First draft prepared by
Dr J. B. Greig
Food Standards Agency
London, United Kingdom
Studies relevant to the determination of the prevalence of allergy to carmine of cochineal
Cochineal extract is obtained from the dried bodies of female Dactylopius coccus Costa insects (cochineal). The extract is used directly in food and is also processed further to carmines. Specifications exist for cochineal extract and carmines, both of which contain carminic acid as the colouring principle. The Committee evaluated cochineal extract at its eighteenth and twenty-first meetings but did not allocate an ADI (Annex 1, references 35 and 44). It evaluated carmines at its twenty-first, twenty-fifth, and twenty-sixth meetings (Annex 1, references 44, 56, and 59). At its twenty-sixth meeting, it allocated an ADI of 0–5 mg/kg bw for carmines, as ammonium carmine or the equivalent of calcium, potassium or sodium salts. It did not reconsider this ADI at its present meeting but responded to a request from the Codex Committee on Food Additives and Contaminants (Codex Alimentarius Commission, 2000) to consider the potential allergenicity of cochineal extract, carmine and carminic acid, collectively referred to in this report as ‘cochineal colours’.
At its fifty-third meeting (Annex 1, reference 143), the Expert Committee considered the report of an ad hoc Panel on Food Allergens that had been convened to consider issues relating to the allergenicity of foodstuffs. The Panel identified criteria for adding foodstuffs to the list of common allergenic foods developed by the Codex Committee on Food Labelling, if such additions were necessary. The Expert Committee, at its fifty-third meeting, concluded that these criteria form a suitable basis for addressing the allergenicity of food and food products. In summary, the criteria that are required for the addition of a foodstuff to the Codex list of common allergenic foods are:
(i) the existence of a credible cause-and-effect relationship, based on a positive reaction to a double-blind placebo-controlled food challenge or unequivocal reports of a reaction with the typical features of a severe allergic or intolerance reaction;
(ii) reports of systemic reactions following intake of the foodstuff; and,
(iii) ideally, data on the prevalence of food allergies in children and adults in the general populations of several countries or, alternatively, data on the comparative prevalence of a specific food allergy in groups of patients in several countries.
A review of the allergenic properties of food colours of natural origin was submitted for consideration to the Committee (Lucas et al., 2000).
Asthma due to occupational exposure to carmine has been described in two men, aged 36 and 54, one of whom extracted carmine from the insects; the other worked with carmine as a cosmetic colouring agent. The results of skin prick tests on both patients with carmine and common aeroallergens were negative, and radioallergosorbent tests did not identify specific antibodies to an extract of Dactylopius coccus in the serum from the cosmetics worker. The results of bronchial provocation testing of both patients with cochineal extract were positive. Oral challenge of the first patient with cochineal (1 ml diluted with 100 ml water) resulted in severe abdominal pain after 4 h and a 16% decrease in lung function (forced expiratory volume in 1 min, FEV1) after 11 h. The second patient was challenged with Campari (100 ml) and experienced early and late asthmatic reactions with decreases in FEV1 of 15% after 45 min and 18% at 4.5 h. The condition of both patients improved with avoidance of carmine, but exercise-induced asthma persisted (Burge et al., 1979).
A man aged 30 had used carmine in the preparation of chorizo for 3 months when he developed severe asthma necessitating hospitalization. The results of skin tests with aeroallergens were negative, but he had eosinophilia and an elevated serum immunoglobulin (Ig) E concentration. Challenge in a chamber resulted in severe bronchospasm and a 38% fall in peak expiratory flow rate 4 h after exposure. The asthma recurred when he resumed work and ceased when he stopped (Lenz et al., 1983).
