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Letter
Safety of chitosan processed wine in shrimp allergic patients
Wine is an ubiq uit ous product all o ver the world, but up to 1 in 10
consumers reports intoler ance or allergy-like symptoms after drinking
wine.
1
Chitosan is a linear polysaccharide and the product of the
deacetylation of chitin, the main component of the cell walls of some
fungi; the exoskelet ons of arthropods, such as crustaceans and insects;
and the beaks of cephalopods.
2
It also may be used in wine processing.
Concerns have been raised that wines processed with chitosan
could trigger reactions in patients with seafood allergy. Neverthe-
less, biological plausibility is scarce. Major allergens involved in
shrimp allergy are muscle proteins, although some minor allergens,
such as arginine kinase, which was found to be clinically relevant,
have been found in shrimp shells.
3
The chitosan isolation procedure
is expected to remove all proteins and contaminants. Fear of
ingesting a shellsh-derived product may lead to unnecessary
avoidance of wine produced with chitosan lms.
Recently, anaphy lactic reaction to
a
-1,3-galactose has been iden-
tied.
4
Chitosanisstructurally differentfrom
a
-gal becauseitisa linear
cationic (1/4)-2-amino-2-deoxy-
b
-
D
-glucan. There is only one case
report of an immediate anaphylactic reaction with health food (fungi-
derived) chitosan ingestion, with documented sensitization by skin
prick tests.
5
Shrimp-derived chitosan has been given the classication
of generally recognized as safe (GRAS) by the US Food and Drug
Administration (FDA) in 201 2.
6
Moreover, evidence supporting this
classication is limited by the lack of inclusion of individuals with
shrimp allergy and the absence of food challenges. To our knowledge,
no previous studies have evaluated the safety of chitosan as a food
additive in shrimp allergic patients. Therefore, we aimed to assess the
safety of chitosan processed wine in shrimp allergic patients.
This double-blind, placebo-controlled trial was registered at
ClinicalTrials.gov (NCT02151279). Adults (18e65 years) with evi-
dence of IgE-mediated sensitization to shrimp and a history of
anaphylaxis to shrimp and/or a positive oral challenge result to
shrimp were selected. Participants were recruited from the food
allergy unit of an allergy department of a university hospital.
A control group of 6 healthy, nonatopic, nonefood allergic in-
dividuals were invited to participate. All individuals included in this
study were regular consumers of wine and were asked to avoid
alcohol ingestion for at least 3 days before the challenge. Nineteen
individuals were enrolled, including 13 with anaphylaxis to shrimp
(Table 1) and 6 healthy controls.
Skin prick-to-prick tests with wines were performed, as well as a
double-blind, placebo-controlled challenge with both wines (with
and without chitosan) in all participants. The challenges were per-
formed on the same day, separated by at least 2 hours. Successive
increasing doses were administered in 4 steps with 15-minute in-
tervals up to a total of 100 mL of each wine during each challenge. On
completion, participants were observed for 2 hours, and, in case of
any delayed reaction, participants were instructed to contact the
investigators. The research ethicscommittee,Comissão de Ética para
a Saúde do Centro Hospitalar São João e Faculdade de Medicina da
Universidade do Porto, approved the study, and signed informed
consent was obtained from all participants.
The wines processed with chitosan-based lms (active chal-
lenge) and the wines conserved with sulfur dioxide were indistin-
guishable in color, smell, or taste, at least for nonsommelier study
participants. After fermentation, instead of using sulfur dioxide for
wine preservation, chitosan lms cross-linked with genipin were
immersed in the wine in a proportion of 60 cm
2
/L of wine.
7
A positive skin test result was dened as the presence after 15
minutes of a wheal mean diameter of 3 mm or larger than that eli-
cited by the negative control accompanied by erythema. Positive
(histamine, 10 mg/mL) and negative (saline solution) controls were
also included. During challenges, occultation was performed by an
ombudsman, and each wine was placed in identied equal
containers. The randomization codes were packed in sealed, non-
transparent envelopes that remained closed until the end of the
study. Only 1 shrimp allergic participant had positive skin prick test
result to both wines. All the other participants had negative skin test
results to both wines. None of the 13 shrimp allergic patients and
none of the control participants had immediate- or late-phase re-
actions to any of the wines. No subjective symptoms were reported;
therefore, no medical intervention was necessary.
