The latex and food allergy connection
Judy E. Perkin
ABSTRACT
Natural rubber latex is used in the manufacture of many products in the United States. As natural rubber latex allergy becomes of increasing concern, dietitians need to have an understanding of this allergy and how it relates to workplace safety, employee health, and patient feeding and counseling. Natural rubber latex contains more than 35 proteins that may be related to Type I, Ig-E-mediated allergy in numerous segments of the population, including health care workers and patients. Many foods, especially chestnut, banana, and avocado, have the potential to cross-react with natural rubber latex. Chitinase enzymes, related to plant defense, are believed to be involved in this cross-reaction. A strong connection between food allergy and natural rubber latex allergy is recognized and described in this review. J Am Diet Assoc. 2000;100:1381-1384.
As natural rubber latex allergy becomes of increasing concern, it is critical that dietetics professionals have an understanding of this allergy. Dietitians need to be aware of the implications of latex allergy for workplace operations, employee health, and patient counseling and feeding. The link between natural latex allergy and food allergy is of particular concern to dietitians and will be highlighted in this review.
LATEX ALLERGY
Latex allergy, as commonly described, refers to allergy caused by natural rubber latex. Synthetic latex products do not appear to be problematic for those with natural rubber allergy [1]. Synthetic rubber latex is used in many products, such as latex house paints [1].
Natural rubber latex is the milky fluid cytoplasm of the Hevea. brasiliensis tree, which functions in the tree as a protective sealant [2-4]. Humans use natural rubber latex to make a wide variety of products [1,4]. Latex serves as a structural and functional alternative to materials such as plastic, silicone, and vinyl [4]. Natural rubber latex is found in a variety of health care products such as gloves, tubes, syringes, catheters, and tape [4]. It can also be a component of paints and is found in many household and yard supplies [4]. Latex condom use has also been promoted extensively in recent years to prevent a variety of sexually transmitted diseases, including infection with the human immunodeficiency virus [5]. According to a brochure from the American College of Allergy, Asthma, and Immunology (ACAAI) as many as 40,000 consumer products may contain natural rubber latex [1].
Natural rubber latex contains more than 35 proteins with allergenic potential [3]. Protein types most often associated with latex allergy manifestation include hevein (Hev b 6), rubber elongation factor (Hev b 1), Hev b 5, Hev b 7, Hev b 8, and latex particle proteins [3,6,7]. Latex allergen content may vary widely even in the same product. Yunginger et al [8] report a variance of 3,000 fold for latex content in gloves obtained from 10 separate manufacturers. These same researchers also noted that latex content in surgical and chemotherapy gloves was lower than that of examination gloves.
Latex allergy has become an increasing concern in recent years for certain occupational groups, patients with high exposure to latex products, and for the general public including the pediatric population [9-17]. The potential for allergy to latex in rubber was described in 1979 in a case study involving a 34-year old woman who experienced urticaria related to wearing rubber gloves [18].
Recent government information indicates that 8% to 12% of health care workers and 1% to 6% of the general population are sensitized to latex [19]. Another recent publication notes that the prevalence rate for natural rubber latex allergy among health care workers may be as high as 17% [12]. Current statistics also indicate that 3.7% to 8% of rubber industry workers and 18% to 37% of various patient populations are also allergic to natural rubber latex [20]. Children with spina bifida have been identified as a particularly high risk group for acquiring latex sensitivity [13,14]. History of atopy and atopic dermatitis have also been associated with both the occurrence of latex allergy and the combination of latex and food allergy [7,21]. Prevalence rates for latex allergy remain a source of controversy and are variable from study to study. For a thorough review of latex allergy prevalence studies and methodological issues, see Liss and Sussman [9].
Gloves are a major source of latex exposure for health care workers. It has been noted that latex glove use by health care workers increased significantly with the initiation of Universal Precautions [1]. According to the ACAAI, glove imports into the United States increased 247% between 1991 and 1996 [1]. If latex gloves must be used by health care workers, the National Institute of Occupational Safety and Health (NIOSH recommends the use of reduced-protein, powder-free gloves [19]. Powdered latex gloves are not recommended because powder can become airborne and act as a carrier for latex proteins [11,19]. Processing methods for latex gloves that reduce potential latex protein allergenicity are: water soaking, water washing, and chlorination [10,22]. Recent research has examined the cost of a “latex safe” environment for health care institutions. This research defines “latex safe” as meaning “the use of nonlatex gloves.” (12, p 1024).
NIOSH recommends the use of nonlatex gloves for persons preparing foods [19]. Schwartz [23] has reported 2 cases of latex allergy in fast food consumers in which the source of the reaction was latex in gloves worn during foodservice preparation and/or foodservice. Franklin and Pandolfo [24] have also reported an association between food worker use of latex gloves related to stirring juice and clinical reaction in a patient who were sensitive to latex. Another report has visualized and quantified transfer of latex protein to cheese and lettuce when latex gloves were used [25]. In addition to the foodservice area, Erick [26] has noted that dietetics professionals also need to be alert to the potential for natural rubber latex exposure related to equipment associated with both parenteral and enteral formula feeding.
