Q:

1/20/2013
54 year old black female with asthma and allergic rhinitis.
Patient uses Advair bid and Singulair, has Albuterol for rescue. Rarely uses Albuterol. Last po steroid burst 14 months ago.
She is occasionally using Flonase and po antihistamine.
Patient states if she is in an environment where oranges or lemons have been peeled or cut the smell will trigger asthma, nasal congestion and sneeze. Albuterol inhaled and Benadryl help decrease the symptoms. She can eat peeled and then washed fresh orange with no reaction, she can drink lemonade, tea with fresh lemon with no reaction. Is there something in the peel of the orange and lemon that is triggering symptoms? Should I suggest an Epi pen? I have suggested she avoid areas where oranges and/or lemons are being peeled or cut. Thank you.

A:

Thank you for your inquiry.

Asthma due to the inhalation of the peels of citrus fruits has been described a number of times in the literature. I have copied some of the references for you below, and a link to one of the references which you can download free of charge is also copied below.

The most commonly described agent responsible for asthma in this circumstance is pectin. However, asthma has been thought to be due to enzymes in peels as well.

Pectin has also caused anaphylaxis (as you can see by the Annals of Allergy reference cited below). So, theoretically, your patient could be at risk for anaphylaxis, but in my opinion this would be extremely unlikely. I cannot give you a definitive answer as to whether or not you should prescribe an automatic epinephrine injector; you would need to make a judgment based upon your assessment of the severity of this patient’s previous reactions and her ability to avoid future exposures.

Thank you again for your inquiry and we hope this response is helpful to you.

Occupational asthma caused by pectin inhalation during the manufacture of jam.

A J Cohen; M S Forse; S M Tarlo
Chest. January 1993;103(1):309-311. doi:10.1378/chest.103.1.309

Ronald M. Ferdman, Annals of Allergy, Asthma & Immunology Volume 97, Issue 6, December 2006, Pages 759–760

Asthma caused by occupational exposure to pectin.
Jaakkola MS, Tammivaara R, Tuppurainen M, Lahdenne L, Tupasela O, Keskinen H.
J Allergy Clin Immunol. 1997 Oct;100(4):575-6. No abstract available.

Pectin-induced occupational asthma.
Baldwin JL, Shah AC.
Chest. 1993 Dec;104(6):1936-7.

Sen et al: Occupational asthma in fruit salad processing. Clinical & Experimental Allergy. Volume 28, Issue 3, pages 363–367, March 1998
Background: Three subjects employed in the preparation of fruit for fruit salads reported work-related respiratory symptoms. Their work entailed removing the peel from citrus fruits, primarily oranges, following soaking of the fruits in a bath of enzymes including fungal derived pectinase and glucanase.
Objectives: To investigate the respiratory symptoms reported by these workers and determine their causes.
Methods: The three workers were investigated by a respiratory physician, including spirometry and serial peak flow measurements. Blood was taken for the measurement of IgE and IgG antibody responses against the enzyme solution.
Results: Predominant symptoms in these workers were shortness of breath, chest tightness and wheezing which were all alleviated at weekends and holidays only to occur when returning to work. Serial peak flow measurements showed a clear work-related pattern. All three had strong IgE responses to the enzyme solution used at the workplace and showed distinct patterns of binding in immunoblots. All three improved immensely following withdrawal from the workplace environment.
Conclusion: Enzymes appear to be widely used in the preparation of fruit and although they are used in liquid form, exposure can occur to induce immunological sensitization and asthma.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology