Drugs may also induce allergic reactions in sensitized individuals through passionate kissing
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Drugs may also induce allergic reactions in sensitized individuals through passionate kissing To the Editor: We greatly appreciated the article of Maloney et al 1 on peanut allergen exposure through saliva during passionate kissing or through sharing different utensils. The transport of allergenic materials and consequent exposure by con- tact with oral mucosa may be more common than ex- pected. Maloney et al 1 found high levels of Ara h 1 in saliva only 5 minutes after the ingestion of 2 tablespoons of commercially prepared peanut butter (PB) on a sand- wich. Because the collection of saliva was carried out only twice (at 5 minutes and 60 minutes) after PB inges- tion, we believe that the amounts of Ara h 1 secreted in saliva might be significantly different if collected at 5 min- utes or 60 minutes. The suggested methods (rubbing the tongue over the teeth and along the gums and palate) to remove residual PB and the sandwich particles from the mouth might not be effective if applied without the use of water. Consequently, it is likely that the amounts of Ara h 1 detected in saliva after 5 minutes might contain higher percentages of allergen originating from the oral cavity than those collected at 60 minutes. In our opinion, more aggressive removal of food residues from the oral cavity by using water before the first salivary collection and the use of multiple (4/5) collections within the first 60 minutes would have been a better approach to define the kinetics of Ara h 1 in the saliva during this crucial period of time without the risk of contamination. We would also like to point out that kissing may lead to allergic reactions to far more than food. We and others have recently published 3 reports of oral allergy syndrome and generalized urticaria in 3 drug-sensitized individuals a few minutes after receiving passionate kisses from their partners who had previously used the drug. 2-4 In each case, penicillin-derived antibiotics (bacampicillin and amoxy- cillin) were involved. In the first case, a patient’s husband was taking 1200 mg bacampicillin twice daily and had ingested a bacampicillin tablet about 2 hours before, 2 so that the drug had reached an adequate concentration in the oral mucosa and in salivary secretions. 5 Similar phar- macokinetics and time of onset of symptoms has been demonstrated for amoxycillin, the antibiotic responsible for allergic reaction in the other 2 cases. 6 In these highly sensitized patients, even the small amount of antibiotic delivered through the kiss was sufficient to elicit the same symptoms as the usual oral administration, even though the symptoms were less severe. Drug allergy induced by kissing is rare, but may be clinically relevant. It is also likely that the prevalence could be underesti- mated considering the relatively high number of drug- intolerant individuals who are sexually active. Drug-induced allergy by passionate kissing should have been mentioned in the article about peanut allergy because it demonstrates the role of saliva as a vehicle for transfer of sensitizing agents, as well as the lack of contamination via the mouth. Physicians should be aware that several sensitizing agents can cause these problems. Gennaro Liccardi, MD Gennaro D’Amato, MD From the Department of Chest Diseases, Division of Pneumology and Allergology, High Speciality ‘‘A. Cardarelli’’ Hospital, Naples, Italy. E-mail: [email protected]. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure through saliva: assessment and interventions to reduce exposure. J Allergy Clin Immunol 2006;118:719-24. 2. Liccardi G, Gilder J, D’Amato M, D’Amato G. Drug allergy transmitted by passionate kissing. Lancet 2002;359:1700. 3. Petavy-Catala C, Machet L, Vaillant L. Consort contact urticaria due to amoxicillin. Contact Dermatitis 2001;44:251. 4. Mancuso G, Berdondini RM. Kiss-induced allergy to amoxycillin. Contact Dermatitis 2006;54:226. 5. Craig WA. Pharmacokinetics of bacampicillin tablets in adults. Bull N Y Acad Med 1983;59:457-67. 6. Meenhorst PL, Mattie H, Hermans J. Comparative clinical study on the absorption of orally administered amoxicillin and bacampicillin. J Anti- microb Chemother 1984;14:267-74. Available online January 31, 2007. doi:10.1016/j.jaci.2006.12.652 Reply To the Editor: We thank Drs Liccardi and D’Amato 1 for their kind comments and interest in our study, which was designed to evaluate the time course of peanut allergen persistence in saliva and to determine the effectiveness of simple mouth-cleaning measures for the removal of peanut pro- tein following peanut butter ingestion. 2 However, their suggestions to include numerous saliva collections and the use of water to enhance recovery of peanut would have diluted samples and disrupted the very aim of our study: to survey residual peanut protein in the saliva in order to provide practical advice. Their suggestions are likely based upon the assumption that peanut protein may be resecreted into saliva following ingestion. How- ever, our study design captured the more likely relevant exposure: specifically, from residual peanut in the mouth following a peanut-containing meal. We, therefore, tracked Ara h 1 at 5 time points, including those beyond when Ara h 1 was no longer detectable. Resecretion of allergens into saliva is a possibility that we addressed in the discussion of our article. Two subjects in the time- course experiments had undetectable levels of Ara h 1 at an early time point, with reappearance later. Resecretion may have accounted for these findings; however, regard- less of the mechanism, the amounts of Ara h 1 measured after initial disappearance, as a marker of total peanut protein, were over 100-fold below concentrations reported to elicit objective symptoms in those with peanut allergy, indicating that resecretion is an unlikely trigger of an allergic response compared to residual protein in the oral cavity. 3-5 J ALLERGY CLIN IMMUNOL MARCH 2007 756 Correspondence
