To the Editor:

Although mango, the national fruit of India, is consumed in large quantities, immediate hypersensitivity reaction to mango is extremely rare.

To date, there have been only nine reported cases of immediate hypersensitivity reaction, which has presented, variously, as anaphylaxis, angioedema, erythema, urticaria, and wheezing dyspnea.(1-8) Delayed hypersensitivity reaction, manifesting as contact dermatitis, can also occur, twelve cases having been reported.(9-16)

The paucity of data regarding allergic manifestations to mango prompted this description of a 46-year-old female patient with immediate hypersensitivity reaction after the ingestion of fresh mango. The patient had nasal symptoms for 4 years which were followed by wheezing dyspnea and cough for 2 years. Her visit to our institute was motivated by specific aggravation of wheezing dyspnea and paroxysmal cough after consumption of ripe mangoes during the current mango season. There was no temporal relationship between her symptoms and the ingestion of any other food items. There was no history of reactions to drugs, including aspirin. Her mother had had asthma since her teens. The nasal mucosa of the patient was erythematous, with mucopurulent secretions on the left side. Bilateral polyphonic expiratory rhonchi were audible over both lungs.

The results of a complete blood workup and chest X-ray were within normal limits. However, a noncontrast CT scan of the paranasal sinuses revealed pansinusitis with left maxillary polyp. Pulmonary function testing showed an FEV1/FVC ratio of 65%, with an FVC of 2.43 L (87% of predicted) and an FEV1 of 1.52 L (64% of predicted). This was suggestive of moderate airflow obstruction with no significant reversibility. Prick testing was performed with mango extract from a fresh ripe mango, with a negative control (buffered normal saline) and a positive control (histamine). This elicited a type I hypersensitivity reaction to the mango extract. Immediate hypersensitivity was confirmed with an intradermal test.

The patient declined to undergo skin prick testing with the standard aeroallergens/food allergens. However, she agreed to undergo an open oral food challenge test under observation. Her PEF was recorded before and after eating mango. Immediately after ingestion (within 15 min), she had a bout of coughing, wheezing dyspnea, and throat irritation, with an increase in the intensity of the polyphonic rhonchi. The PEF fell from 4.91 L to 4.42 L, a decrease of 490 mL (9%). This reaction subsided within half an hour after nebulization with albuterol and ipratropium. The patient was subsequently lost to follow up, and we were therefore unable to evaluate the levels of specific IgE antibodies to mango.

Of the nine patients reported to have an immediate hypersensitivity reaction to mango (Table 1), three developed erythema,(3,4,7) five developed angioedema,(2,4,6-8) eight developed respiratory distress/dyspnea,(1-8) and two developed anaphylaxis,(2,3) which progressed to life threatening anaphylactic shock in one.(2) Information regarding the skin test for allergy to mango was available for seven of the nine patients, and the result was positive in all seven.(2,4,5,6-8) Specific IgE to mango was evaluated in six patients,(4-9) but only three patients tested positive.(5,6,8) It is possible that specific IgE antibodies against mango antigen are not apparent in some patients, because the corresponding allergens might be unstable and remain undetected. The IgE detection system currently available appears to be lacking some of the specific mango allergens, and there is as yet no benchmark for the diagnosis of type 1 sensitization to mango.





Immediate hypersensitivity reaction is mediated through the classical IgE pathophysiological mechanisms and is thought to occur in previously sensitized individuals. Sensitization may occur by prior ingestion or by intake of other fruits belonging to the family Anacardiaceae. Canned or packaged mango can also cause an allergic reaction, because the allergenicity of mango nectar persists even after heating, enzymatic degradation, and mechanical tissue damage.

Our patient had episodic breathlessness with wheezing for the preceding two years and had a left nasal polyp. She had no history of an allergic reaction to any drug including aspirin. However, Samter's syndrome could not be ruled out, because the patient was lost to follow-up, and therefore neither skin testing for aspirin sensitivity nor oral challenge with aspirin could be performed.

