Occupational generalised urticaria and allergic airborne asthma due to anisakis simplex

ARTICLE

Case report

A 48-year-old non atopic woman, a worker in a frozen-fish factory, employed in washing and cutting several types of fish (cod, tune, salmon and shrimp), after 4 months developed a generalized urticarial rash accompanied by dry cough, dysphonia and dyspnea. These symptoms improved on Sundays, days on which she did not handle fish. Spirometry study revealed a moderate obstructive pattern (FEV₁, 68%). All those symptoms completely disappeared after work place exposure was ceased.

Two months later, the patient was referred to our outpatients clinic. After obtaining the patient's written consent, an allergy study was carried out. The patient had no personal nor family history of allergy. Furthermore, since childhood, the patient had never eaten any fish.

Skin prick tests (SPT) were negative with all inhalant allergens tested (including Dermatophagoides Pteronyssinus, Dermatophagoides Farinae and German cockroach), food allergens (including several fish extracts: cod, tune, salmon and shrimp), but strongly positive with AS extract (ALK-Abello A/S, Horsholm, Denmark). The saline solution produced a negative result and histamine 1 mg/ml epicutaneous prick test resulted in an 8 mm wheal with flare. Similar results were obtained also evaluating specific IgE that were negative for all the allergens tested, but strongly positive for AS (92 KU/l, CAP system FEIA, Pharmacia Upjohn, Uppsala, Sweden). Moreover, SDS-PAGE IgE immunoblotting confirmed the specific pattern of AS hypersensitivity [1, 2]. Spirometry study showed a normal respiratory function (FEV₁, 110%).

Discussion

Anisakis simplex (AS) is a nematode parasite of fish, crustaceans and cephalopods, belonging to the anisakidae family, that may cause IgE mediated reaction after the ingestion of raw or undercooked parasitized fish [3-6]. However, these allergic reactions may also occur when the fish has been properly cooked, and hence these allergens are thought to be heat-stable.

Rhinitis or bronchial asthma due to seafood ingestion or exposure to cooking vapors are quite common among subjects suffering from seafood allergy and among workers exposed to lobsters and shrimps [7]. In a similar way, inhalation of particles of AS may cause respiratory or conjuctival symptoms [8, 9]. Allergenic cross reactivity between AS and several dust mite species or other nematodes (i.e. German cockroach), presumably due to tropomyosin, have been widely demonstrated [11, 12]. By contrast our patient was negative to all the other allergens tested.

The occurrence of urticarial and asthmatic symptoms after employment in a frozen-fish factory, the regression of symptoms after discontinuation of work place exposure and, finally, the SPT positivity and the presence of specific IgE versus AS in the absence of other sensitisation, led us to strongly suggest that our patient had an occupational allergy due to inhalation of airborne AS allergens. Therefore, we recommend considering AS as an important and maybe underestimated cause of occupational type I hypersensitivity in the fish industry.

To our knowledge, this is the first case reported of both occupational generalised urticaria and allergic airborne asthma due to anisakis simplex in the same patient.

Article accepted on 13/2/01

REFERENCES

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