Results prick). The results were compared with those obtained All of the patch tests on the back gave negative results, with negative (0.9% saline) and positive (histamine but there were positive resu lts on the residual scars of 10 mg/ml) controls. Readings were performed at 20 min, the forearmsat 30min for shrimp, pollock, freshwater 1hr, and 24hr. The allergen-specific immunoglobulin E fish (carp, yellow perch, and pike), tuna, anchovy, and
Table 1. Results ofskin tests, prick tests performed on normal skin, and patch t ests performed on scars Prick tests on Prick tests on forearms Patch tests on forearm scars forearms (normal skin) 20 min 1 hr 24 hr 20 min D2/D4 Avocado (A) -P3 E6 E6 NT NT Salmon (A) -P1 E10 E3 --/- Monkfish (PP) -P4 E6 E6 NT NT Tuna (A) ---Tuna canned ++/+ Tuna fresh ++/+(bullous) Anchovy (fresh) NT NT NT ++/+ Pollock (A) ---++/+ Herring (fresh) ++/+ Freshwater fish (S) ---++/+ Cod (A) ---NT NT Whiting (A) ---NT NT Sardine (A) ---NT NT Wet gauze dressing --/- Mackerel (fresh) NT NT NT --/- Mussel (A) --- Shrimp (A) ---++/+ Crab (A) -----/- Lobster (A) ---NT NT Scampi (A) ---NT NT Latex (A) ---NT NT Paracetamol (C) -----/- A, Allerbio-ALK® laboratory commercial extracts; C, Chemotechnique® laboratory comme rcial extracts; E, diameter (mm) of the erythema; NT, not tested; P, diameter (mm) of the papules; PP, prick-to-prick; S, Stallerg `enes® laboratory commercial extracts. Patch tests performed on the back all gave negative results. The extract freshwat er fish contains proteins from carp, yellow perch, andpike. © 2011 John Wiley & Sons A/S Contact Dermatitis, 65,43 58 Contact Dermatitis Contact Points NEUTROPHILIC FIXED FOOD ERUPTION WATONETAL. herring (Table 1). These reactions changed to papuloerythematous plaques on D2, with a central blister in some sites. Prick test results on normal skin on the forearms were negative after 20 min, but became positive after 1hr for avocado, salmon, and monkfish (Table 1). These tests were also positive at 24hr (erythematous infiltrating reactions). The allergen-specific IgE antibody tests gave negative results for all foods tested. A biopsy sample taken at 20min from positive patch tests with fresh tuna showed a dermal oedema without any cell infiltrate. At 24h, on another positive site, there was necrosis of suprabasal keratinocytes, with dermo-epidermal blistering and a neutrophilic, polymorphonuclear, perivascular infiltrate (Fig. 2)without vasculitis. Discussion A fixed drug eruption, described in 1894 (1), is characterized by cutaneous or mucosal well-demarcated erythematous plaques that recur on the same site each time that the drug is administered. The biopsy sample shows focal necrosis of the basal keratinocytes, with melanin incontinence and a perivascular lymphocytepredominant inflammatory infiltrate. In 1992, Hatzis
et al. (2) reported the first case of fixed eruption caused by cheese crisps , and in 1996 Kelso (3) introduced the term fixed food eruption. Since then, other cases have been published that involved asparagus (4), cashew nuts (5), lactose (6), lentils (7), Japanese sand lance (8), liquorice (9), quinine (10), and strawberries (3). Prick tests wereperformed in only 2 cases (3, 4), and were negative. In 2001, Agnew et al. (11) reported a bullous fixed eruption, caused by amoxycillin clavulanic acid, with intraepidermal spongiosis, a marked perivascular References and interstitial mixed inflammatory infiltrate with a predominance of intact neutrophils. The authors proposed calling this new entity neutrophilic fixed drug eruption. Two other cases of this have been described with naproxen (12, 13). We report a case of neutrophilic fixed eruption that recurred following contact with oringestion of fish. Considering the histological findings, our case cannot strictly be classified as a fixed food eruption. We propose that