Our study found thatwine processed withchitosan-based lms as
a preservative agent may be safely consumed by shrimp allergic in-
dividuals. We selected patients with severe shrimp allergy, and all of
them tolerated this wine; consequently, it is unlikely that individuals
with a similar history of allergic reactions or mild allergic reactions
would react to this type of wine. To our knowledge, this is the rst
study to evaluate the safety of seafood-derived chitosan in shrimp
allergic patients, using double-blind, placebo-controlled challenges.
W e also found that the isolated use of skin testing is insufcient for
diagnosis. One patient had positive skin test results to both wines. Skin
prick t esting with nonstandardized matrices, such as wine, can be
associated with nonspecic testing, as previously described for orange
juice.
8
However, there was no clinical signicance of the positiv e skin
test results because the oral challenge result was negative. Another
strength is that our sample only included patients with anaphylaxis to
shrimp. This decreases the concern that reactions may occur only in a
dose-dependent manner and reinforces the statement of the FDA that
chitosan is GRAS, even in patients with severe shrimp allergy.
Chitosan is considered to be a nontoxic and nonallergenic
material that is suitable for use in medical and pharmaceutical
applications.
9
Furthermore, it has been tested as topic bandages in
shellsh allergic patients, and no adverse reactions were
reported.
10
Our study contributes to overcome the paucity of data
regarding the patients with shrimp allergy. Furthermore, evidence
that sulte-free chitosan-treated wines are also a safe alternative
for shrimp allergic patients broadens its use.
Disclosures: Authors have nothing to disclose.
Contents lists available at ScienceDirect
http://dx.doi.org/10.1016/j.anai.2016.02.004
1081-1206/Ó 2016 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Ann Allergy Asthma Immunol xxx (2016) 1e2
The number of included participants may be a limitation.
Nonetheless, all the participants had previous history of anaphylaxis
to shrimp and other seafood, and all of them had atopic comorbid-
ities, making them a particularly high-risk group. In conclusion, this
study indicates that wine treated with chitosan is unlikely to trigger
allergic reactions in patients with shrimp allergy.
Luís Amaral, MD
*
Diana Silva, MD
*
,
y
Mariana Couto, MD
y
,
z
Cláudia Nunes, PhD
x
Sílvia M. Rocha, PhD
x
Manuel A. Coimbra, PhD
x
Alice Coimbra, MD
*
André Moreira, MD, PhD
*
,
y
*
Serviço de Imunoalergologia
Centro Hospitalar São João
y
Faculty of Medicine of University of Porto
z
Allergy Unit
Hospital & Instituto CUF Porto
Porto, Portugal
x
QOPNA & Departamento de Química
Universidade de Aveiro
Aveiro, Portugal
luis.m.amaral@gmail.com
References
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January 13, 2014.
[7] Nunes C, Maricato É, Cunha Â, Nunes A, da Silva JAL, Coimbra MA. Chito-
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Table 1
Demographic and clinical characteristics of the shrimp allergic patients
Characteristics N (%)
Age (years), median IQR 34, [26e42]
Female 10 (77)
House dust mite sensitization 11 (85)
Atopic diseases 13 (100)
Allergic rhinitis 13 (100)
Asthma 5 (38.5)
Atopic eczema 2 (15.4)
Symptoms
Anaphylaxis 13 (100)
Cutaneous 13 (100)
Other
a
13 (100)
Time (years) since last shrimp allergic reaction, median IQR 2, [1e4]
Wheal size of skin prick test with shrimp extract, mean (sd) 6.1 (2.1)
Wheal size of skin prick-prick test, mean (sd) 9.4 (7.5)
Shrimp sIgE (kU/L), mean (sd) 12.5 (31.4)
Abbreviations: IQR, interquartile range; sd, standard deviation; sIgE, specic IgE.
Data is presented as number and percentage, except when otherwise stated.
a
Dyspnea, throat tightness, oropharyngeal pruritus, hypotension, vomit, abdominal
pain and diarrhea.
Letter / Ann Allergy Asthma Immunol xxx (2016) 1e22
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The use of chitosan films has been limited due to their high degradability in aqueous acidic media. In order to produce chitosan films with high antioxidant activity and insoluble in acid solutions caffeic acid was grafted to chitosan by a radical mechanism using ammonium cerium (IV) nitrate (60mM). Genipin was used as cross-linker. This methodology originated films with 80% higher antioxidant activity than the pristine film. Also, these films only lost 11% of their mass upon seven days immersion into an aqueous solution at pH 3.5 under stirring. The films surface wettability (contact angle 105°), mechanical properties (68MPa of tensile strength and 4% of elongation at break), and thermal stability for temperatures lower than 300°C were not significantly influenced by the covalent linkage of caffeic acid and genipin to chitosan. Due to their characteristics, mainly higher antioxidant activity and lower solubility, these are promising materials to be used as active films.