One woman and two men aged 36-54 employed in the food industry and working with carmine of cochineal developed respiratory problems after periods of employment of between 2 months and 10 years. None had a prior history of atopy or respiratory disease. The woman presented with asthma, rhinitis, cough, and dyspnoea on exercise, and these symptoms were exacerbated when she handled carmine and improved when she was hospitalized. The results of skin tests to common aeroallergens were negative, as was that of a skin prick test to a solution of carmine. Although no carmine-specific IgE was found by radioallergosorbence, a dose-dependent liberation of histamine was found in the presence of carmine. One of the men presented with cough and asthmatic crises precipitated by handling carmine, which resolved during leave from the workplace. The result of a skin scratch test with carmine powder was positive, and exposure to carmine in a chamber resulted in a fall in the peak expiratory flow rate of 65% within 2 min, necessitating emergency treatment. The second man, who had worked with food colours for only 2 months, had several episodes of bronchospasm necessitating hospitalization. The result of a skin scratch test with carmine powder was positive, and exposure to carmine in a chamber resulted in a fall in the peak expiratory flow rate of 43% within 10 min (Tenabene et al., 1987).
Subsequently, a sales manager in the same company at which two of the patients described avove had worked experienced recurrent episodes of spasmodic cough, followed 2-4 h later by an influenza-like syndrome. The episodes occurred over a period of 2 years, only on those days when carmine was used. The result of skin prick testing with carmine powder was negative, and the results of tests for lung function and a chest radiograph were normal in the absence of exposure. No immediate reaction occurred on challenge with 25% carmine powder mixed with lactose, but after 2 h the patient experienced coughing and decreased lung function. He complained of nausea and vomiting 3 h after exposure, and these symptoms were maximal 4 h later. His body temperature rose to 39 °C, crackles (râles) were heard in the chest, and chest radiographs showed a slight basal interstitial infiltrate. Two serum precipitin bands against carmine were found by immunodiffusion. The authors suggested that carmine was strongly implicated as the cause of allergic alveolitis in this patient (Dietemann-Molard et al., 1991).
Workers involved in the production of carmine, annatto, and curcuma (turmeric) were investigated for allergy to the colours. The group included nine current workers (four men and five women aged 17-40) and one former worker (a man aged 23). The materials used in the study were a cochineal extract, carmine prepared from cochineal extract (containing 52% carminic acid), and commercially available carminic acid. The responses to a questionnaire revealed that two current employees at the factory had work-related symptoms of rhinitis and, in one case, of asthma. The former employee, who had been affected by carmine-induced asthma and rhinitis, had been symptom-free since leaving the workforce. The basal peak expiratory flow rates of all the workers were within normal limits, but the serial rates of the worker with asthma dropped significantly from baseline values with greater variability on the days he worked with carmine. This man showed bronchial hyperresponsiveness to methacholine, and the responses to bronchial provocation tests were positive (> 20% fall in FEV1) with both carmine and cochineal extract but not with carminic acid or annatto. Three control subjects with asthma did not react in bronchial provocation tests to the highest concentrations of cochineal extract or carmine. The results of skin prick tests with cochineal extract and carmine were positive in only the three subjects who had work-related symptoms. No reactions were observed in any of the employees in skin prick tests with curcuma, annatto, or common aeroallergens. Comparison groups comprising 15 unexposed atopic individuals and 15 unallergic patients did not react to cochineal or carmine. None of the employees was atopic, and only one had a family history of atopy. Although IgG antibodies specific to cochineal and carmine were found in all the employees surveyed, only the individual with current work-related asthma had specific IgE antibodies to cochineal and carmine; the result of a radioallergosorbent test of his serum to a carminic acid–human serum albumin conjugate was negative. Competitive radioallergosorbence with cochineal and carmine and with fractions of these substances separated on the basis of relative molecular mass led the authors to conclude that this patient was sensitized to an antigen or antigens with a relative molecular mass of 10-30 kDa (Quirce et al., 1993, 1994).
A non-smoking, non-atopic 18-year-old man who had worked for 1 year weighing batches of carmine in the cosmetics industry was assessed for occupational asthma. Alterations in lung function and increased airway responsiveness to histamine were recorded after challenge in a chamber with lactose powder containing 3% carmine. The patient was unaware of the nature of the challenge, as lactose powder coloured with amaranth was used in the control trial (Durham et al., 1987; Graneek et al., 1988).
