Mango
Summary
Mango (Mangifera indica) is part of the Anacardiaceae family and grown worldwide. There are many different cultivars, which vary in appearance, flavor and uses. Peel and flesh of the fruit are the main sources of hypersensitivity and allergic reactions, though pollen may also be implicated in allergies. A large number of mango allergens have been described.
Immediate hypersensitivity is a common clinical presentation of mango allergy, with symptoms ranging from localized to systemic, including anaphylaxis. Pollen-food allergy syndrome (PFAS) and one of its common presentations, oral allergy syndrome (OAS) may be experienced. Contact dermatitis is also a known clinical presentation of mango allergy. Cross reactivity with a number of other plant food and pollen allergens can occur.
Epidemiology
Worldwide distribution
Mango allergy has been reported in many countries, from where mango is grown and also from other countries that import the fruit.
Risk factors
Male patients and adults (19–60 years old) might be at higher risk of mango sensitization. Preschool age children may also be at higher risk of mango hypersensitivity than younger children.
Exposure during the spring season and suffering from eczema increased the risk of anaphylaxis to certain fruits, including mango.
Previous sensitization to urushiol (found in poison ivy and poison oak) increases the risk of hypersensitivity contact reactions to mango peel. In addition, working as mango pickers (if having a history of contact with, or living in areas where poison ivy and poison oak are endemic) may be a risk factor for developing mango contact dermatitis.
Route Of Exposure
Main
Ingestion of the fruit, contact with the peel.
Clinical Relevance
Immediate hypersensitivity is a common clinical presentation of mango allergy. This can be localized or show systemic symptoms, including anaphylaxis. Patients may present with a combination of the following: erythema and urticaria, angioedema of the face or extremities, rhinorrhea and rhino-conjunctivitis, dyspnea/respiratory distress, cough, gastrointestinal symptoms. Anaphylactic shock may present within few minutes of mango ingestion. In a study of 250 patients referred to hospital with fruit-induced anaphylaxis, 9.2% of cases were caused by mango. Approximately 10% of patients experienced severe reactions, 15% had mild reactions and the remaining presented with moderately severe reactions.
Testing of specific IgE in a 30-year old woman with history of seasonal rhinitis showed that this patient is multi-sensitized to a number of plant allergens; however, the only severe anaphylactic reaction experienced until then was following mango ingestion. It was suspected that the symptoms may be due to cross-reactivity with mugwort antigens.
Allergic rhinitis
Although most patients experience mango allergy after ingestion of the fruit, mango tree pollen was shown to be a sensitizing agent in 16% of patients with allergic rhinitis. In another study, asthma/allergic rhinitis (AR) patients showed hypersensitivity to mango allergens, as shown by IgE specificities.
Other diseases
Contact dermatitis (type IV delayed hypersensitivity response) to mango peel was the cause of the diffuse, macular, blanching, erythematous and pruritic rash presented by a 41-year old patient two days after handling mangos. He reported a remote history of contact dermatitis to poison ivy. Periorbital edema, eczematous rash and blisters around the mouth, alongside contact dermatitis, have also been described following exposure to mango.
Allergic conjunctivitis (AC) was the topic of a study which showed preschool children with this condition were significantly more likely to present with mango (and other foods)-specific serum IgE than younger age groups.
OAS (considered a manifestation of pollen-food allergy syndrome PFAS), consisting of IgE-mediated allergy symptoms limited to the oral cavity, is another presentation of mango allergy.
Diagnostics
Testing for food allergies involves measuring serum specific IgE responses, skin prick tests (SPTs) and oral challenges. In a study of 309 patients with known history of asthma AR, specific allergen IgE testing showed that 14.5% of serum samples reacted to mango allergens.
In another study of a 100 patients suffering from AR, 16% has positive SPT to mango tree pollen. Other researchers analyzing food-specific IgE responses in 1795 patients of all age groups showed that mango elicited moderate to high positivity (42.8% and 28.6% respectively). A large study, in China (Henan Province) recruited 15,534 patients after analysis of their medical records. A patient would be included if they had experienced symptoms suggestive of allergies such as skin rash, hives, eczema, runny nose, red or itchy eyes, sneezing and shortness of breath. The results showed mango sensitization in 4.94% of samples, as determined by the presence of specific IgE.
Prevention And Therapy
Allergen immunotherapy
Mangiferin (a polyphenol present in different tissues of the mango tree) showed antioxidant, anti-inflammatory and anti-allergic effects in a murine model of AR, by reducing nasal inflammation. This suggests that mangiferin might be a suitable candidate for the treatment of human AR.
Prevention strategies
Avoidance consists of eliminating mango from the diet, once accurately diagnosed to avoid unnecessary diet restrictions.
Cross-Reactivity
Cross-reactivity between members of the Anacardiaceae family has been reported.
A study of 18 children with pistachio and/or cashew nut allergies (both Anacardiaceae) showed that mango was well tolerated in food challenges, suggesting elimination diets may be unnecessary.
In a larger study, initial results suggested that 21% of cashew allergic patients (up to 52% with a history of eczema, asthma or AR) had mango hypersensitivity; the follow-up study carried out open food challenges with mango which did not elicit any clinical reactions. In another study, 50% of patients with specific IgE to cashew nut showed cross sensitivity to pistachio, mango, pink peppercorn or sumac.
Cross reactivities with other plants pollens have also been discussed in the context of pollen-food allergy syndrome (PFAS), especially birch-mango. Mugwort pollen, celery and carrot have also been associated with mango cross-reactivity, due to allergens related to Bet v 1 (birch) and Art v 1 (mugwort) and birch profilin Bet v 2. The pan-allergen hevein (present in latex) is known to cause cross reactions with certain allergens present in a number of common foods such as banana, avocado, kiwi, tomato, wheat, mango, chestnut, peach, orange and passion fruit.
Cross-reactivity between mango peel and poison ivy/poison oak (also of the family Anacardiaceae) has been reported.
References
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