Some persons exhibit immunological sensitivity to latex upon testing but do not exhibit clinical symptoms. Others demonstrate latex sensitivity both immunologically and clinically. Clinical symptoms of natural rubber latex allergy include: rhinitis, erythema, urticaria, asthma, angioedema, dysphonia, nausea, vomiting stridor, hypotension and anaphylaxis [1,2,27].
Latex rubber gloves can cause other clinical reactions that may be confused with Type I, IgE-mediated natural rubber latex allergy [10,17]. These clinical reactions include an irritant dermatitis and a Type IV allergic reaction related to glove additives such as chemical accelerators [10,17]. Irritant dermatitis can appear as dry, cracked skin potentially accompanied by pruritis. Irritant dermatitis on the hands can be associated with numerous factors. Examples include: overexposure to water, chemical exposure, or exposure to environmental conditions favoring skin dryness [10]. The Type IV allergic reaction is delayed in onset (12 to 36 hours after exposure) and is characterized by skin abnormalities such as “redness, itching, swelling, and blistering” (10, p 62).
Casein from cow’s milk used as a rubber latex glove additive may cause contact urticaria in persons allergic to this protein. The addition of casein to rubber gloves may also cause persons to falsely skin test positive to natural rubber latex [28].
THE LATEX-FOOD ALLERGY CONNECTION
It has been recognized that in some persons there is a link between latex allergy and food allergy. Erick (26, p 793) has referred to this as the “latex diet syndrome.” Patients with latex allergy need to be evaluated and, if appropriate, counseled related to diagnosed food allergies. It has been recommended that patients allergic to natural rubber latex be tested to assess potential sensitivity to foods commonly associated with natural rubber latex allergy and also to foods associated with tree or grass pollen allergy [29]. The rationale for this recommendation is that pollen-associated atopy, which is also related to food allergy, is believed to coexist with natural rubber latex allergy in some cases [29]. Patients with certain food allergies may also need assessment and counseling related to potential or diagnosed latex allergy.
Some have estimated that as many as 50% to 70% of persons with latex allergy also have IgE antibodies to some foods, such as fruits, vegetables, nuts, and/or grain [30]. The latex allergy- food allergy connection is believed to be the result of cross-reacting proteins between foods and natural rubber latex. Considerable research is being undertaken to define the proteins involved in these corss reactions.
Current research would implicate the involvement of chitinases. Chitinases are enzymes involved in plant defense systems [31]. They are hydrolytic enzymes that work to break down chitin, which is a structural component of insect exoskeletons and cell walls of fungi [32,33]. There appear to be benefits of these enzymes to plants that may result in increased crop yield. These enzymes have protein domains similar to those in natural rubber latex and these appear to be causative in terms of cross-reactions with foods [30,31,32,34-43]. One author has indicated that allergenic potential needs to be considered when engineering food crops to have increased chitinase levels [43].
One study of 137 patients with rubber latex allergy [44] found that 21.1% also had allergies to foods. Foods to which patients in that study were allergic included banana (18.3%); avocado (16.3%); shellfish (12.2%); kiwi fruit (12.2%); fish (8.1%); tomato (6.1%), and watermelon, peach, and carrot (less than 5% each) [44]. Other individual food sensitivities were also noted in this study [44]. Beezhold, Sussman, Liss, and Chang [45] reported positive skin tests in persons with latex-sensitivity to the following foods; avocado, potato, banana, chestnut, kiwi fruit, and tomato. Conversely, GarciaOrtiz et al [20] studied fruit-allergic patients and found latex sensitization in 49 of 57 (86%) compared to latex sensitization in only 2 of 50 controls (4%). Fruits most commonly associated with clinical symptoms of allergy in this study were muskmelon, watermelon, peach, banana, cherry, and pear. Some subjects with latex sensitivity in this study also had evidence of allergy to other foods such as almond, hazelnut, s unflower seeds, and walnuts [20].
Chestnut, banana, and avocado have been some of the most studied foods with regard to potential cross-reactivity with latex [1,7,21,34-45]. Diaz-Perales et al [37] have isolated Class I chitinases with a hevein-like domain from chestnuts and avocado and believe these to be the allergens involved in producing symptoms in latex-sensitive patients consuming these foodstuffs. Research by Posch et al [41] has associated Class I chitinases and their hevein domain with avocado and natural rubber latex-linked allergies. Blanco et al [34] studied 18 subjects with latex-sensitivity who were either allergic to chestnut or avocado or both. Chestnut class I chitinase evoked a positive skin prick test in 13 of the 18 subjects and avocado class I chitinase evoked a positive skin prick test in 12 subjects. Chen et al [35] implicated hevein as the cross-reacting allergen in latex that interacts with avocado, Chen et al [35] also found seropositive IgE avocado antibodies in a high percentage of persons in 2 study groups–118 health care workers and 78 spina bifida patients both with latex allergies. These IgE avocado antibodies were significantly associated (P[less than].001) with hevein-specific IgE antibodies in these populations. Sowka et al [43] identified a 32-Kda avocado allergen called Prs a 1, which was recognized by 15 to 20 avocado and/or natural rubber latex sensitive patients. The Prs a 1 avocado allergen demonstrated cross-reactivity with latex proteins, especially a 20-Kda allergen believed to be prohevein. In this study, the avocado and latex allergens were cited as being 70% alike in terms of the domains that were chitin-binding [43].
