Latin name: Mangifera indica
Source material: Fresh fruit
A food, which may result in allergy symptoms in sensitised individuals.
This evergreen tree (in a family that includes cashew, pistachio and poison ivy) has been cultivated for over 6 000 years. It is native to South-East Asia and Indo-Malaysia. Some 35 Mangifera species grow in South-East Asia, but many are now cultivated or have become naturalised in tropical and sub-tropical regions throughout the world. (1)
The mango tree grows 15-30 m high and bears green to yellow and red ovoid fruit, with pink-orange flesh and a large central seed.
Mangoes are delicious simply peeled and eaten plain. They are also good in fruit salads and have long been made into chutney, pickles and squash. The ground seed is a source of flour. Green or unripe mango has many uses in the cuisines of India, Malaysia and Thailand. Mango is used in various vegetable and lentil dishes, and also as a meat tenderiser. It is a good source of beta carotene and vitamin C.
More than 1 000 strains of mango are cultivated. In a study, allergens from 4 mango varieties were evaluated using sera from 7 mango-sensitised patients: all 4 varieties shared at least 5 allergens, of approximately 14, 30, 40, 43 and 67 kDa. There were no significant differences in allergenic potency between the 4 mango strains. (2) Other studies have reported no significant differences in allergenicity among 8 mango varieties. A 40 and a 30 kDa protein were characterised as major allergens, and minor allergens between 24 and 94 kDa, as well as between 14 and 16 kDa (a profilin), were detected. Interestingly, the profilin was detected in mango peel and pulp. The ripeness of the mango did not influence its allergenicity. (3) Other studies have found similar-sized allergens: IgE binding to mango proteins of 25-50 kDa in a patient's serum was demonstrated. (4)
In a study utilising sera of 52 patients with IgE-mediated sensitisation to mango to identify IgE-binding allergens, sera from 46 were shown to contain 2 allergens with molecular weights of approximately 40 and 30 kDa, designated Man i 1 and Man i 2, respectively. Other IgE-binding patterns were detected for fewer than 50% of the assigned sera. It was demonstrated that there was no significant difference in allergenic potency during fruit ripening. (5) Based on inhibition studies and observed cross-reactions between mango fruit, mugwort pollen, birch pollen, celery, and carrot, a third allergen (now known as Man i 3), related to Bet v 1 and Art v 1, was isolated. (6)
The following allergens have been characterised:
Man i 1, a major allergen, a 40 kDa protein with an unknown function. (3, 7, 8)
Man i 2, a major allergen, a 30 kDa protein with an unknown function. (3, 7, 8)
Man i 3, a minor allergen, a profilin. (9, 10)
Eight (44%) of 18 mango-allergic patients tested were shown to have specific IgE-antibodies directed at recombinant mango profilin. (9)
A 14 kDa protein, a Bet v 1 homologue/group 1 Fagales-related protein, has been isolated, (6, 11) as well as a chitinase allergen. (12) The presence in mango of an isoflavone reductase (IFR) (a 35 kDa protein with homology to the birch allergen Bet v 5) was inferred in studies. (13, 14)
Mango allergens were shown to be very stable during technological processing, irrespective of enzymatic matrix decomposition, mechanical tissue disintegration and heating during peeling, mash treatment, and pasteurisation. Significant loss of allergenicity could not be observed in extracts of mango purées and nectars. (3, 7) Unusually, mango profilin appeared to show very high stability against heat and processing. (3)
The ‘allergens’ causing contact dermatitis to mango have long been suspected to be alk(en)yl catechols and/or alk(en)yl resorcinols; there have been observed cross-sensitivity reactions to mango in patients known to be sensitive to poison ivy and poison oak. The 3 resorcinol derivatives are heptadecadienylresorcinol (I), heptadecenylresorcinol (II) and pentadecylresorcinol (III); they are collectively named ‘Mangol’, and have been reported as mango allergens. Heptadec(adi)enyl resorcinols known to be present in mango have been shown to elicit positive patch-test reactions in mango-sensitive patients. (15)
Extensive cross-reactivity between different individual species of the family and genus (e.g. pistachio and cashew nut) could be expected, but in fact does not occur frequently. (16)