A non-atopic man aged 35 who had worked for 4 years in a spice warehouse reported asthma and rhinoconjunctivitis when handling carmine at work, which had started 5-6 months before his first visit to the clinic. Two weeks before that visit he had developed a systemic reaction, with rhinoconjunctivitis and dyspnoea, after eating a sweet containing a carmine dye (E120). Tests of lung function showed decreases > 25% in peak flow rate after exposure to carmine. The results of skin prick tests with the cochineal insect and carmine were positive, but those of tests with common aeroallergens, several mites, foods, and spices were negative. The result of a specific bronchial challenge test with a cochineal extract was positive, with a dual pattern (20% and 24% falls in FEV1). An oral challenge with carmine gave a positive response. The patient’s serum contained specific IgE for various high relative-molecular-mass proteins from the cochineal extract, as shown by immunoblotting (Acero et al., 1998).
Three women aged 32-59, who reported soreness of the lips with cracking and bleeding, were found to react when their coloured lip salve was used for skin patch tests. Two of the women also reacted to an oil-soluble carmine preparation (Sarkany et al., 1961).
A 19-year-old regular soldier who volunteered to simulate a casualty in a military exercise had an anaphylactic reaction during application of make-up containing carmine red to his trunk and was transferred to emergency facilities. On examination, he was found to be shocked and confused, he had tachycardia, and his blood pressure was unrecordable. He recovered, but no follow-up was possible (Park, 1981).
Patients allergic to carmine in food or drink have reported reactions to carmine-containing cosmetic products (Kägi et al., 1994; Kägi & Wüthrich, 1996; Baldwin et al., 1997; DiCello et al., 1999).
A 34-year-old atopic woman had a severe anaphylactic reaction 15 min after drinking Campari with orange juice. After initial sneezing, rhinitis, and conjunctivitis, pruritus, urticaria, Quincke’s oedema, dyspnoea, bronchospasm, chills, nausea, vomiting, and diarrhoea developed, requiring emergency treatment. The results of skin prick tests with Campari, the carmine dye (E120) used in the manufacture of Campari, and a commercially available carmine preparation were positive, but those of tests with extracts of common food allergens, including those from foods that the woman had eaten just before the anaphylactic reaction, were negative. She had previously experienced reactions to various carmine-containing cosmetic products, and the results of skin prick tests to these substances were positive. Specific IgE to carmine was not detected at the time of the anaphylactic reaction but only after 1 year, during which time she had suffered minor allergic episodes caused by the presence of undeclared colours in foodstuffs (Kägi et al., 1994; Kägi & Wüthrich, 1996).
The same group subsequently reported this case and four others that had been referred to them over 2 years. All the new patients were female (aged 25-43) and had drunk Campari with orange or Campari Bitter before experiencing either acute urticaria and angioedema (two cases) or an anaphylactic reaction requiring emergency treatment (two cases). Two of the four new patients had a history of atopic disease. All had positive responses in skin prick tests with Campari or the carmine used in its manufacture, but only one patient reacted to a commercially available carmine preparation. The results of specific skin prick tests were positive for camomile and celeriac (two cases) or mugwort (one case). Class 1 or 2 reactions were found in a radioallergosorbent test to carmine; in only one case was a positive response found in a radioallergosorbent test to a carminic acid-human serum albumin conjugate (Wüthrich et al., 1997).
A woman aged 35 presented to an emergency service with generalized urticaria, angioedema, and asthma that had begun 2 h after she had eaten a yoghurt containing carmine dye. She had experienced similar episodes after eating various red-coloured foods. The amount of carmine in the yoghurt was estimated to have been 1.3 mg. The results of skin prick tests with the same brand of yoghurt and with carmine powder were positive, as was that of a test for the release of histamine from leukocytes, with a maximum of 18% release of histamine at a concentration of carmine of 0.1 mg /ml (Beaudouin et al., 1995). The amount of carmine was estimated from information provided by the French food industry on the content of carmine of cochineal in a yoghurt containing 'forest fruits' (Moneret-Vautrin, 2000).
