Anaphylaxis after ingestion of food containing guar gum: report of two cases

There is a wide variety of synthetic and natural substances that are used as food additives. They serve many technical purposes, such as preserving, flavoring, sweetening, thickening, coloring, and stabilizing foods; most cannot be consumed alone [1]. E numbers have been assigned to food additives in the European Union to identify them, and labels must include the names, functions and E numbers of the additives [2]. Gums act as stabilizing and thickening ingredients in foods, making mixtures more viscous without altering their taste [3]. Food products may include a variety of gums. The most famous are guar gum, locust bean gum, tragacanth and gum arabic. Guar gum (E 412) is obtained from a plant (Cyamopsis tetragonoloba), which is a member of the Bean family [1,3]. It is often used in the baking industry to prevent bread from going stale and increase its shelf life and quality [4]. A report by the World Health Organization and the Joint FAO/WHO Expert Committee on Food Additives states that there is no acceptable daily intake of gums (ADI, mg/kg). It is also noted that they do not have a toxicological effect on human health [5]. Although gums are well known to cause occupational asthma and rhinitis, they rarely cause allergic reactions after ingestion. [1]. Here, we present two cases of anaphylaxis following ingestion of food containing guar gum.

Case 1

A 23-year-old woman with no known allergies ate two packages of Indomie Noodle® (Indonesia) at 3:00 p.m., mixing a special aroma and vegetable taste. Thirty minutes later she started itching and then hives. The first visit to the emergency department was at 18:30 (approximately three and a half hours after exposure), with the development of severe itching and generalized urticaria. Her complaints subsided after intravenous (IV) treatment with pheniramine maleate and methylprednisolone. The next day at 6:00 AM (15 hours after exposure), she presented with generalized urticaria, dyspnea, bronchospasm, dizziness, and syncope. With these symptoms and findings for the second time within 24 hours, she was admitted to the intensive care unit and immediately given epinephrine. After the first injection of adrenaline, almost all symptoms disappeared quickly, except for moderate urticaria. Therefore, at 11:30, she was sent to the allergy department. During the assessment of allergies, in addition to urticaria, unilateral angioedema of the tongue was observed. Due to the persistence of her symptoms for a long time, prolonged anaphylaxis was considered. She was hospitalized and observed for four days. After the complete disappearance of all symptoms, an epinephrine auto-injector was prescribed and the patient was discharged from the hospital.

Diagnostic studies

The tryptase level was measured as 30.6 μg/L (UniCAP®, Pharmacia, Uppsala, Sweden) when she was initially admitted to the allergy unit, whereas the basal tryptase was 2.82 μg/L. During the second visit a month later, prick tests were first performed with a standard aeroallergen panel and 12 food allergens (banana, cow’s milk, egg white, egg yolk, peanut, walnut, tomato, kiwi, sesame, hazelnut, wheat flour, soy flour). All of them were negative.

Second, we questioned the daily diet and investigated the ingredients that may be included in the noodles consumed. Wheat flour is the main nutritional component of noodles and also contains many additives. During this period, she was able to consume gluten, the main allergen, as well as supplements other than guar gum, without experiencing any adverse reactions.

Blood samples were then taken for allergen-specific IgE: cumin, mace, cardamom, clove, basil, fennel seed, ginger, anise, egg white, milk, fish, wheat, peanut, and soy-specific IgE were negative; in contrast, guar gum was class 6 positive (114 kA/L). An oral provocation test was not performed because specific IgE for guar gum was detected in the blood. To our knowledge, this is the first case of hypersensitivity to guar gum with such a high specific IgE value and prolonged anaphylaxis.

Case 2

A 19-year-old patient came to the outpatient clinic with complaints of swollen lips and shortness of breath 3-4 hours after eating corn bread a week ago. He has perennial allergic rhinitis with exacerbation of symptoms when interacting with birds at home. He also suffered from intermittent shortness of breath for two months.

Diagnostic studies

First, he was examined for asthma and allergic rhinitis. Broncholytic reversal test was positive. Prick tests for herbal mixture (5*6 mm), wormwood (3*4 mm) and cat hair (4*4 mm) were positive, peripheral eosinophilia (1022/mm3) was detected. Allergen-specific Ig E was found to be class 2 positive (0.7–3.5 kA/L) for most pollen, e.g. perennial lily, grain of ryecommon wormwood and herb mixtures (fragrant anthoxanthum, perennial lily, phleum pretence, grain of rye, holcus lanatus), but class 3 (3.5 – 17.5 kA/l) is positive for a mixture of bird feathers (budgie feathers, canary feathers, parrot feathers, parakeet feathers, finch feathers ). With a diagnosis of allergic asthma and rhinitis, a combination of long-acting inhaled corticosteroids/beta-agonists, intranasal corticosteroids, and leukotriene antagonists is prescribed.