Two isoforms of Mango fruit profilin have been characterised. Both have a high amino acid sequence identity with other allergenic profilins (73-90%). A high degree of cross-reactivity was found between mango profilin and profilin from birch pollen. Man I 3.02 was the isoform closest to profilin of other fruit such as pear (80%), peach (90%) and apple (80%). (9)
A panallergen has been identified in birch pollen, ragweed pollen, Timothy grass pollen, celery, carrot, apple, peanut, paprika, anise, fennel, coriander and cumin. EAST inhibition and immunoblot inhibition demonstrated that cross-reactions between mango fruits, mugwort pollen, birch pollen, celery, and carrot are based on allergens related to Bet v 1 and Art v 1, the major allergens of birch and mugwort pollen, respectively. (6)
In latex-fruit syndrome, banana, avocado, chestnut and kiwi are the most frequently implicated foods, but associations with several other fruits and vegetables have been reported, including pineapple, fig, passion fruit, mango, tomato, bell pepper, carrot, oregano, dill, sage, papaya, wheat and cherimoya. The allergen responsible for most cases of this syndrome is hevein (Hev b 6.02; a class I chitinase-like protein), the amino-terminal fragment of prohevein; homologous proteins have been found in avocado, chestnut, banana, kiwi, tomato, passion fruit, papaya, and mango. (12, 17)
An association between allergies to latex proteins and allergies to various foods has been reported, and confirmed by RAST and immunoblotting inhibition. Serum samples of 136 patients with well-documented, clinically relevant, immediate-type hypersensitivity against latex proteins were analysed for IgE antibodies against a panel of different fruits. Cross-reacting IgE antibodies recognising latex and fruit and other allergens (papaya, avocado, banana, chestnut, passion fruit, fig, melon, mango, kiwi, pineapple, peach, and tomato) were demonstrated by RAST inhibition tests. (18) Similar patterns have been demonstrated in other studies. (19)
Between 10% and 15% of birch pollen-allergic individuals have specific IgE to the 35 kDa minor birch pollen allergen, and there is cross-reactivity with proteins of comparable sizes from litchi, mango, banana, orange, apple, pear and carrot. The 35 kDa protein is immunologically independent of the major birch pollen allergen Bet v 1. A subsequent study determined this protein to be an isoflavone reductase (IFR) with homology to the birch allergen Bet v 5. (9, 13, 14) Researchers also observed IgE binding to a 34 kDa structure, which appears to be a Bet v 1 dimer.
Cross-reactivity was found between pistachio nut, cashew nut, and mango seed, but this cross-reactivity did not extend to mango pulp. (20)
Celery allergies have commonly been associated with mugwort pollen allergy, and also with an allergy to spices of the Umbelliferae family. An association between celery-mugwort allergy and allergy to mango was described, but could not be explained. (21)
In Europe (as opposed to North America), poison ivy rash is hardly known. A young German woman who became sensitised to poison ivy or poison oak while in the USA showed a cross-reaction to other Rhus species, as well as to mango. (22)
Mango may result in hypersensitivity reactions in mango-sensitised individuals. (23) Two distinct clinical presentations of hypersensitivity reactions caused by mango have been described. (24) Symptoms may be as a result of immediate hypersensitivity reactions or delayed hypersensitivity reactions. A review of 17 reports described 10 patients (four with immediate reaction; six with delayed reaction) from geographical areas cultivating mango, whereas twelve patients (six with immediate reaction; six with delayed reaction) were from the countries where large-scale mango cultivation does not occur. Mango fruit can cause immediate and delayed hypersensitivity reactions, and also ‘oral allergy syndrome’. Owing to cross-reactivity, reactions may even occur in individuals who have not had prior exposure to mango. (24)
Adverse reactions may occur as a result of ingestion of mango or contact with mango skin. Allergy to mango as a result of cross-reactivity to latex has frequently been described. (18) The frequency of reported adverse reactions to Mango resulting in symptoms of food allergy in sensitised individuals may be underestimated because of the infrequent consumption of this fruit in the Northern Hemisphere. With wider consumption of mango, increased frequency of reported adverse reactions is likely.