Transcript of Drugs may also induce allergic reactions in sensitized individuals through passionate kissing
Reply
To the Editor:We thank Drs Liccardi and D’Amato1 for their kind
comments and interest in our study, which was designedto evaluate the time course of peanut allergen persistencein saliva and to determine the effectiveness of simplemouth-cleaning measures for the removal of peanut pro-tein following peanut butter ingestion.2 However, theirsuggestions to include numerous saliva collections andthe use of water to enhance recovery of peanut wouldhave diluted samples and disrupted the very aim of ourstudy: to survey residual peanut protein in the saliva inorder to provide practical advice. Their suggestions arelikely based upon the assumption that peanut proteinmay be resecreted into saliva following ingestion. How-ever, our study design captured the more likely relevantexposure: specifically, from residual peanut in the mouthfollowing a peanut-containing meal. We, therefore,tracked Ara h 1 at 5 time points, including those beyondwhen Ara h 1 was no longer detectable. Resecretion ofallergens into saliva is a possibility that we addressed inthe discussion of our article. Two subjects in the time-course experiments had undetectable levels of Ara h 1 atan early time point, with reappearance later. Resecretionmay have accounted for these findings; however, regard-less of the mechanism, the amounts of Ara h 1 measuredafter initial disappearance, as a marker of total peanutprotein, were over 100-fold below concentrations reportedto elicit objective symptoms in those with peanut allergy,indicating that resecretion is an unlikely trigger of anallergic response compared to residual protein in the oralcavity.3-5
J ALLERGY CLIN IMMUNOL
MARCH 2007
756 Correspondence
Drugs may also induce allergic reactionsin sensitized individuals throughpassionate kissing
To the Editor:We greatly appreciated the article of Maloney et al1 on
peanut allergen exposure through saliva during passionatekissing or through sharing different utensils. The transportof allergenic materials and consequent exposure by con-tact with oral mucosa may be more common than ex-pected. Maloney et al1 found high levels of Ara h 1 insaliva only 5 minutes after the ingestion of 2 tablespoonsof commercially prepared peanut butter (PB) on a sand-wich. Because the collection of saliva was carried outonly twice (at 5 minutes and 60 minutes) after PB inges-tion, we believe that the amounts of Ara h 1 secreted insaliva might be significantly different if collected at 5 min-utes or 60 minutes. The suggested methods (rubbing thetongue over the teeth and along the gums and palate) toremove residual PB and the sandwich particles from themouth might not be effective if applied without the useof water. Consequently, it is likely that the amounts ofAra h 1 detected in saliva after 5 minutes might containhigher percentages of allergen originating from the oralcavity than those collected at 60 minutes. In our opinion,more aggressive removal of food residues from the oralcavity by using water before the first salivary collectionand the use of multiple (4/5) collections within the first60 minutes would have been a better approach to definethe kinetics of Ara h 1 in the saliva during this crucialperiod of time without the risk of contamination.
We would also like to point out that kissing may lead toallergic reactions to far more than food. We and othershave recently published 3 reports of oral allergy syndromeand generalized urticaria in 3 drug-sensitized individuals afew minutes after receiving passionate kisses from theirpartners who had previously used the drug.2-4 In each case,penicillin-derived antibiotics (bacampicillin and amoxy-cillin) were involved. In the first case, a patient’s husbandwas taking 1200 mg bacampicillin twice daily and hadingested a bacampicillin tablet about 2 hours before,2 sothat the drug had reached an adequate concentration inthe oral mucosa and in salivary secretions.5 Similar phar-macokinetics and time of onset of symptoms has beendemonstrated for amoxycillin, the antibiotic responsiblefor allergic reaction in the other 2 cases.6 In these highlysensitized patients, even the small amount of antibioticdelivered through the kiss was sufficient to elicit thesame symptoms as the usual oral administration, eventhough the symptoms were less severe. Drug allergyinduced by kissing is rare, but may be clinically relevant.It is also likely that the prevalence could be underesti-mated considering the relatively high number of drug-intolerant individuals who are sexually active.
Drug-induced allergy by passionate kissing shouldhave been mentioned in the article about peanut allergybecause it demonstrates the role of saliva as a vehiclefor transfer of sensitizing agents, as well as the lack ofcontamination via the mouth. Physicians should be
aware that several sensitizing agents can cause theseproblems.
Gennaro Liccardi, MD
Gennaro D’Amato, MD
From the Department of Chest Diseases, Division of Pneumology and
Allergology, High Speciality ‘‘A. Cardarelli’’ Hospital, Naples, Italy.
E-mail: [email protected].
Disclosure of potential conflict of interest: The authors have declared that they
have no conflict of interest.
REFERENCES
1. Maloney JM, Chapman MD, Sicherer SH. Peanut allergen exposure
through saliva: assessment and interventions to reduce exposure. J Allergy
Clin Immunol 2006;118:719-24.
2. Liccardi G, Gilder J, D’Amato M, D’Amato G. Drug allergy transmitted
by passionate kissing. Lancet 2002;359:1700.
3. Petavy-Catala C, Machet L, Vaillant L. Consort contact urticaria due to
amoxicillin. Contact Dermatitis 2001;44:251.
4. Mancuso G, Berdondini RM. Kiss-induced allergy to amoxycillin. Contact
Dermatitis 2006;54:226.
5. Craig WA. Pharmacokinetics of bacampicillin tablets in adults. Bull N Y
Acad Med 1983;59:457-67.
6. Meenhorst PL, Mattie H, Hermans J. Comparative clinical study on the
absorption of orally administered amoxicillin and bacampicillin. J Anti-
microb Chemother 1984;14:267-74.
Available online January 31, 2007.doi:10.1016/j.jaci.2006.12.652