As can be seen in Table 2, urticaria was present in eight of the twelve reported cases of delayed hypersensitivity reaction to mango,(9-12,14) whereas periorbital edema was present in two.(12,14) Three of those twelve patients developed the symptoms after ingesting mango,(9,12,14)





whereas the remaining nine patients developed the reaction after contact with mango skin or the bark of the mango tree.(10,11,13,15,16) Patch testing was performed in ten patients,(10,12-16) and the result was positive in all ten. Cross-reactivity and positivity for specific IgE antibodies against mango antigen were not reported in any patient.

Delayed hypersensitivity reaction to mango is cell-mediated and can result from direct contact with the fruit or even with the tree itself. Ingestion can also cause a cell-mediated reaction. The sensitizing substances include urushiol, cardol, limonene and B-pinene which are present in the skin, bark, and pericarp, as well as in the mango pulp, up to five millimeters below the skin.(14)

Mango antigen is also known to cross-react with artemisia pollen, birch pollen, poison ivy, mugwort, celery, carrot, pistachio nut, tomato, papaya, and banana.(8) Latex is known to cross-react with fruits of the Anacardiaceae family, to which the mango belongs.(7) However, none of the patients with documented mango allergy had associated latex hypersensitivity.

Our report highlights the fact that, albeit rare, the mango fruit can cause an immediate hypersensitivity reaction which can result in a life threatening event. It is imperative to recognize such manifestations early in order to avoid morbidity and mortality in susceptible patients.


Richa Sareen
Junior Resident,
Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India

Ayush Gupta
Junior Resident,
Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India

Ashok Shah
Professor,
Department of Respiratory Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India


References


1. Kahn IS. Fruit sensitivity. Southern Med J. 1942;35(9):858-9.

2. Rubin JM, Shapiro J, Muehlbauer P, Grolnick M. Shock reaction following ingestion of mango. JAMA. 1965;193(5):397-8.

3. Dang RW, Bell DB 2nd. Anaphylactic reaction to the ingestion of mango. Case report. Hawaii Med J 1967;27(2):149-50.

4. Miell J, Papouchado M, Marshall AJ. Anaphylactic reaction after eating a mango. BMJ. 1988;297(6664):1639-40.

5. Duque S, Fernández-Pellón L, Rodríguez F. Mango allergy in a latex-sensitised patient. Allergy. 1999;54(9):1004-5.

6. Hegde VL, Venkatesh YP. Anaphylaxis following ingestion of mango fruit. J Investig Allergol Clin Immunol. 2007;17(5):341-4.

7. Renner R, Hipler C, Treudler R, Harth W, Süss A, Simon JC. Identification of a 27 kDa protein in patients with anaphylactic reactions to mango. J Investig Allergol Clin Immunol. 2008;18(6):476-81.

8. Silva R, Lopes C, Castro E, Ferraz de Oliviera J, Bartolome B, Castel-Branco MG. Anaphylaxis to mango fruit and crossreactivity with Artemisia vulgaris pollen. J Investig Allergol Clin Immunol. 2009;19(5):420-2.

9. Samuel JZ. Contact dermatitis due to mango. JAMA. 1939;113(20):1808.

10. Calvert ML, Robertson I, Samaratunga H. Mango dermatitis: allergic contact dermatitis to Mangifera indica. Australas J Dermatol. 1996;37(1):59-60.

11. Tucker MO, Swan CR. Images in clinical medicine. The mango-poison ivy connection. New Eng J Med. 1998;339(4):235.

12. Weinstein S, Bassiri-Tehrani SB, Cohen DE. Allergic contact dermatitis to mango flesh. Int J Dermatol 2004;43(3):195-6.

13. Oka K, Saito F, Yasuhara T, Sugimoto A. A study of cross-reactions between mango contact allergens and urushiol. Contact Dermatitis 2004;51(5-6): 292-6.

14. Wiwanitkit V. Mango dermatitis. Indian J Dermatol. 2008;53(3):158.

15. Thoo CH, Freeman S. Hypersensitivity reaction to the ingestion of mango flesh. Australas J Dermatol. 2008;49(2):116-9.

16. Lee D, Seo JK, Lee HJ, Kang JH, Sung HS, Hwang SW. A case of allergic contact dermatitis caused by a duoderm extrathin® dressing. [Article in Korean]. Korean J Dermatol. 2009;47(5):612-4.