Flagellate mushroom (Shiitake) dermatitis and photosensitivity

Appearance of a "Whip-Like" Rash in a Young Male Undergoing Therapy for Testicular Embryonal Carcinoma

Bleomycin, a cytotoxic antibiotic commonly used as part of combination chemotherapy regimes in the treatment of germ cell tumors, is well known among clinicians for its potential pulmonary toxicity. Less well known, although postulated to occur through a similar pathomechanism, are the wide spectrum of dermatologic adverse reactions associated with bleomycin therapy. The current case report describes the sudden and distressing appearance of a pruritic erythematous flagellate "whip-like" rash in a 30-year-old Caucasian male undergoing treatment for testicular embryonal carcinoma following the second infusion of bleomycin-containing chemotherapy. Diagnosed as bleomycin-induced flagellate dermatitis, the case describes the dermatologic sequela and therapeutic interventions utilized. While commonly used in testicular cancer, decreasing use of bleomycin-containing chemotherapy regimens has made the appearance of this increasingly rare, yet important and distressing, toxic adverse reaction a diagnostic challenge. Given that patients may present acutely to primary care providers, dermatologists, and nurse practitioners, awareness of this rare adverse reaction is important in order to alleviate patient anxiety, initiate appropriate therapy, set expectations of expected dermal sequela, and initiate an informed collaborative discussion regarding the continuation versus cessation of bleomycin-containing therapy.

A case of shiitake dermatitis in the United States

A 65-year-old male presented to our dermatology clinic with a two-day intensely pruritic rash covering his back. The lesions were predominantly on his chest, upper extremity, and back. He denied any prior history of similar rashes and his past medical history was non-contributory. A detailed exposure history revealed the patient had eaten Shiitake mushrooms for dinner 48 hours previously.

Physical examination showed a truncal dominant rash. Close-up examination confirmed the papulovesicular nature of the rash with multiple small vesicles grouped both along the breadth and length of each linear streak on an erythematous background. Biopsies showed spongiosis with micro-vesiculation. Blood work showed a nominal CBC and CRP/ESR and serum IgE. The patient was put on topical steroid and the rash resolved in one week.

With increasing mushroom consumption [1], cognizance of this etiology avoids a diagnostic ‘odyssey’ and prevents recurrence of this very characteristic rash.

A characteristic rash caused by Shiitake mushrooms - An emerging concern?

Shiitake mushroom dermatitis is a striking rash that can present as an emergency. Despite the dramatic appearance, the rash is an idiosyncratic reaction which resolves spontaneously and does not progress to anaphylaxis.

Clinical Approach to Linear Hyperpigmentation: A Review Article

Linear hyperpigmentation is an unusual anatomical configuration in clinical dermatology. Owing to its rarity, consensus on the most effective method of classification is lacking. While linear hyperpigmentation generally follows Blaschko's lines, this is not universal. Clinical findings such as adherence to Blaschko's lines, associated morphological findings (including other cutaneous lesions), and systemic manifestations can be used to further characterize and diagnose variants of the disorder. Early detection of any underlying disease is vital, especially in cases with effective management, because the disorder may make it difficult to manage hyperpigmentation. Herein, we introduce a logical clinical diagnostic approach that represents a useful tool for dermatologists to efficiently evaluate patients presenting with linear hyperpigmentation. A simplified systematic and evidence-based approach is useful for this clinical condition owing to the heterogeneous causes and lack of specific diagnostic tools.

Not a fungi to be with: Shiitake mushroom flagellate dermatitis

Shiitake dermatitis is a rare adverse cutaneous reaction to the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). We report the case of a patient who developed a striking linear flagellate dermatitis without urticaria three days after returning from a trip from Tokyo where he had eaten shiitake mushrooms. The rash resolved after two weeks with topical corticosteroids and antihistamines given for symptomatic relief. Shiitake dermatitis is thought to be either a toxic or hypersensitivity reaction to lentinan, a heat-inactivated polysaccharide found in the cell walls of shiitake mushrooms. Although this mushroom is widely consumed in Eastern Asia, with the increasing globalisation of cuisine and travel, cases are likely to become more common in the Western world.

Histological Features of Flagellate Erythema

Flagellate erythema is a distinctive eruption characterized by "whip-like" linear or curvilinear streaks and plaques, occurring mainly on the trunk. It has classically been described in 2 disparate clinical settings: chemotherapy with bleomycin and ingestion of mushrooms (most commonly Shiitake mushrooms). Most of the literature comprises single case reports, often with minimal histological description of rather nonspecific features. We describe in detail the histological features of 3 cases of flagellate erythema (2 related to bleomycin therapy and one related to ingestion of mushrooms) and review the findings described in the literature to define the spectrum of histological changes encountered in this eruption. Our 3 cases showed mild epidermal changes, with spongiosis and variable interface inflammation. All 3 showed a relatively prominent dermal lymphohistiocytic infiltrate, with features suggestive of a lymphocytic vasculopathy extending to at least the mid-reticular dermis. Eosinophils were a prominent component of the inflammatory infiltrate in 2 cases. Our review of the literature identified a total of 45 publications, representing reports of 46 patients, containing histological information. As well as bleomycin- and mushroom-related cases, similar eruptions have been reported in the context of connective tissue disease and other drugs. Although cases related to connective tissue disease show features of the underlying condition, cases secondary to drugs or mushrooms predominantly show features compatible with common patterns of exanthematous/morbilliform drug reaction. In particular, subtle spongiosis and/or interface dermatitis combined with a dermal lymphocytic infiltrate that includes increased numbers of eosinophils is a common finding. Features of a lymphocytic vasculopathy may be seen in a subset of these cases.

