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Allergic Reaction to Mint Leads to Asthma

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Respiratory and cutaneous adverse reactions to mint can result from several different mechanisms including IgE-mediated hypersensitivity, delayed-type hypersensitivity (contact dermatitis), and nonimmunologic histamine release. Reactions to cross-reacting plants of the Labiatae family, such as oregano and thyme, as well as to the chemical turpentine, may clue the clinician in on the diagnosis of mint allergy. Contact dermatitis can result from menthol in peppermint. Contact allergens have been reported in toothpastes, which often are mint-flavored. Allergic asthma from mint is less well-recognized. A case of a 54-year-old woman with dyspnea on exposure to the scent of peppermint is presented in whom mint exposure, as seemingly innocuous as the breath of others who had consumed Tic Tac candies, exacerbated her underlying asthma. This case highlights the importance of testing with multiple alternative measures of specific IgE to mint, including skin testing with mint extract, and skin testing with fresh mint leaves. Additionally, this cases suggests that asthma can result from inhaling the scent of mint and gives consideration to obtaining confirmatory pre- and postexposure pulmonary function data by both impulse oscillometry and spirometry.
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Allergic reaction to mint leads to asthma
Anthony M. Szema, M.D., and Tisha Barnett, B.S.
ABSTRACT
Respiratory and cutaneous adverse reactions to mint can result from several different mechanisms including IgE-mediated
hypersensitivity, delayed-type hypersensitivity (contact dermatitis), and nonimmunologic histamine release. Reactions to
cross-reacting plants of the Labiatae family, such as oregano and thyme, as well as to the chemical turpentine, may clue the
clinician in on the diagnosis of mint allergy. Contact dermatitis can result from menthol in peppermint. Contact allergens have
been reported in toothpastes, which often are mint-flavored. Allergic asthma from mint is less well-recognized. A case of a
54-year-old woman with dyspnea on exposure to the scent of peppermint is presented in whom mint exposure, as seemingly
innocuous as the breath of others who had consumed Tic Tac candies, exacerbated her underlying asthma. This case highlights
the importance of testing with multiple alternative measures of specific IgE to mint, including skin testing with mint extract,
and skin testing with fresh mint leaves. Additionally, this cases suggests that asthma can result from inhaling the scent
of mint and gives consideration to obtaining confirmatory pre- and postexposure pulmonary function data by both
impulse oscillometry and spirometry.
(Allergy Rhinol 2:43–45, 2011; doi: 10.2500/ar.2011.2.0008)
Although food allergy reactions are becoming in-
creasingly recognized,
1,2
adverse reactions on
exposure to the mint plant and products containing
mint and related plants are often unrecognized. We
present a case of a newspaper reporter who wheezed
when interviewing persons eating Tic Tac mint candy
(Ferrero, USA).
CASE
The patient is a 54-year-old woman with the chief
complaint, “I can’t breathe near mint.” Additionally,
she has noted for the past year that her “right lung
hurts near mint.” When persons at work chew Tic Tacs
(mints), she gets short of breath. In the context of her
duties as a New York City reporter, she interviews
many people, less than an arm’s length away, who
consume mints. Her asthma inhaler does not help with
one puff. She has noted a significant exposure history
to a mint garden, which she played in for hours at a
time as a child, every summer. Mint-scented cleaning
fluids make her shortness of breath worse.
Collateral allergic history is notable for seasonal al-
lergic rhinitis because of known tree pollen allergy.
Physical examination was unremarkable. Laboratory
evaluation including pulmonary function tests and as-
sessment for specific IgE to peppermint is shown in
Tables 1–3 and Fig. 1.
Question
In evaluating a patient who experiences severe exac-
erbations of asthma (without rash) near mint-contain-
ing products, what workup is most appropriate if
serological measurement of specific IgE to mint is neg-
ative?
A. Skin test to mint extract and obtain pre- and post-
lung function measurements on exposure to mint.
B. Patch test with menthol and peppermint to be in-
terpreted on day 5 (D5).
C. Ask patient about reactions to oregano, thyme, and
turpentine.
D. Refer patient for psychiatric consultation.
CLINICAL CHARACTERISTICS AND
PATHOPHYSIOLOGY
The literature reports infants and children with con-
tact dermatitis from menthol in peppermint.
3
Contact
allergens have been reported in toothpastes, which
often are mint-flavored.