A 27-year old woman with a history of allergic rhinitis and positive responses to skin prick tests with various aeroallergens experienced an anaphylactic reaction requiring emergency treatment after eating a popsicle (iced lollipop) containing carmine. There was immediate onset of nausea, and pruritus, urticaria, and hypotension with tachycardia developed within 3 h. She reported having had a pruritic, erythematous eruption after applying a cosmetic containing carmine directly to the skin, which did not occur if the cosmetic was applied over a foundation make-up. This reaction was not reproduced in the clinic. The results of skin prick tests with the popsicle and a carmine preparation used in the manufacture of the popsicle were positive in the patient and negative in her husband. Twenty additional control subjects gave negative reactions to skin prick tests with the carmine preparation. None of the other ingredients of the popsicle elicited positive reactions in either skin prick tests or open oral challenge of the patient. Passive sensitization (Prausnitz-Küstner test) with the husband as recipient was used to demonstrate the presence of carmine-specific IgE in the patient’s serum. Reactions did not occur at sites on the husband’s arm which had been injected with heat-treated serum but did occur at sites injected with untreated serum (Baldwin et al., 1997).
The same group reported the cases of two non-atopic women aged 27 and 42 who had experienced anaphylactic reactions requiring emergency treatment after ingestion of, respectively, a carmine-containing yoghurt and Campari. Both had experienced reactions to foodstuffs and carmine-containing cosmetics on previous occasions. Positive reactions in skin prick tests to a dilution of carmine and to a carmine filtrate containing materials of relative molecular mass < 3 kDa were reported in both women; the results of skin prick tests to common aeroallergens were negative. The patients refused a double-blind placebo-controlled food challenge. Forty-two control subjects, of whom 29 were considered to be atopic, did not react to a skin prick test with carmine, and 10 control subjects, who may have comprised a separate group, did not react to a skin prick test with the carmine filtrate (DiCello et al., 1999).
The results of studies on the proteins in carmine that reacted with antibodies in the sera of three female patients who had experienced allergic reactions to carmine-containing foods were reported in an abstract. Two of these cases may not have been reported previously. Minced Dactylopius coccus insects retained a red colour after dialysis; after sodium dodecyl sulfate-polyacrylamide gel electrophoresis, several bands of relative molecular mass 23–88 kDa were recognized by sera from individual patients. The binding was inhibited by carmine. Similarly, three bands from dialysed carmine lake were detected by the sera of two of the three patients. The authors suggested that insect-derived proteins, possibly complexed with carminic acid, are responsible for allergy to carmine (Chung et al., 2000).
A 28-year old woman noted a disorder of the larynx 1 h after drinking a Campari from an unspecified company. One hour later she had irritation and oedema of the eyelids, which was followed by generalized urticaria, severe stomach ache, and diarrhoea. Similar symptoms had occurred on three previous occasions after consumption of strawberry-flavoured milk or red-coloured cocktails. The results of skin prick tests to the strawberry milk, the Campari, and a cochineal extract were positive (Kume et al., 1997).
A 35-year-old man who had developed asthma and rhinoconjunctivitis after handling carmine at work (see above) reported an asthmatic episode after ingestion of a red-coloured sweet containing carmine. The result of a double-blind oral challenge with E 120 was positive (Acero et al., 1998).
Six food colours (including carminic acid), sodium benzoate, aspirin, and penicillin were tested in vitro in an antigen stimulation test with lymphocytes from two groups of patients. The control group comprised 48 hospital patients with non-allergic clinical conditions; the test group included 36 patients with urticaria or chronic Quincke’s oedema of unknown cause from a group of 61 patients presenting with these conditions. One of the lymphocyte preparations from 21 control patients and 7 of 34 preparations from the test group were stimulated by the addition of carminic acid. The results of skin tests with carminic acid were positive in 10 of 34 test patients, and five of these subjects also had positive reactions in the lymphocyte stimulation test. Four of the five subjects with positive responses in both the stimulation and skin tests who were challenged sublingually with carminic acid reacted with at least a simple pruritic reaction (Fernandes et al., 1977).
Twelve atopic and 12 non-atopic individuals, comprising four men and 20 women, with a diagnosis of irritable bowel syndrome of no demonstrable organic origin and with symptoms that had persisted for between 8 months and 13 years were asked to adhere to an allergen exclusion diet. After 3 weeks, other foods were reintroduced singly or in series. If the reintroduction resulted in exacerbation of symptoms, the foods were withheld for 1 or 2 weeks and then reintroduced. Provocation tests were conducted in individuals who reported exacerbation at the second reintroduction. Serum IgE concentrations were measured and skin prick tests were performed with common aeroallergens, six food additives, and 18 food antigens; no radioallergosorbent test was performed with food additives. Only one non-atopic patient responded to exclusion of carminic acid (and erythrosine) from the diet. The result of the skin prick test with carminic acid was negative, as was the challenge. One atopic individual had a positive reaction in a skin prick test with carminic acid (Petitpierre et al., 1985).
