Correspondence

Anaphylaxis with Anisakis simplex in the Gastric Mucosa

N Engl J Med 1997; 337:350-351July 31, 1997

Article

To the Editor:

Anisakis simplex is a nematode (Anisakidae family, Ascaridoidea superfamily) that parasitizes sea mammals. Common intermediary hosts include the codfish, hake, sardine, anchovy, salmon, tuna, mackerel, and squid.1 Humans acquire the larvae by eating raw or undercooked seafood.2 Anisakis larvae can be invasive, penetrating the host's stomach or intestinal wall,3 but it is very unusual to find the nematode in the gastric mucosa. We have seen three patients with allergic reactions and clinical findings that led us to suspect acute gastric anisakiasis.

A 47-year-old woman had anaphylaxis, vomiting, and gastric pain two hours after eating raw anchovy in vinegar sauce. Gastroscopy showed a gastric erosion. The symptoms disappeared after 12 hours. A 51-year-old man had urticaria, bronchospasm, and gastric discomfort 90 minutes after eating raw anchovy in vinegar sauce, and a 34-year-old woman had gastric discomfort, urticaria, and angioedema 60 minutes after eating undercooked hake. Gastroscopy in each of these two patients showed a live worm in the gastric mucosa (Figure 1Figure 1 Anisakis simplex Larva in the Gastric Mucosa.). The worms were removed, and the symptoms disappeared. Sensitization to anisakis was demonstrated by positive skin-prick tests (International Pharmaceutical Immunology, Madrid), the presence of specific IgE in serum (CAP system, Pharmacia, Uppsala, Sweden), or both. Sensitization to seafood was not detected. The worms were identified as A. simplex.

In Western countries it is uncommon to find patients with nematodes in the gastric mucosa, but gastroscopy is rarely performed in patients who have allergic or gastric symptoms after eating seafood. In patients with allergic reactions who also have gastric symptoms after eating raw or undercooked seafood, endoscopy can be used to prevent the penetration of live larvae into the gastric mucosa. We think our three patients had systemic IgE-mediated reactions (caused by their sensitization to anisakis) and local gastric reactions, which may also have been mediated by IgE,3 to the parasite in the gastric mucosa. The two events, allergic reaction and infestation, can occur together, and allergic reactions with gastric symptoms may be clues to the presence of acute gastric anisakiasis.

The best treatment for anisakiasis is prophylaxis. Larvae cannot survive a temperature higher than 60°C for 10 minutes or lower than -20°C for 24 hours. However, the ingestion of safely cooked but parasitized seafood can cause an allergy.4,5 Allergic reactions after the ingestion of seafood, without evidence of IgE against the implicated food (negative skin tests and the absence of specific IgE in serum), may be due to anisakis allergy in sensitized patients.5

Alicia Alonso, M.D.
Alvaro Daschner, M.D.
Alvaro Moreno-Ancillo, M.D.
Hospital General Universitario La Paz, Madrid 28046, Spain

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