Allergic urticaria from tonic water R. Gonza ´ lez, R. Mercha ´ n, J. F. Crespo, J. Rodrı ´guez* Key words: double-blind placebo-controlled food challenge; quinine; tonic water; urticaria. . WE evaluated a 50-year-old male who was admitted to the emergency room because of generalized pruritus and urticarial lesions on his abdomen, arms, and face, as well as mild periorbital edema. He had no past medical history of chronic medical conditions. He denied a history of previous episodes of urticaria triggered by heat, cold, pressure, exercise, sunlight, emotional stress, medications, foods or food additives. The patient reported having had a half of a glass of tonic water 30–40 min before the onset of symptoms. In the emergency room, the patient was treated with intramuscular epinephrine injections (0.3 mg), methylprednisolone sodium succinate (60 mg), and dexchlorpheniramine (5 mg). His urticarial lesions disappeared within 8 h. After obtaining informed consent, we investigated the patient and 10 healthy, non-atopic control subjects. We conducted skin prick tests for the same brand of tonic water at 1:10 dilution and quinine sulfate at 3 mg/ml. The response was evaluated 20 min later. A positive reaction was observed with tonic water (wheal: 435 mm in diameter; flare: 8312 mm) and with quinine sulfate (wheal: 535 mm; flare 9311 mm). The 10 control subjects had no skin test response to tonic water and quinine sulfate. The patient underwent an open oral challenge with increasing doses of the same brand of tonic water. Fifteen minutes after a 60 ml dose (5.4 mg of quinine hydrochloride) the patient developed pruritic wheals on his trunk and arms. The suspicion of quinine as the causative agent prompted us to perform a double-blind placebo-controlled food challenge with quinine. Increasing doses of quinine sulfate or placebo (dextrose) were administered in opaque capsules at 30-min intervals. The verum and placebo were randomly given on two separate days with an interval of 48 h. The patient reacted with generalized pruritic wheals to a cumulative dose of 9 mg of quinine sulfate. Quinine-related hypersensitivity manifestations have been reported to include thrombocytopenia and hemolytic uremic syndrome (1), lupus-like syndrome (2), photosensitivity (3), cutaneous vasculitis (4), and anaphylactic shock (5). In our patient, the results of oral challenges established a definite causal relationship between quinine and urticaria. Furthermore, the positive results of skin testing suggest that urticaria resulted from an IgE-dependent hypersensitivity mechanism. Tonic water is widely consumed worldwide and may be an unrecognized cause of urticaria. The concentration of quinine in commercial beverages should be considered as a potential cause of acute IgE-mediated urticaria and angioedema. *Julia Rodriguez, MD Hospital Universitario Doce de Octubre Servicio de Alergia Ctra. Andalucia km 540028041 Madrid Spain Accepted for publication 21 June 2001 Allergy 2002: 57:52 Copyright # Munksgaard 2002 ISSN 0105-4538 References 1. GLYNNE P, SALAMA A, CHAUDHRY A, SWIRSKY D, LIGHTSTONE L. Quinine-induced immune thrombocytopenic purpura followed by hemolytic uremic syndrome. Am J Kidney Dis 1999;33:133–137. 2. ROSA-RE D, GARCIA F, GASCON J, ANGRILL J, CERVERA R. Quinine induced lupus-like syndrome and cardiolipin antibodies. Ann Rheum Dis 1996; 55:559–560. 3. LJUNGGREN B, HINDSEN M, ISAKSSON M. Systemic quinine photosensitivity with photoepicutaneous cross-reactivity to quinidine. Contact Dermatitis 1992;26:1–4. 4. PRICE EJ, BEVAN JS, REES A. Quinine- induced cutaneous vasculitis. Br J Clin Pract 1992;46:138–139. 5. PIN I, DOR PJ, VERVLOET D, SENFT M, CHARPIN J. Immediate hypersensitivity to quinine. Presse Med 1985;14:967–969. ALLERGY 2002: 57:52^64 . COPYRIGHT G MUNKSGAARD 2002 . ISSN 0105-4538 . ALL RIGHTS RESERVED . CONTRIBUTIONS TO THIS SECTION WILL NOT UNDERGO PEER REVIEW, BUT WILL BE REVIEWED BY THE ASSOCIATE EDITORS . A patient with positive SPT to quinine Immediate hypersensitivity due to pseudoephedrine M. Venturini*, A. Lezaun, T. Abos, J. Fraj, S. Monzo ´n, C. Colas, F. Duce Key words: ephedrine; epinephrine; hypersensitivity; pseudoephedrine. . SYMPATHOMIMETIC agents are used widely but despite this extensive use as vasoconstrictors hypersensitivity reactions from sympathomimetic drugs are rare. The most frequent adverse reaction is contact dermatitis caused by eyedrops, eardrops, or any topical preparations (1,2) and the most common reaction to oral sympathomimetics is nonpigmenting fixed exanthema (3). We present three cases of reactions to pseudoephedrine with different sympto- matology: urticaria and anaphylaxis. Case 1. A 33-year-old man took a rinoebastel tablet (pseudoephedrine and Lower limb paresis due to contact allergy. 52