the clinical and histological characteristics of this new entity should be called neutrophilic fixed food eruption. As observed in neutrophilic fixed drug eruption, there was aneutrophilic polymorphonuclear perivascular infiltrate without vasculitis. Are these histological findings specific for this entity, or should it be considered as a stage in the histopathological evolution of any fixed eruption (14)? The occurrence of the lesion through contact and the rapid outbreak after contact with or ingestion of fish or seafood, reproduced by the patch tests, which showed positive reactions after 20min, are uncommonin fixed eruption. Chronologically, in our case the hypersensitivity to ingested food seems to have been secondary to previous professional skin contact sensitization to fish and crustaceans. The pathophysiological mechanism responsible for the induction of this reaction is unknown, but it seems to be a combination of localized immediate and delayed hypersensitivity, as in protein contact dermatitis. However, its clinical features and histological findings are different from those of a protein contact dermatitis. This multisensitization could be attributable to hypersensitivity to fish albumin (15), to a common crustacean allergen, such as tropomyosin, arginine kinase, or myosin light chain (16), or to an avocado allergen without crossreactivity with latex. 1 Brocq L. Eruption eryth´emato-pigment´ee fixe due `a l antipirine. Ann Dermatol Syphiligr 1894: 3: 308 313. 2 Hatzis J, Noutsis K, Hatzidakis E, Bassioukas K, Perissios A. Fixed drug eruption in a mother and her son. Cutis 1992: 50: 50 52. 3 Kelso JM. Fixed food eruption. JAm Acad Dermatol 1996: 35: 638 639. 4 Volz T, Berner D, Weigert C, R¨ocken M, Biedermann T. Fixed food eruption caused by asparagus. JAllergy Clin Immunol 2005: 116: 1390 1392. 5 Fukushima S, Kidou M, Ihn H. Fixed food sand lance. Clin ExpDermatol 2009: 34:
eruption caused by cashew nut. Allergol e309 e310. Int 2008: 57: 285 287. 9 Benomar S, IsmailiN, Koufane J, 6 Tsuruta D, Sowa J, Kobayashi H, IshiiM. Senouci K, Hassam B. Erytheme pigment ´e Fixed food eruption caused by lactose fixe induit par de la r´eglisse. Ann Dermato l identified after oral administration offour Venereol 2010: 137: 121 123. unrelated drugs. JAm Acad Dermatol 10 BelB, JeudyG, Bouilly D, Dalac S, 2005: 52: 370 371. Vabres P, Collet E. Fixed eruption due to 7 Yanguas I, Oleaga JM, Gonz ´alez-G¨uemes quinine contained in tonic water: positiv e M, Goday JJ, Soloeta R. Fixed food patch-testing. Contact Dermatitis 2009: eruption caused by lentils. JAm Acad 61: 242 244. Dermatol 1998: 38: 640 641. 11 Agnew KL, Olivier GF. Neutrophilic fixed 8 Tsuruta D, Sowa J, Kobayashi H, IshiiM. drug eruption. Australas JDermatol 200 1: Fixed food eruption caused by Japanese 42: 200 202. 46 © 2011 John Wiley & Sons A/S Contact Dermatitis, 65,43 58 Contact Dermatitis Contact Points ALLERGIC CONTACT DERMATITIS CAUSED BY ACRYLATES GOULDING &FINCH 12 Ozkaya E, Buyukbabani N. Neutrophilic ¨¨ fixed drug eruption caused bynaproxen: a real entityor a stage in the histopathologic evolution ofthe disease? JAm Acad Dermatol 2005: 53: 178 179. 13 Soares T, DiCaudo D, Warschaw K. Neutrophilic fixeddrugeruption. JAm Acad Dermatol 2007: 56: AB49. 14 van Voorhees A, Stenn KS. Histological phases of Bactrim-induced fixed drug eruption. The report ofone case. Am commonlyconsumed fish. JAllergy Clin Immunol 2005: 116: 1314 1320. 16 Ayuso R, Grishina G, Bardina L, JDermatopathol 1987: 9: 528 532. Carrillo T, Blanco C, Ib´a nez MD, Sampson 15 Van Do T, Elsayed S, Florvaag E, Hordvik I, Endresen C. Allergy to fish parvalbumins: studies on the cross-reactivity of allergens from 9 HA, Beyer K. Myosin light chain is a novel shrimp allergen. JAllergy Clin Immunol 2008: 122: 795 802. © 2011 John Wiley & Sons A/S Contact Dermatitis, 65,43 58