Second, eosinophilia and food allergy screening were conducted. Aspergillus-specific IgE was negative, and paranasal computed tomography showed mild mucosal thickening of the ethmoid and sphenoid sinuses. Eosinophilic granulomatosis with polyangiitis (EGPA) and allergic bronchopulmonary aspergillosis (ABPA) were excluded. A standardized food panel of 12 allergens and a prick-to-prick test with cornbread were negative. Total IgE was found to be 207 cu/L and basal tryptase was 3.18 μg/L.

Finally, an oral provocation test with cornbread was performed. 2 hours after eating cornbread, he developed flushing, sweating, erythema of the conjunctiva, shortness of breath with bilateral wheezing. Treatment for anaphylaxis was prescribed immediately. Since the patient could only consume corn, supplements in bread were investigated. The specific IgE of guar gum, which is used as a thickener, especially in gluten-free bakery products, was high (49.2 kA/L, class 4), while the tryptase level was very close to the basal level (4.47 μg/L). .

Three cases were found in PubMed using the keywords “guar gum” and “anaphylaxis”. [6-8]. The first case was in a patient who developed anaphylaxis minutes after consuming a soy drink and pasta (Tortelline®) in 2002. Although guar gum-specific IgE was negative in this case, the basophil activation test was positive [6]. There was an allergic reaction during a dental procedure in the second case described in 2005. Guar gum was used as a preservative in the lidocaine gel, and the patient did not respond to the lidocaine challenge. Prick tests with gum derivatives showed positive results, but did not show specific IgE. Tryptase was also tested in this case, but no increase was seen [7]. In a third case reported in 2007, a 52-year-old patient used a diet for weight loss (Gerlinea [France]) and ASA together, so aspirin was accepted as a factor that increases allergic side effects. Both gingival prick tests and specific IgE (27.2 kA/L) were positive in this case [8].

Tryptase has only been tested in one case in the literature [7], and she was not promoted. In contrast, we found a very high level of tryptase in the first case. In addition, the first case is a very rare example of anaphylaxis. Prolonged anaphylaxis is defined as a condition meeting the criteria for anaphylaxis lasting at least four hours [9]. The patient described in the literature developed urticaria the next day, accompanied by nausea, vomiting, and spasm-like abdominal pain. Interestingly, the level of tryptase remained elevated in the blood sample on the third day [10]. Similarly, in one case, other symptoms of anaphylaxis appeared 15 hours after urticaria, and tryptase levels were positive 18 hours later. In addition, symptoms persisted for four days despite treatment. So it was considered prolonged anaphylaxis, which is an unusual form of anaphylaxis.

Whereas specific IgE-positive was determined in only one patient so far [8], we demonstrated the highest serum-specific IgE values ​​in the literature in both patients. Although positive predictive values ​​for common food allergies have been established, no study has shown predictive value for guar gum [11]. However, values ​​greater than 17.5 kA/L can be considered IgE-mediated guar allergy.

In a case published in 2007, the simultaneous use of guar gum and ASA was shown to increase anaphylaxis [8]. In our cases, there were no predisposing factors such as drugs or exercise to enhance the response.

Allergy histories of the patients were not recorded in the published cases, or they were not known to have an allergy [6-8]. The second case was allergic to pollen and bird feathers, and he was diagnosed with allergic asthma and rhinitis. In this regard, it can be hypothesized that the presence of several atopic diseases may lead to hypersensitivity to guar gum.

Food additive allergy should be considered in cases where patients have allergic symptoms to several different foods and/or packaged foods that are well tolerated when prepared at home. [12].

To our knowledge, the first case is a unique form of prolonged anaphylaxis and hypersensitivity to guar gum in which tryptase was elevated 10-fold with a positive level 6 specific IgE to guar gum. We were able to demonstrate an IgE-mediated immune mechanism in both cases. We instructed our patients to read food labels and advised them to avoid guar gum and to use epinephrine autoinjectors when necessary. No response was observed during the six-month follow-up of both patients.

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