Generalised Urticaria in a Young Woman treated with Clomipramine and after Ingestion of Codfish

We report a case of generalized dermatitis and itch induced by a possible drug-food interaction in a young woman who was consuming clomipramine for Obsessive Compulsive Disorder (OCD). A 33-year-old woman affected by anxiety symptoms presented to our observation for a clinical evaluation. After psychiatric evaluation, the diagnosis of OCD was performed according to DSM-IV-TR and a pharmacological treatment with clomipramine (75-100 mg/day) plus alprazolam (0.5 mg/day) was started. About one month later, the patient developed a severe generalized urticaria with intense itch. A new anamnesis revealed that on the day before the development of the skin rash, no other drug was consumed and the patient had eaten codfish; clomipramine was then gradually discontinued and changed into paroxetine (30 mg/day). At the moment the patient does not show any OCD related symptom and any adverse event to paroxetine treatment has been recorded. We postulate a possible interaction between clomipramine and codfish ingestion. Allergic potential of clomipramine was investigated, while clomipramine de-challenge induced a decrease of the skin rash, the drug re-challenge performed one month later did not induce any adverse event. In contrast, when the combined re-challenge of codfish and clomipramine was performed urticaria was newly observed. The Naranjo Probability Scale Score suggested a probable causal relationship between drug-food interaction and the skin rash. In conclusion, we suggest evaluating also the complete risk of drug-food interaction occurring on clomipramine treatment.