A register of cases of fatal anaphylaxis in the United Kingdom (Pumphrey, 2000a), which contains over 200 cases more than 50 of which are attributable to food allergy, contains none attributed to carmine of cochineal. However, the cause of the anaphylactic reaction has not been determined for some cases (Pumphrey, 2000b).
Carmine of cochineal is reported to have been used in medicinal products. A request to the United Kingdom’s Medicines Control Agency for reports of adverse reactions to carmine received the following response: "At the time of writing, the Committee on Safety of Medicines/Medicines Control Agency have received no reports of suspected Adverse Drug Reactions associated with the colourant carmine." (Committee on Safety of Medicines, 2000).
A group of 903 patients with food allergy or intolerance have contributed to the database of the Cercle d’Investigations Cliniques et Biologiques en Allergologie Alimentaire in France. Of these, 5.5% had an intolerance to food additives, and of these eight cases corresponded to an intolerance to food colours. Only one case of the eight was attributable to carmine of cochineal (Moneret-Vautrin, 2000). Although this information is possibly indicative of a low incidence of allergy to carmine of cochineal, the Committee considered that it cannot be used to estimate the prevalence of this allergy.
Adverse reactions to cochineal colours after occupational exposure, dermal contact, or consumption of coloured food and drinks have been the subject of case reports. The reported effects were the consequence of allergic reactions, and the involvement of an immunologically mediated mechanism has been demonstrated. The nature of the adverse reactions, e.g. urticaria, rhinitis, diarrhoea, and anaphylaxis, provides clear evidence that systemic reactions can follow exposure of a sensitized individual to cochineal colours. Some of the adverse reactions were severe and required emergency treatment. The weight of evidence suggests that proteins in the food colours are the allergenic species; however, the structures of the proteins and the role of protein-bound carminic acid in the allergic reaction are unknown. The Committee considered that the first two criteria for the addition of a foodstuff to the Codex list of allergenic foods were satisfied.
The data on allergic reactions to food and drinks containing the cochineal colours are derived predominantly from case reports. Although tests on control groups of patients were reported, in general the studies were not designed so as to allow estimation of the incidence or prevalence of allergy to the cochineal colours in the general population. Additional data were available that suggested that sensitization to the cochineal colours is rare, but the data did not allow estimation of even comparative prevalence rates between countries, and the third criterion for the addition of a foodstuff to the Codex list of allergenic foods was not satisfied.
Cochineal colours are present in many foods and drinks. The quantity of the cochineal colours that provoked an adverse reaction in an individual was estimated in only one study. Because the occurrence and severity of an allergic reaction after ingestion of a specific amount of cochineal colours depends on the sensitivity of each atopic individual, the Committee concluded that estimates of the long-term intake of these colours in a population were irrelevant to its deliberations.
The Committee concluded that cochineal extract, carmines, and, possibly, carminic acid in foods and beverages may initiate or provoke allergic reactions in some individuals. Because some of the adverse reactions are severe, it considered that appropriate information, for example noting the presence of the colour in foods and beverages, should be provided to alert individuals who are allergic to these compounds.
Acero, S., Tabar, A.I., Alvarez, M.J., Garcia, B.E., Olaguibel, J.M. & Moneo, I. (1998) Occupational asthma and food allergy due to carmine. Allergy, 53, 897–901.
Baldwin, J.L., Chou, A.H. & Solomon, W.R. (1997) Popsicle-induced anaphylaxis due to carmine dye allergy. Ann. Allergy Asthma Immunol., 79, 415–419.
Beaudouin, E., Kanny, G., Lambert, H., Fremont, S. & Moneret-Vautrin, D.A. (1995) Food anaphylaxis following ingestion of carmine. Ann. Allergy Asthma Immunol., 74, 427–430.
Burge, P.S., O’Brien, I.M., Harries, M.G. & Pepys, J. (1979) Occupational asthma due to inhaled carmine. Clin. Allergy, 9, 185–189.