Mikkola et al [39] found that 9 out of 15 serum samples from patients allergic to latex with IgE to hevein also showed IgE binding to 32 and 33 Kd banana proteins. These researchers reported that the hevein-like domain of endochitinase in banana was responsible for cross-reaction. Sanchez-Monge et al [42] also identified Class I chitinases with hevein as being the agents in banana responsible for cross-reactivity with latex. In an earlier case study involving a nurse with latex-sensitivity working in a surgical intensive care unit, it was demonstrated by radioallergosorbent testing that banana extract could inhibit binding of latex-specific IgE to solid phase latex in a dose-dependent fashion (r=0.97) in persons with latex sensitivity [40].
In addition to chestnut, avocado, and banana, other foods have been implicated as being potentially cross-reactive with natural rubber latex and therefore capable of causing a Type Imediated food allergy. Potato and tomato have also been noted as potentially cross-reactive. It is postulated that patatin, a storage protein with structural similarity to rubber latex proteins, may be involved in these cross-reactions [45,46]. Kiwi fruit containing a 43 Kda allergen may also cross-react with latex [38]. Cross-reactivity between latex and sweet pepper has also been reported. These researchers noted a potential link with prohevein [47]. Before that report, a case study of a 23-year old nurse sensitive to pepper was published [48]. Cross-reactivity has also been noted between buckwheat and rubber latex. This cross-reactivity may be of importance, according to the authors, because of the use of buckwheat flour in many health food products [49]. Papain is extracted from the latex of the papaya tree and is not only us ed in food processing procedures, such as clarifying beer or tenderizing meat, but is also used in drug and beauty products [50]. One study demonstrated that papain extract caused positive skin prick tests reactions in 18 of 30 persons with latex sensitivity [50].
Foods commonly cited as being potentially cross-reactive with natural rubber latex are shown in the Table. Other foods or food products implicated as being cross-reactive with latex include dill, peaches, plums, cherries, hazelnut, sage, melon, celery, mango, carrot, apple, pear, papaya, oregano, almonds, ginger, and bromelin from pineapple [1,26,51,52]. The ACAAI asserts that cross-reaction with citrus, coconut, condurango bark, mango, passion fruit, peanut, peppers, and fig are rare [1]. Condurango bark is sold as an herb and is purported to have diuretic effects and medicinal properties [53]. Kumar [16] also notes that cross-reaction with apricot is rare. Numerous other vegetables, pollens, and plants have been listed as being potential or suspected as being rubber latex cross-reactive [26,30]. Further, a recent report cited the potential of jelutong sap (a natural chewing gum base) to be cross-reactive with natural rubber latex [54]. Common food allergens such as soybean and peanut have been listed as be ing associated with natural rubber latex allergy in the category of “low or undetermined” association (26, p 793).
In some instances, the coexistence of natural rubber latex allergy and food allergy may simply represent separate allergies in an atopic person and may not be the result of cross-reaction. The presence of food proteins in nonfood products and potential cross-reaction with natural rubber latex should also be noted. One case study has been reported involving a 42-year old woman where angioedema seemed to be provoked by natural rubber latex, banana, and banana hair conditioner [55].
APPLICATIONS
* Natural rubber latex allergy has numerous implications for dietetic practice. Latex products may be used in the delivery of dietetic services, and therefore appropriate precautions or product substitutions need to be made to accommodate those who have natural rubber latex allergies. Questioning and record-keeping with regard to latex allergy should occur with both employees and patients to ensure that appropriate and effective safety measures are instituted. Latex allergy information should be covered in institutional safety courses.
* Dietitians need to be alert to the potential for patients with natural rubber latex allergy to be allergic to foods that have cross-reacting proteins, such as avocado, banana, and/or chestnut. Nonfood products that contain cross-reacting food proteins may also be problematic.
* Dietitians need to be alert to the potential for natural rubber latex sensitivity in patients with food allergies, particularly allergies related to fruits or vegetables.
* Dietitians may assist physicians by diagnosing and defining the relationship between latex and food allergies in patients and being actively involved in counseling these patients with regard to dietary avoidance and nutrient supplementation, as appropriate.
J.E. Perkin is associate dean and an associate professor in the College of Health, University of North Florida, 4567 St Johns Bluff Rd, South, Jacksonville, FL 32224-2645.
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