4,5
Also, turpentine-induced
sensitivity to peppermint oil has been noted.
6
D5 patch
test reactions to menthol and peppermint are an avail-
able option.
7
Dental screening patch testing has been
validated.
8
Contact sensitivity to menthol and pepper-
mint has been reported in patients with intraoral
symptoms.
9
In addition, systemic reactions to ingestion of oreg-
ano and thyme are further related, because these and
mint belong to the Labiatae family.
10
Skin tests with
inhalants in a group of patients in one study were
positive to grasses and with plants of the Labiatae
From State University of New York at Stony Brook School of Medicine, Stony Brook,
New York
The authors have no conflicts to declare pertaining to this article
Address correspondence and reprint requests to Anthony M. Szema, M.D., Stony
Brook Allergy & Asthma, Stony Brook Medical Perk, 2500 Nesconset Highway, Suite
17A, Stony Brook, NY 11790
E-mail address: anthony.szema@stonybrook.edu
Copyright ©2011, OceanSide Publications, Inc., U.S.A.
Allergy & Rhinology 43
family, which comprises other plants such as mint
(Mentha piperita) as shown in Fig. 2. Thus, plants be-
longing to the Labiatae family seem to show cross-
sensitivity based on clinical history and in vitro and in
vivo test results.
10
Histamine release caused by pepper-
mint can also depend on nonimmunologic mecha-
nisms.
11
Allergic asthma from mint is less well recog-
nized.
DIAGNOSIS
In summary, this 54-year-old woman was symptom-
atic with dyspnea near peppermint and had a positive
skin-prick test to a commercial peppermint extract.
Mint exposure, as seemingly innocuous as Tic Tacs,
exacerbated her underlying asthma. Objective testing
pre- and postexposure to peppermint confirmed re-
duced lung function, suggesting the diagnosis of aller-
gic asthma triggered by mint, in this woman who may
have been sensitized by inhaling mint in her garden as
a child. Impulse oscillometry (IOS), a noninvasive mea-
sure of small airways impedance showed increased
airways resistance from an R5 of 2.2 at baseline, in-
creasing to 4.4. This patient should avoid mint expo-
sure and take albuterol metered-dose inhaler with
Aerochamber.
This case highlights the importance of testing with
multiple alternative measures of specific IgE to mint,
including skin testing with mint extract and skin testing
with fresh mint leaves. Additionally, this case suggests
that asthma can result from inhaling the scent of mint and
gives consideration to obtaining confirmatory pre- and
postexposure pulmonary function data by both IOS and
spirometry. This case also suggests that serological tests
Table 1 Spirometry pre- and postbronchodilator
Percent Predicted
Prebronchodilator
FEV
1
2.59 88
FVC 3.53 97
FEV
1
/FVC 73%
Postbronchodilator
FEV
1
2.69 92.3
FVC 3.44 99.6
FEV
1
/FVC 78%
FEV
1
forced expiratory volume in 1s; FVC forced vital
capacity.
Table 2 Pulmonary function testing pre– and
post–mint exposure (inhalation)
Pre–Mint
Exposure
(6/23/10)
Percent
Predicted
Post–Mint
Exposure
Percent
Predicted
FEV
1
2.46 2.46
FVC 3.31 3.31
FEV
1
/
FVC
74% 74%
IOS* R5
Hz
2.2 (nl) 66.5 4.41# 122
IOS R20
Hz
1.6 (nl) 77 2.8 (nl) 88
IOS X5Hz 13.03 2638 18§ 2506
*IOS after inhaling mint and skin prick test. IOS is a
noninvasive way to measure the respiratory system imped-
ance and reliably measures central and peripheral airways
resistance at different oscillation frequencies.
#R5 4.41–8 suggests mild small airways narrowing is
increased.
§X5Hz ⫽⫺18 abnormal suggests airway hyperresponsive-
ness.
FEV
1
forced expiratory volume in 1 s; FVC forced vital
capacity; IOS impulse oscillometry; nl normal.
Table 3 Testing for specific IgE
SPT
(wheal/flare)
In Vitro
Histamine 5/10
Saline 0/0
Fresh mint leaves 0/0
McCormick Pure
Peppermint
Extract*
5/10
Mentha piperita
(peppermint)
0.10 KU/L
*McCormick & Company, Inc., Sparks, MD.
