Anaphylactic shock induced by Codonopsis lanceolata, traditional Chinese medicine in a patient with allergic rhinitis.

Codonopsis lanceolata (CL) contains various active components including tannins, saponins, polyphenolics, alkaloids, essential oils and steroids. Therefore, it has been prescribed as a traditional folk medicine to treat several inflammatory diseases (1, 2). To date, there have been no published reports of allergic reactions to CL. In this report, we present a serious anaphylactoid reaction following ingestion of CL roots in an 18-year-old student who had suffered from allergic rhinitis symptoms including runny nose, nasal itching, sneezing and nasal obstruction from childhood. He visited our clinic after he had experienced serious systemic reactions following the ingestion of raw CL roots. His symptoms included dizziness, sweating, chest tightness, angioedema and generalized urticaria. The results of a skin prick test (SPT) showed strong positive reactions to numerous common inhalants and food allergens including CL extract. The extract used was prepared in our laboratory as described previously (3). Results are expressed as the ratio of the mean wheal diameter of allergens to histamine: Dermatophagoides pteronyssinus, 5.0; birch, 3.5; mugwort, 9.12; carrot, 1.17; celery, 1.8; and CL, 2.0. Based on our SPT results, the patient may have mugwort–celery–carrot syndrome (4, 5). Although he was sensitized to other food allergens such as celery and carrot, he had never experienced any allergic reactions after ingesting celery or carrot roots. Enzyme-linked immunosorbent assay (ELISA) results showed high serum specific IgE level to mugwort pollen; however, specific IgE levels to CL, celery, and carrot root extracts were undetectable compared to 11 nonatopic healthy controls (data not shown). A basophil histamine release (HR) test was performed in order to further clarify the mechanisms regulating his response. We found that HR was remarkably increased when the patient s basophils were incubated with 15 lg/ml of CL extract (72.1%, Fig. 1). In contrast, minimal HR was noted in basophils from three normal healthy controls. Increased HR was also noted when the basophils were incubated with anti-IgE antibodies (69.57% at 10 lg/ml) and calcium ionophore (82.35% at 3 lM). An open oral challenge with CL root was also performed. The dosage of CL root began at 5 g and then was doubled until an allergic reaction occurred. Severe systemic reactions including hypotension (90/40 mmHg), chest discomfort, dyspnea, diaphoresis and generalized urticaria developed within 30 min following ingestion of 20 g of CL. Therefore, the patient was confirmed as having an anaphylactoid reaction due to CL root ingestion, probably through a direct histamine releasing mechanism. Codonopsis lanceolata belongs to the Family Campanulaceae. Mugwort is in the same family; therefore, the patient may be displaying cross-reactivity with mugwort pollen. However, when we performed an IgE-ELISA inhibition test using mugwort pollen as an antigen and CL extract as an inhibitor, no cross allergenicity was suggested (data not shown). Open oral challenge tests with 25 g of celery and 25 g of carrot showed negative responses. Therefore, we speculate that CL itself can lead to a severe Codonopsis lanceolata can induce severe food allergies, including anaphylaxis, through direct histamine releasing mechanisms.