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This chapter focuses and reviews on the characteristics and biomedical application of chitosan and collagen from marine products and advantages and disadvantages of regeneration medicine. The understanding of the production processes of chitosan and collagen and the conformation of these biomaterials are indispensable for promoting the theoretical and practical availability. The initial inflammatory reactions associated with chitosan application to hard and soft tissues need to be controlled before it can be considered for clinical application as scaffold. Further, as chitosan takes too long for biodegradation in vivo, generally it is not suitable for the scaffold for degenerative medicine in especially dental pulp tissue. The collagen extract from the scales of tropical fish has been reported to have a degeneration temperature of 35°C. The properties of biocompatibility and biodegradation of fish atelocollagen are suitable for the scaffold in regenerative medicine.
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In 2005, the Office of the Surgeon General mandated that every soldier carry a HemCon bandage. Made from chitosan, a polysaccharide derived from shrimp shells, this bandage effectively stops bleeding. There are no studies reporting the safety of this bandage in shellfish allergic patients. Patients who reported shellfish allergy were recruited. Initial assessment included a detailed history, IgE skin prick testing (SPT), and serum testing to shellfish allergens. Participants who demonstrated specific shellfish IgE underwent a bandage challenge. Nineteen participants were enrolled; 10 completed the study. Seven (70%) were male and the average age was 44.8 + 10 years. Nine (90%) reported a shrimp allergy history and five (50%) reported multiple shellfish allergies. All participants completing the study had positive SPT and serum IgE testing to at least one shellfish; eight (80%) had shrimp positive SPT and ten (100%) demonstrated shrimp-specific IgE. No participant had a positive SPT to chitosan powder or experienced an adverse reaction during bandage challenges. No protein bands were visualized during gel electrophoresis analysis of chitosan powder. All participants tolerated the HemCon bandage without reaction. This is the first study demonstrating the safety of this bandage in shellfish allergic subjects.
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Oranges are suspected of inducing adverse skin reactions in patients with atopic eczema. We studied 21 adult patients with atopic eczema and a history of adverse reactions to oranges and 10 patients without. A dietary history, skin tests, serum IgE and oral provocation tests with oranges were obtained. Severity of eczema was monitored by SCORAD, and serum tryptase, eosinophil cationic protein and urinary methylhistamine were measured. No allergic reactions were found to orange in skin prick or patch tests. However, 23 patients (74%) had specific serum IgE to orange. Oral provocation testing resulted in pruritic eczematous or maculopapular skin lesions predominantly at the predilection sites in 16 patients (52%). The SCORAD increased significantly in patients positive to the oral provocation test (p <0.05). Specific IgE to orange did not correlate with the clinical outcome of the oral provocation test. No significant changes were found in serum mast cell tryptase, eosinophil cationic protein or in urinary methylhistamine excretion. The negative results in the skin tests and a lack of correlation between specific IgE and oral provocation tests indicate that non-IgE-mediated mechanisms are involved in cutaneous adverse reactions to oranges in patients with atopic eczema.
Article
Chitosan is a linear polysaccharide with about 10(5)-10(6) molecular weight existing in cell walls of zygomycetes. Chitosan decreases serum neutral fat and cholesterol levels and has dietary fiber action, and many products have recently been sold as health foods. Here, we report a case of immediate-type allergy for chitosan-containing health food with a review of the literature. The patient was a 47-year-old female person who developed systemic urticaria and difficulty in breathing after oral ingestion of chitosan. Since skin tests (prick test and scratch patch test) were positive, the test was done using another commercial chitosan, and was positive. The patient was diagnosed as having chitosan-induced immediately-type allergy, and was instructed to avoid ingestion of chitosan. The patient has developed no symptom thereafter. Regarding allergic reactions to chitin and chitosan, contact dermatitis induced by chitosan-containing cream has been reported from France and Portugal, but to our knowledge, there has been no report of immediate-type allergic reactions. Chitosan is a polysaccharide, not protein, but may have functioned as a food allergen because of its molecular weight and general properties.