Anaphylaxis due to mint

To The Editor: I read the article “A rare case of anaphylaxis caused by mint-containing toothpaste in a child: A case report” by Tan et al. [1] with great interest. However, clarifying my questions regarding this report’s diagnostic methods and care will help me better understand this case and the rare mint allergy. This patient, who was reported to have experienced anaphylaxis, continued to have shortness of breath upon arrival at the hospital, and mild retractions and wheezing were observed [1]. The reported vital signs of SpO2 100% (room air) and respiratory rate of 20 breaths/minute are inconsistent with the clinical picture [1]. Furthermore, the rapid improvement of symptoms following intramuscular administration of epinephrine (1:1000) confirms our suspicion. Brand B, a brand previously tolerated by the patient, also caused anaphylaxis; this has been linked to possible contamination of the toothbrush with residues of Brand A toothpaste, which the patient had previously used. Table 1 also includes the phrase “option of mint flavor” in Brand B toothpaste [1]. This has also confused us. It is unclear whether the anaphylaxis of Brand B toothpaste was caused by contamination, the mint, or another ingredient [1]. Although the clinical parameters suggested anaphylaxis, the decision not to administer epinephrine because the patient was stable and to treat the shortness of breath with salbutamol via inhalation only is a situation that could lead to misunderstandings in the management of anaphylaxis [2]. However, the patient could not link the anaphylaxis symptoms specifically to toothpaste containing mint [1]. We were just as baffled as he was. The fact that he had used it before, that there were no symptoms other than mild itching, that the mint-specific serum immunoglobulin E test was negative, and that there was no reaction to mint tea consumed before and after the anaphylaxis cast doubt on the accuracy of the diagnosis [1]. The diagnosis seems hypothetical. Since there is confusion here, conducting an oral food challenge with mint and confirming the diagnosis would be good. The skin prick test performed with mint leaves was positive [1]. However, it was necessary to consider the irritant effects of raw mint and perform the test on healthy controls in the same manner to demonstrate that it was negative [1]. As said in the article, common causes of allergies related to toothpaste are known to include aromatic substances, particularly carvone, limonene, and menthol. Mint contains menthol, a naturally occurring chemical compound. No action was taken regarding this and other fragrant substances in this patient [1]. Minor concerns: in the article text, “prick-to-prick” is incorrectly written as “prick-top-prick.” There are various errors in Table 3. In the Papa et al. case, “skin provocation test” is mentioned, but no such test exists. In the 2001 Holmes et al. case, the “skin prick test” was mentioned for contact dermatitis, but this should have been a patch test. The 2003 Marlowe et al. case describes generalized urticaria and asthma exacerbation, but the clinical picture presented is anaphylaxis. The 2015 Middelberg et al. case mentions delayed-onset anaphylaxis after mint gum consumption, but this clinical picture is more consistent with FPIES [3]. In conclusion, I would like to thank the esteemed authors for this excellent and high-quality case report and its findings, which increase our knowledge and awareness regarding allergies to mint. Conflicts of interest The authors have no financial conflicts of interest Author contributions Özdemir has done everything.