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Occupational protein contact dermatitis from lettuce

Case Report A 25-year-old woman, with no personal or family history of atopy, started work in a supermarket, handling fruit and vegetables. After 6 months, she developed pruritic erythematous papules and subsequent excoriated eczema on the fingers, forearms and face, which flared up after lettuce contact. Her symptoms diappeared on sick leave and recurred on return to work. On examination, there was mild erythema on the fingers. Total IgE was normal at 95 KU/1. Extracts were prepared separately from crushed fresh lettuce leaves, stems and the milky sap exuding from cut stems, and from other crushed fresh salad plants of the Compositae family (endive, chicory and artichoke). After centrifugation (3000 g for 10 min), the supernatants were sterilized through 0.22 J.l.m Millipore filters (Millipore Corp., Bedford, Mass.). Skin prick tests (SPT) with all the above extracts, and with a series of common inhalants and food allergens (Bencard, Worthing, UK) were positive to all salad plants of the Compositae family and Phleum and Lolium pollens (wheal ~ 3 mm larger than control). Rub tests on the patient's forearm with lettuce milky sap, crushed fresh endive and artichoke all gave positive wheal-andflare reactions at 15 min. All such skin tests with salad plants were negative in 10 atopic and 10 non-atopic controls. Closed patch tests with all the above extracts and the GEIDC standard series were negative. Histamine release tests (HRT), by automated fluorometry (1) with modifications (2), with 4, 5 x dilutions of salad plants (lettuce leaf, stem and milky sap, endive, chicory, artichoke) and pollen extracts (Lolium, Phleum) were positive ( > 10% of histamine release). A CAP assay to lettuce (Pharmacia Diagnostics, Uppsala, Sweden) was negative. To detect specific IgE against antigens not commercially available (lettuce leaf, stem and milky sap, endive, chicory and artichoke), cellulose paper discs activated with BrC = N were coupled with our own extracts by 48-h incubation, with shaking, at room temperature. Discs were washed 3 x in phosphate-buffered saline (PBS) 0.1% Tween 20 (PBS-TW). 1% bovine serum albumin (BSA) in PBS was then added and the discs incubated for 1 h at 24°C. A RAST assay by ! 125-labelled anti-IgE (Pharmacia: results in PRU/ml derived from the Phadebas RAST reference system) detected specific IgE only to lettuce milky sap (1.9 PRU /ml). RAST inhibition assays followed: 20 f.l.l of serial dilutions (1:1, 1:10, 1:1.00 v/v) of the inhibitor allergen (lettuce milky sap, chicory, artichoke, Lolium pollen), and 20 f.ll of PBS as control, were incubated with 50 111 serum for 1 h at 24°C as liquid phase, discs of our own milky sap extracts being added as solid phase. After a 3-h incubation, assay was continued by standard RAST (Pharmacia),% RAST inhibition being expressed as 1(cpm test sample/cpm PBS control) x 100%. Lettuce milky sap, chicory, and Lolium pollen extracts all inhibited dose-dependently the binding of specific IgE to lettuce milky sap allergens bound to the discs. No inhibition was observed with artichoke. These in vitro tests were all negative in 5 atopies and 5 non-atopies.