Macrolide hypersensitivity is a rarely reported event. Carmine dye has become increasingly important as a provocative agent for allergic reactions.Carmine, also called Crimson Lake, Cochineal, Natural Red 4, C.I. 75470, or E120, is a pigment of a bright red color obtained from the carminic acid produced by some scale insects ("beetle juice"), such as the cochineal and the Polish cochineal, and is used as a general term for a particularly deep red color.
Carminic acid. Image source: Wikipedia, public domain.
This is a case report of a woman with documented carmine hypersensitivity, who reported anaphylaxis 90 minutes after ingestion of a generic azithromycin. She had not problems with the brand name Zithromax taken on previous occasions.
The cause of anaphylaxis was an allergy to the carmine dye in the tablet's coating rather than to the antibiotic (azithromycin).
Azithromycin. Image source: Wikipedia, public domain.
Seven extracts were prepared including carmine dye, crushed dried female cochineal insects, crushed tablets of Zithromax (Pfizer Inc.) and generic azithromycin (Teva Pharmaceuticals), and the crushed colored coatings from both tablets. The exctracs were dissolved in normal saline, and then applied as a skin-prick test and read at 30 minutes.
The skin-prick skin test results were 4+ to histamine and carmine dye, but negative to cochineal insect extract, Pfizer crushed tablets, and negative control. The patient was 1+ to the Teva crushed tablet, but was 4+ to the Teva brand coating and negative to the Pfizer brand coating, which did not contain carmine.
The patient subsequently ingested Pfizer Zithromax without any sequelae.
According to the authors, this is the first reported case of carmine anaphylaxis attributed to carmine-containing medication.
References:
Carmine hypersensitivity masquerading as azithromycin hypersensitivity. Greenhawt, Matthew1; McMorris, Marc; Baldwin, James. Allergy and Asthma Proceedings, Volume 30, Number 1, January/February 2009 , pp. 95-101(7).
Testing for red coloring agents added to foods - AAAAI Ask the Expert, 2011.
The data suggests an extremely rare occurrence of azithromycin allergy http://goo.gl/6fZHL
Q&A: How can I find out which ingredients are in a medication? http://goo.gl/UQWQf
Carmine, from Wikipedia, the free encyclopedia. The best price for azithromycin is at Costco: 18 tablets for $18. Drug provocation tests remain the key to diagnosing macrolide allergy http://goo.gl/WM5rj
"Starbucks admits Strawberry Frappuccino contains crushed bugs" - carmine is natural alternative to artificial dyes http://goo.gl/XXIhW
The Fascinating Story of How Tropical Insects Were the Best Choice to Color Your Starbucks Coffee (cochineal red) http://goo.gl/ecZmL
Image source: Variations on a common tablet design, which can be told apart by both color and shape. Wikipedia, Ragesoss, Creative Commons Attribution ShareAlike 3.0 License.
Twitter comments:
@AllergyNet: For me, x2/25 yrs, x1 in sausage x1 in chocolate RT @Allergy: Carmine allergy masquerading as azithromycin allergy http://goo.gl/gST6h
@AllergyNet: Macrolide antibiotic allergy: Which tests are really useful? http://j.mp/jAr3zV Bottom line: NONE (except challenge) Full PDF
Dr. Ellis @DrAnneElli: Have seen this as well - great summary and work up plan for Carmine Allergy.
David Fischer, MD @IgECPD4: Once saw a pt with reaction to strawberry yogurt. Negative to strawberry and milk but +ve to carmine dye
New labeling requirements have been made which will effect those with allergies to carmine http://foodallergyfamilies.blogspot.com/2011/01/beetle-juice-new-label-requirements-for.html
ReplyDeleteFirst reported but many patients have had a reaction to carmine in RX drugs. Doctor's are not knowledgeable about carmine allergy in and assume it is the antibiotic. More would be reported but they do not associate it correctly. This is a highly dangerous colorant in any food or medication. It should be banned in cosmetics as well.
ReplyDeleteI agree this should be banned. I have severe allergies to carmine. My most recent episode caused facial swelling so severe that I my vision was impaired for days. Anytime I had an attack though, the allergist only suggested a zyrtec injection in my hand.
ReplyDeleteI had taken Zithromax in the past and have never had a reaction though I am allergic to many antibiotics.
ReplyDeleteThe last time I was prescribed it I noticed that it had a red coating instead of the usual white one .
Within 60 minutes I had one of the worst reactions I have ever had.
It started with my palms itching and my scalp. I started turning red from my head and you could see it visibly spread down my body. I start to have a burning itching all over my body as red streaks appeared every where on my body. I have a picture of my arm so I could show my doctor.
My husband witnessed this as I laid on our bathroom floor with all my clothes off because anything that touched me made it worse!
Since I had had similar reactions I knew what it was as soon as my palms and scalp started to itch and immediately took 4 liquid Benedryls. I would have gone to the hospital but moving made the twitch like itching so much worse I refused. About 45 minutes to an hour after the Benadryl it started to lessen.
The red streaks on my body didn't go away completely for over a month.
I had a similar reaction last week to 2 small red advil tablets that I took for a headache. I have taken ibuprofen before, but never had a reaction. After 2 benedryls taken about 5 hours later, the itching and welts diminished and went away in about an hour.
ReplyDeleteWhat scared me was that 8 months ago, while traveling abroad, I had a severe allergic reaction to tylenol which I had brought from home. This was also reversed by benedryl, which I also carried with me. Since then, I include tylenol as part of my allergy profile. After my alarming experience with advil a few days ago,I called my pharmacist who asked me the color of the advil ....it was red!...So was the tylenol I suffered the severe reaction to months ago. It was my pharmacist who suggested that the common ingredient was the colored coating, and that indeed many people have a allergic reactions to the coating! I am going to call the manufacturer.