Discussion
Approximately 80,000 fungal species have been identified, and >1 million may exist.6 Respiratory and skin symptoms caused by exposure to these environmental allergens are not uncommon in the atopic population,4 with rates of sensitization in allergy patients ranging from 5% to 20%.6 Case reports suggest that previous sensitization may lead to life-threatening anaphylactic reactions through direct ingestion of molds.4,7
In previous case reports, the most common molds identified as food contaminants were Penicillium, Fusarium, Mucor, Aspergillus, Alternaria, and Cladosporium. 2–5,8 The molds encountered in food spoilage are strictly aerobes.9Oxygen must enter the packaging during manufacturing or afterwards by compromise of the seal, after which high water and carbohydrate content and low light create an environment ripe for mold growth, .9
Our two patients with allergic symptoms after drinking juices and positive skin tests for mold were tested for only five of the most common mold types in our area: Alternaria alternata, Bipoaris sorokiniana, Hormodendrum cladospor, Aspergillus mix, andPenicillium mix. The third patient did not test positive for these molds, but could theoretically be allergic to a different mold species present in her beverage. Although the fourth patient could not be tested for mold, he experienced an allergic reaction following consumption of a packaged juice, and later tested negative to the ingredient which might have explained his reaction. Together, these results are concerning for mold contamination in packaged, preservative-free juices. In response to this risk, Capri Sun changed their juice packaging in 2014 to include clear bottoms, so consumers can detect the presence of molds. 10
Our four patients did not experience true anaphylaxis, but previously published case reports describe patients with previous sensitization to allergens who have experienced anaphylaxis after ingesting food with hidden contaminants. Many health implications associated with ingesting mold cause concern for the safety of children who drink packaged, preservative-free juices. Further studies are needed.
Veronica Kwiatkowski, MD1, Jeanne M. Lomas, DO2
1 Department of Pediatrics, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642
2 Department of Allergy and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642