Oral Allergy Syndrome (OAS) is a set of reactions to mango ingestion. (4) Among the symptoms reported in individual cases are urticaria, facial swelling, angioedema, pruritis of the eyes and/or mouth, more generalised pruritis, abdominal cramping, erythema, and dermatitis. (25, 26) Respiratory complaints include wheezing, dyspnoea, and asthma. (18, 26)
A 42-year-old woman presented with systemic contact dermatitis (itchy palpable purpuric lesions over her arms, legs, neck and abdomen) 4 days after ingestion of a small amount of fresh mango gelato. The lesions persisted for 5 weeks despite treatment with topical steroids and avoidance of mango. The patient denied any prior contact with mango skin, but had experienced previous sensitising reactions to mango flesh. Patch testing was strongly positive to mango skin and mango flesh. Skin-prick testing was negative. (27)
Anaphylaxis after eating mango has long been described. (11,) (28, 29, 30, 31) A 32-year-old fruiterer presented with periorbital oedema, facial erythema, widespread urticaria, and dyspnoea 20 minutes after eating a fresh mango. This was the first time he had eaten mango; he had handled mango only once before. A skin-prick test was positive, but serum-specific IgE was negative. (32)
A 43-year-old woman experienced oropharyngeal itching, swelling of the face and other parts of the body, and difficulty breathing within a few minutes of eating ripe mango. The woman had no history of pollen or latex allergy. However, she reported instances of milder food-allergic reactions to Indian dill and cashew apple. Skin-prick tests were positive to mango fruit pulp, Indian dill, and cashew apple extracts. A mango-specific IgE test was positive. (30)
Nine patients with mango allergy were reported. (21) Mango allergy was reported in a latex-sensitised 45-year-old nurse. She had been diagnosed with latex allergy 3 years before, and had occasionally eaten mango for the 2 years before this episode. She suffered oral allergy syndrome, rhinoconjunctivitis, cough and dyspnoea immediately following ingestion of mango. Skin-specific IgE and serum-specific IgE were positive. Although cross-reactivity between mango and latex has been described, in this instance it could not be confirmed. (4)
In a French study conducted over a period of 9 years (1984-1992), a group of 580 patients was analysed who had pathological reactions to foods – in 60 cases, presenting with severe, near-fatal reactions. Researchers sought the causes of the food sensitisation and considered them in relation to the main tendencies of food consumption in France. The food products most frequently incriminated in anaphylactic reactions were found to be not of primary nutritional importance – celery (30%), crustaceans (17%), fish (13%), peanuts (12%), mango (6%), and mustard (3%) – but these are often hidden allergens in commercial foods. (33)
Of 132 children aged 3-19 years, 58% reported food-allergic reactions during the previous 2 years. The offending food was identified in 34 of 41 reactions, cow’s milk being the causative food in 11 (32%); peanut in 10 (29%); hen’s egg in 6 (18%); tree nuts in 2 (6%); and soya, wheat, celery, mango or garlic in 1 (3%) each. (34)
Three patients were found to be allergic to mango and pistachio nut. One of them, a 28-year-old woman, developed a burning sensation in her mouth, swelling of the lips, face and tongue, and nausea and abdominal cramps immediately after eating a peeled mango. A 28-year-old man experienced episodes of vomiting immediately after eating mango. All 3 were skin-prick test-positive to fresh mango, but not to mango extracts. (35)
