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Effective treatment of refractory severe heat urticaria with omalizumab

and lactose. The total IgE level was 46 kU/l (<100 kU/l) (Pharmacia ImmunoCAP, Phadia, Sweden). Specific IgE to common seasonal or perennial allergens, to maize and latex was not detected. The skin prick test for major food allergens was negative. We then performed prick to prick testing of the tablets she was working with. Positive reaction was found for ASA tablets from her and a competing drug company. Excipients were identical for both tablets. Testing of 10% pure ASA in 20 g glycerin was negative. An allergy to the tablet coingredients was then suspected, especially to its maize components. A type I sensitization to maize bran was detected by skin prick test, then by intracutaneous tests for maize bran and flour. Spirometry showed a light obstructive syndrome, and metacholin provocation confirmed a bronchial hyperreactivity at 4 mg/ml of metacholin. Nasal provocation test with maize bran revealed a strong positive reaction with sneezing, conjunctival injection and pruritus of the nose and eyes after 6 min. Moreover, the nasal flow diminished from 70 to 35 l/min after 10 min. Western blot of maize flour incubated with patient serum showed a marked band at 50 kDa (Fig. 1) possibly matching the reduced soluble protein allergen of the maize endosperm (3). These findings suggest that our patient developed her maize allergy during occupational exposure by airway and cutaneous contact to the allergen. Although maize starch consists almost exclusively of carbohydrates it may contain 0.3–1% protein, whereas flour contains about 7–13% protein. As maize starch particles measure 5–10 lm in diameter, they can easily be inhaled. Allergic respiratory reactions to inhaled maize dust in exposed workers and anaphylactoid reactions with contact urticaria because of maize starch in exam or surgical gloves have been described previously (4, 5). To our knowledge, this is the first report of maize as an occupational allergen in tablet manufacturing. Our data suggest that patients working in tablet manufacturing and presenting occupational allergy symptoms should be tested for sensitization to drug excipients in particular maize starch.