Figure 1. Skin test to peppermint: Saline is labeled S to the far left
and is negative; histamine is in the middle and raised a 5-mm wheal
and 2-cm flare. Mint is to the right and raised a 5-mm wheal and
2-cm flare.
44 January–March 2011, Vol. 2, No. 1
for IgE to peppermint are less sensitive than skin-prick
testing.
MANAGEMENT
The patient was comforted by having obtained a defin-
itive diagnosis of her symptoms. Previously, she thought
that she was imagining her adverse reactions. It helped
alleviate tension between the patient and her colleagues
and led to the recommendation to take her albuterol
inhaler p.r.n. and avoid situations with exposure to mint.
As allergists/immunologists caring for children and
adults, we have the opportunity to recognize and prevent
adverse reactions from mint exposure. As the aforemen-
tioned case illustrates, these exposures may be previously
unrecognized sources of anxiety and morbidity.
Correct Answer to Question: A and C
Clinical Pearls
Allergic asthma can result from inhaling the scent of
mint.
Pre- and post-IOS may be more sensitive than spi-
rometry to assess acute small airways narrowing on
exposure to mint.
Skin testing with mint extract may be more sensitive
than specific serum IgE to mint.
D5 patch testing may determine if a delayed contact
dermatitis to mint is present but does not verify if an
immediate hypersensitivity reaction is present.
Lichenoid oral lesions have been reported with men-
thol mouthwashes.
9
Reactions to cross-reacting plants such as oregano
and thyme, as well as the chemical turpentine, may
clue in the clinician on the diagnosis of mint allergy.
Clinical Pitfalls
Other physicians dismissed the patient’s complaints
on exposure to mint and did not request skin testing.
Spirometry may be insensitive compared with IOS,
which is not widely available.
Gell-Coombs immediate hypersensitivity (type I) is
tested with the skin-prick test but Gell-Coombs type
IV is assessed with D5 patch testing.
Many dental products contain mint, and even asthma
medication Aerobid M (Forest Laboratories, New
York, NY) contains menthol.
ACKNOWLEDGMENTS
The authors thank Steven Spungen from CareFusion Corp. (Yorba
Linda, CA) for the generous use of a Jaeger Impulse Oscillometer/
Spirometer and exhaustive hands-on technical assistance.
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Figure 2. Peppermint. (Borrowed with permission courtesy of
White Flower Farm, Litchfield, CT.)
Allergy & Rhinology 45
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The present study summarizes information on toothpaste composition as supplied by the manufacturers. The survey covered 48 items, virtually all toothpastes offered for sale in Finland. It was concluded that the toothpastes are not entirely safe to use, because almost 50% of the products studied contained a total of some 30 compounds widely recognized as allergens. According to the literature, the most common allergens in toothpastes are flavours (e.g., cinnamic aldehyde, cinnamon oil and peppermint) and preservatives. Symptoms include stomatitis, cheilitis, glossitis, gingivitis, perioral dermatitis and immediate hypersensitivity.
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There are no cases described in the medical literature of systemic allergic reactions due to oregano (Origanum vulgare) or thyme (Thymus vulgaris). These herbs belong to the Lamiaceae (Labiatae) family which comprises other plants such as hyssop (Hyssopus officinalis), basil (Ocimum basilicum), marjoram (Origanum majorana), mint (Mentha piperita), sage (Salvia officinalis) and lavender (Lavandula officinalis). We describe three systemic allergic reactions caused by oregano and thyme in the same patient. Skin tests with inhalant allergens and plants of the Labiatae family were done. We used the prick by prick technique with dried commercial plants and prick tests with extracts prepared with the Frugoni method in our patient and in ten control patients. Total serum IgE was determined by Phadezym IgE PRIST (Pharmacia). Specific IgE was measured by two methods: CAP system (Pharmacia) and Phadezym RAST (Pharmacia Diagnostics, Uppsala, Sweden) with activated discs of the allergenic extracts that were prepared in our laboratory. Skin tests with inhalants were positive to grasses. Skin tests with plants of the Labiatae family were positive in all cases when the skin prick technique was used; tests were negative with basil and lavender, and positive with all the others when we used the prick by prick technique. We did not detect any positive skin tests nor specific IgE to plants of the Labiatae family in control patients. Total serum IgE was 406 U/mL. Specific IgE was detected to all herbs tested; higher levels were obtained with the CAP system. Plants belonging to the Labiatae family seem to show cross-sensitivity on the basis of clinical history and in vitro and in vivo test results.