Shiitake Mushroom Dermatitis: A Review

Shiitake mushroom dermatitis is a cutaneous reaction caused by the consumption of raw or undercooked shiitake mushrooms. Symptoms include linear erythematous eruptions with papules, papulovesicles or plaques, and severe pruritus. It is likely caused by lentinan, a heat-inactivated beta-glucan polysaccharide. Cases were initially reported in Japan but have now been documented in other Asian countries, North America, South America, and Europe, as this mushroom is now cultivated and consumed worldwide. Shiitake mushroom dermatitis may result from mushroom ingestion or from handling, which can result in an allergic contact dermatitis.

Shiitake dermatitis recorded by French Poison Control Centers - new case series with clinical observations

CONTEXT

Shiitake (Lentinula edodes) is an edible mushroom which was initially grown in Japan and China and is now sold on the European market. Flagellate erythema may arise following shiitake consumption and was first described in Japan in 1974.

OBJECTIVE

This paper reports a French shiitake dermatitis case series.

METHODS

The findings of retrospective study of shiitake dermatitis cases, reported to French Poison Control Centres (PCC) from January 2000 to December 2013, are reported.

RESULTS

Among 32 exposed patients, 15 presented flagellate urticarial lesions after raw shiitake consumption. The first case of this series was reported in 2006 and the last nine cases were reported as of 2012. After shared meals, no symptoms were reported among guests, who preferred cooked shiitake to the raw mushroom. In this series, rashes appeared 12 h to 5 days (median: 24 h) after raw shiitake ingestion. Linear and itchy urticarial lesions formed on the trunk, arms, and legs within a few hours and persisted for 3-21 days. In four cases, rash and pruritus were either triggered or worsened by sun exposure. Eleven patients received corticosteroids, antihistamines, or both. All patients completely recovered.

CONCLUSION

Due to the rapidly increasing consumption of exotic food in Western countries, it is no surprise that cases of shiitake dermatitis are now appearing in Europe. The mechanism of shiitake dermatitis is thought to be toxic and due to lentinan, a polysaccharide component of the mushroom. There is no specific validated treatment for shiitake dermatitis. Health professionals and the general population should be aware of both the risk associated with raw shiitake consumption and of the good prognosis of this very spectacular and uncomfortable toxic dermatitis.

Flagellate dermatitis after consumption of Shiitake mushrooms

Flagellate dermatitis occurs in patients who have eaten Shiitake mushrooms. We are reporting on a 55-year-old man, who developed whiplash-striped, severely itching efflorescences on the trunk 3 days after eating Lentinula edodes. Flagellate dermatitis is also known as a cutaneous side effect of bleomycin therapy.

Flagellate dermatitis caused by shiitake mushrooms

Shiitake (Lentinus edodes) is the second most consumed mushroom in the world. It has long been known in Asian medicine for its anticarcinogenic, antihypertensive and serum cholesterol level reduction properties. Nevertheless, the consumption of raw or not well-cooked mushrooms may cause skin eruptions which usually occur 24 to 48 hours after ingestion and are characterized by linearly arranged pruritic erythematous papules and plaques. We present a 36-year-old patient that developed typical symptoms 24 hours after consumption of shiitake mushrooms and summarize therapeutic options and particularities of this disease.

Flagellate dermatitis following consumption of shiitake mushroom

Japanese dermatologists were the first to describe the very characteristic flagellate dermatitis following consumption of undercooked or raw shiitake mushroom (Lentinus edodes). These similar eruptions were also reported in patients treated with bleomycin, in dermatomyositis and adult onset Still's disease. We report a case where a 40 year old chinese female developed flagellate dermatitis following ingestion of a bun containing shiitake mushroom.

Flagellate dermatitis as a bleomycin-specific adverse effect of cytostatic therapy: a clinical-histopathologic correlation

In oncology, bleomycin is a frequently used drug for the treatment of several malignancies. In particular, it is part of chemotherapy protocols in testicular cancer. We report on two patients with testicular cancer who received bleomycin-including chemotherapy and developed flagellate dermatitis. This is a typical adverse effect of bleomycin therapy; however, its pathophysiology has not yet been clarified. We discuss possible pathophysiologic mechanisms for this reaction. In general, it has been postulated that histopathologic findings in flagellate dermatitis share similarities with those observed in fixed drug eruptions. In fact, published cases in the literature have shown a broad variety of histologic changes and the histopathologic investigation of our two patients was not indicative of fixed drug eruption-like changes. Histology of one patient showed a superficial and deep, perivascular and periadnexal infiltrate of lymphocytes and eosinophils with a prominent perisudoral distribution, whereas the other patient was remarkable only for the presence of a rather sparse, superficial, perivascular lymphocytic infiltrate with occasional eosinophils and a few melanophages. Epidermal changes, in particular necrotic keratinocytes, were not present in either patient. We provide an overview of all reported histologic changes in bleomycin-induced flagellate dermatitis, including our experience with two patients. Based on these data, we present a summary of the clinical and histologic features.

Contact dermatitis to Shiitake mushroom

A 44-year-old woman with occupational allergic contact dermatitis to Shiitake mushroom (Lentinus edodes), sawdust and thiuram. She presented with an 8-month history of hand and face dermatitis that developed after working for 2.5 years in a mushroom farm. Within 3 months of ceasing work at the farm, her symptoms resolved completely.