References

• 1 Aas K, Elsayed S M. Characterization of a major allergen (cod). Effect of enzymic hydrolysis on the allergenic activity.  J Allergy. 1969;  44 333-343
• 2 Balant-Gorgia A E, Gex-Fabry M, Balant L P. Clinical pharmacokinetics of clomipramine.  Clin Pharmacokinet. 1991;  20 447-462
• 3 Besler M, Steinhart H, Paschke A. Stability of food allergens and allergenicity of processed food.  J Chromatogr B Biomed Sci Appl. 2001;  756 207-228
• 4 Brosen K. Some aspects of genetic polymorphism in the biotransformation of antidepressants.  Therapie. 2004;  59 5-12
• 5 Degner D, Grohmann R, Kropp S, Ruther E, Bender S, Engel R R, Schmidt L G. Severe adverse drug reactions of antidepressants: results of the German multicenter drug surveillance program AMSP.  Pharmacopsychiatry. 2004;  37 (Suppl 1) S39-S45
• 6 DeVeaugh-Geiss J, Moroz G, Biederman J, Cantwell D, Fontaine R, Greist J H, Reichler R, Katz R, Landau P. Clomipramine hydrochloride in childhood and adolescent obsessive-compulsive disorder: a multicenter trial.  J Am Acad Child Adolesc Psychiatry. 1992;  31 45-49
• 7 Feinberg M. Clomipramine for obsessive-compulsive disorder.  Am Fam Physician. 1991;  43 1735-1738
• 8 Flament M F, Rapoport J L, Berg C J, Sceery W, Kilts C, Mellstrom B, Linnoila M. Clomipramine treatment of childhood obsessive-compulsive disorder: a double-blind controlled study.  Arch Gen Psychiatry. 1985;  42 977-983
• 9 Fujita K. Food-drug interactions via human cytochrome P450 3A (CYP3A).  Drug Metabol Drug Interact. 2004;  20 195-217
• 10 Grohmann R, Hippius H, Helmchen H, Ruther E, Schmidt L G. The AMUP study for drug surveillance in psychiatry - a summary of inpatient data.  Pharmacopsychiatry. 2004;  37 (Suppl 1) S16-S26
• 11 Hansen T K, Bindslev-Jensen C, Skov P S, Poulsen L K. Codfish allergy in adults: IgE cross-reactivity among fish species.  Ann Allergy Asthma Immunol. 1997;  78 187-194
• 12 Katz R J, DeVeaugh-Geiss J, Landau P. Clomipramine in obsessive-compulsive disorder.  Biol Psychiatry. 1990;  28 401-414
• 13 Kelso J M. Pollen-food allergy syndrome.  Clin Exp Allergy. 2000;  30 905-907
• 14 Naranjo C A, Busto U, Sellers E M, Sandor P, Ruiz I, Roberts E A, Janecek E, Domecq C, Greenblatt D J. A method for estimating the probability of adverse drug reactions.  Clin Pharmacol Ther. 1981;  30 239-245
• 15 Osterballe M, Hansen T K, Mortz C G, Host A, Bindslev-Jensen C. The prevalence of food hypersensitivity in an unselected population of children and adults.  Pediatr Allergy Immunol.. 2005;  16 567-573
• 16 Pendleton R G, Williams M, Chung C, Cook P, Risley E. Comparison of central gastric antisecretory effects of desmethylimipramine, doxepin and pirenzepine in rats.  Naunyn Schmiedebergs Arch Pharmacol.. 1984;  326 210-214
• 17 Sampson H A. Fatal food-induced anaphylaxis.  Allergy. 1998;  53 125-130
• 18 Sampson H A. Anaphylaxis and emergency treatment.  Pediatrics. 2003;  111 1601-1608
• 19 Sampson H A. Update on food allergy.  J Allergy Clin Immunol . 2004;  113 805-819
• 20 Scholl I, Untersmayr E, Bakos N, Roth-Walter F, Gleiss A, Boltz-Nitulescu G, Scheiner O, Jensen-Jarolim E. Antiulcer drugs promote oral sensitization and hypersensitivity to hazelnut allergens in BALB/c mice and humans.  Am J Clin Nutr.. 2005;  81 154-160
• 21 Taylor S L, Lehrer S B. Principles and characteristics of food allergens.  Crit Rev Food Sci Nutr. 1996;  36 S91-S118
• 22 The Clomipramine Collaborative Study G roup. Clomipramine in the treatment of patients with obsessive-compulsive disorder.  Arch Gen Psychiatry. 1991;  48 730-738
• 23 Thoren P, Asberg M, Cronholm B, Jornestedt L, Traskman L. Clomipramine treatment in obsessive compulsive disorder: I. a controlled clinical trial.  Arch Gen Psychiatry. 1980;  37 1281-1285
• 24 Untersmayr E, Bakos N, Scholl I, Kundi M, Roth-Walter F, Szalai K, Riemer A B, Ankersmit H J, Scheiner O, Boltz-Nitulescu G, Jensen-Jarolim E. Anti-ulcer drugs promote IgE formation toward dietary antigens in adult patients.  FASEB J. 2005;  19 656-658
• 25 Untersmayr E, Poulsen L K, Platzer M H, Pedersen M H, Boltz-Nitulescu G, Skov P S, Jensen-Jarolim . The effects of gastric digestion on codfish allergenicity.  J Allergy Clin Immunol. 2005;  115 377-382
• 26 Untersmayr E, Schoell I, Swoboda I, Beil W J, Forster-Waldl E, Walter F, Riemer A, Kraml G, Kinaciyan T, Spitzauer S, Boltz-Nitulescu G, Scheiner O, Jensen-Jarolim E. Antacid medication inhibits digestion of dietary proteins and causes food allergy: a fish allergy model in BALB/c mice.  J Allergy Clin Immunol. 2003;  112 616-623
• 27 Wu Z L, Huang S L, Ou-Yang D S, Xu Z H, Xie H G, Zhou H H. Clomipramine N-demethylation metabolism in human liver microsomes.  Zhongguo Yao Li Xue Bao. 1998;  19 433-436
• 28 Yagami T, Haishima Y, Nakamura A, Osuna H, Ikezawa Z. Digestibility of allergens extracted from natural rubber latex and vegetable foods.  J Allergy Clin Immunol. 2000;  106 752-762