A 36-year-old woman with allergic rhinitis, who had previously experienced urticaria and angioedema immediately after the ingestion of sunﬂower seed, reported an immediate onset of urticaria and angioedema after the ingestion of mango. She tolerated pistachio and cashew nut without any problem. Prick-by-prick tests to mango, pistachio nut, cashew nut and sunﬂower seeds were all positive. The results of serum-specific IgE tests for mango, sunﬂower seed, Bet v1 and Bet v2 were CAP class 0; CAP class 2 for pistachio nut and cashew nut; and CAP class 4 for Artemisia and sunflower pollen. Inhibition studies demonstrated significant inhibition of pistachio and cashew nut by Artemisia pollen. Artemisia pollen was inhibited only by Helianthus pollen. (36)
Contact dermatitis has been reported, (37, 38) as well as contact dermatitis of the face and lips. (39) Mango dermatitis is sometimes limited to vesicles at the angles of the mouth, but it usually affects the entire periorbital region and may affect the buccal mucosa. The hands can carry the allergen to the eyes and neck. Eruptions may become generalised. (1)
A 22-year-old white female student presented with a 2-day history of patchy pruritic erythema of the face, neck, and arms, with periorbital oedema. The eruption began as an isolated patch of nasal erythema, with subsequent extension to involve the entire face. Within 2 days, fine pinpoint papules were noted on the face, anterior chest, neck, and upper extremities. Periorbital oedema was present without intra-oral abnormalities or laryngeal changes. An erythematous, mildly lichenified plaque was noted on the ventral left wrist. She reported frequent ingestion of peeled mango. Mango skin and mango flesh were evaluated in patch tests and resulted in bullous reactions to both. Complete avoidance of mango led to resolution of the initial eruption. (38)
A recent study suggests that skin-prick testing with fresh mango fruit may be useful when serum-specific IgE determination is negative. Two patients who developed anaphylactic reactions after ingestion of fresh mango were investigated. Although a skin-prick test and cellular allergen stimulation tests were positive, serum-specific IgE were negative in both. Two major allergens, with a molecular weight of 27 kDa, were detected as reactive in both patients, in addition to a 15 kDa allergen in 1 patient and a 32 kDa allergen in the other; the authors suggested that currently available serum IgE assays appear to be lacking these mango allergens. (31)
Sensitisation may occur to mango pollen (40) and to mango seed. (20)
Some patients complain of abdominal distension and excessive flatus after ingesting certain fruits, such as mango; this could be a result of fructose intolerance. (41)
The leaves, stems and pericarp of the fruit of the mango plant contain several substances thought to be sensitisers, such as cardol, uroshiol, beta-pinene and limonene. Beta-pinene and limonene are known to cause allergic contact dermatitis mediated by a type IV delayed hypersensitivity mechanism. (32, 42) Urushiol can also cause such dermatitis. Other species belonging to the family of Anacardiaceae, such as poison ivy, contain urushiols as well (see cashew nut f202), and may cause allergic contact dermatitis. (43) Acute allergic contact dermatitis can arise on first exposure to mango in patients who have been sensitised beforehand by contact with other urushiol-containing plants, e.g. poison oak or poison ivy. A study described 17 American patients, employed in mango picking at a summer camp in Israel, who developed rashes of varying severity. All the patients had been in contact with poison ivy/oak in the past, or had lived in areas where these plants are endemic. None recalled previous contact with mango. In contrast, none of their Israeli companions (who had never been exposed to poison ivy/oak) developed mango dermatitis. The authors hypothesised that previous oral exposure to urushiol in the local Israeli population might have established immune tolerance to these plants. (44)
Hawaiian locals were found to be able to tolerate mango sap, whereas visitors were prone to developing contact dermatitis. (45, 46)
Asthma and allergic rhinitis from mango tree pollen have been reported. (47)
Compiled by Dr Harris Steinman, firstname.lastname@example.org
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