Correspondence

Anaphylaxis from the Carboxymethylcellulose Component of Barium Sulfate Suspension

N Engl J Med 1998; 338:623February 26, 1998

Article

To the Editor:

In their report of an anaphylactic reaction caused by the carboxymethylcellulose component of barium sulfate suspension (Oct. 30 issue),1 Muroi and colleagues refer to another case report 2 of an anaphylactic reaction during barium administration. They appear to cite the reference as an example of exposure to latex, which has been implicated among the causes of allergic reactions to barium contrast medium. The case report 2 demonstrated that carrageenan, a sulfated polysaccharide that is also used as a suspending agent in barium preparations, was the cause of the anaphylactic reaction, on the basis of positive skin-puncture testing and the detection of specific IgE antibodies to carrageenan in serum. Muroi et al. did not test for immediate hypersensitivity to carrageenan. Were trace amounts of carrageenan used in the preparation of the carboxymethylcellulose component? If so, might they have affected the results of the skin test and the leukocyte histamine-release assay?

Joel S. Klein, M.D.
9301 Golf Rd., Des Plaines, IL 60016

2 References

1. 1

   Muroi N, Nishibori M, Fujii T, et al. Anaphylaxis from the carboxymethylcellulose component of barium sulfate suspension. N Engl J Med 1997;337:1275-1277
   Full Text | Web of Science | Medline

2. 2

   Tarlo SM, Dolovich J, Listgarten C. Anaphylaxis to carrageenan: a pseudo-latex allergy. J Allergy Clin Immunol 1995;95:933-936
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Although Tarlo et al.1 reported an anaphylactic reaction to carrageenan during a barium enema and 3 of 33 barium sulfate suspensions that are commercially available in Japan contain carrageenan, the barium sulfate suspension used in the double-contrast upper gastrointestinal examination of our patient did not contain carrageenan. The impurities of carboxymethylcellulose are inorganic salts such as sodium chloride, sodium sulfate, and sodium silicate. No organic substances were added to the carboxymethylcellulose during manufacturing. It is generally accepted that carboxymethylcellulose is neither digested nor absorbed by the gastrointestinal tract. Our patient received about 3 g of carboxymethylcellulose, and a minute amount could have entered the circulation and caused the anaphylactic reaction, since the patient was sensitized to carboxymethylcellulose. The use of an air–contrast technique2 might affect the tight junction between absorptive epithelial cells, allowing the transit of carboxymethylcellulose into the subepithelial space.

Masahiro Nishibori, M.D., Ph.D.
Okayama University Medical School, Okayama 700-0914, Japan

Nobuyuki Muroi, Ph.D.
Takashi Fujii, M.D.
Ako Municipal Hospital, Ako 678-0233, Japan

2 References

1. 1

   Tarlo SM, Dolovich J, Listgarten C. Anaphylaxis to carrageenan: a pseudo-latex allergy. J Allergy Clin Immunol 1995;95:933-936
   CrossRef | Web of Science | Medline

2. 2

   Janower ML. Reactions to contrast materials during gastrointestinal studies. Radiology 1990;177:287-287
   Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   A RIVALTRINGALI, N GUNERASAAD, F BERARD, V CHAMBOST, A ROZIERE, I GUILLOTPOUGET, J NICOLAS. (2008) Tolérance de la carboxyméthylcellulose par voie orale chez deux malades ayant développé une anaphylaxie à la carboxyméthylcellulose injectable. Annales de Dermatologie et de Vénéréologie 135:5, 402-406
   CrossRef

2. 2

   N. Muroi, S. Mori, S. Ono, H. K. Takahashi, T. Fujii, S. Hosoi, K. Henmi, M. Nishibori. (2002) Allergy to carboxymethylcellulose. Allergy 57:12, 1212-1213
   CrossRef