Chung, K., Chou, A., Baker, J., Jr & Baldwin, J. (2000) Identification of carmine allergens among three carmine allergy patients [Abstract]. J. Allergy Clin. Immunol., 105, S132.
Codex Alimentarius Commission. Report of the Thirty-first Session of the Codex Committee on Food Additives and Contaminants, The Hague, 22–26 March 1999. Rome, Food and Agriculture Organization of the United Nations, 2000 (unpublished FAO document ALINORM 99/12A; available from FAO or WHO).
Committee on Safety of Medicines (2000) Unpublished information submitted to WHO in letter dated 12/05/2000 from V. Newbould, ADROIT Pharmacovigilance Group, Medicines Control Agency, London, United Kingdom.
DiCello, M.C., Myc, A., Baker, J.R., Jr & Baldwin, J.L. (1999) Anaphylaxis after ingestion of carmine colored foods: Two case reports and a review of the literature. Allergy Asthma Proc., 20, 377–382.
Dietemann-Molard, A., Braun, J.J., Sohier, B. & Pauli, G. (1991) Extrinsic allergic alveolitis secondary to carmine [Letter]. Lancet, 338, 460.
Durham, S.R., Graneek, B.J., Hawkins, R. & Newman Taylor, A.J. (1987) The temporal relationship between increases in airway responsiveness to histamine and late asthmatic responses induced by occupational agents. J. Allergy Clin. Immunol., 79, 398–406.
Fernandes, B., Figueiredo, E. & Girard, J.P. (1977) [Studies of several food additives as aetiologic factors for chronic urticaria and angioedema]. Rev. Fr. Allergol., 17, 127–131.
Graneek, B.J., Durham, S.R. & Newman Taylor, A.J. (1988) Late asthmatic reactions and changes in histamine responsiveness provoked by occupational agents. Bull. Eur. Physiopathol. Respir., 23, 577–581.
Kägi, M.K. & Wüthrich, B. (1996) Anaphylaxis following ingestion of carmine [Letter]. Ann. Allergy Asthma Immunol., 76, 296.
Kägi, M.K., Wüthrich, B. & Johansson, S.G.O. (1994). Campari-Orange anaphylaxis due to carmine allergy. Lancet, 344, 60–61.
Kume, A., Fujimoto, M., Hino, N., Ueda, K. & Higashi, N. (1997) A case of Type I allergy due to cochineal extract [Abstract]. In: Program and Abstracts. The 22nd Annual Meeting of Japanese Society for Contact Dermatitis, 28–30 November 1997, Yokohama, Japan. Submitted to WHO by the National Food Colours Association, Basel, Switzerland.
Lenz, D., Pelletier, A., Pauli, G., Roegel, E., Aouizerate, E., Enjalbert, M., Bouvot, J.L. & Courty, G. (1983) [Occupational asthma due to cochineal carmine]. Rev. Fr. Mal. Respir., 11, 487–488.
Lloyd, A.G. (1980) Extraction and chemistry of cochineal. Food Chem., 5, 91–107.
Lucas, C.D., Taylor, S.L., Hallagan, J.B. & Gierke, T.L. (2000) The role of natural colour additives in food allergy. Adv. Food Nutr. Res., in press. Submitted to WHO by the International Association of Color Manufacturers, Washington DC, USA.
Moneret-Vautrin, D.-A. (2000)Unpublished information submitted to WHO by Professor D.A. Moneret-Vautrin, Service d’Immunologie Clinique et d’Allergologie, Hôpital Central, Nancy, France.
Park, G.R. (1981) Anaphylactic shock resulting from casualty simulation. A case report. J. R. Army Med. Corps, 127, 85–86.
Petitpierre, M., Gumowski, P. & Girard, J.-P. (1985) Irritable bowel syndrome and hypersensitivity to food. Ann. Allergy, 54, 538–540.
Pumphrey, R.S.H. (2000a) Lessons for the management of anaphylaxis from a study of fatal reactions. Clin. Exp. Allergy, 6, in press.
Pumphrey, R.S.H. (2000b) Unpublished information submitted to WHO by Dr R.S.H Pumphrey, Northwest Immunology Service, St Mary’s Hospital, Manchester, United Kingdom.
Quirce, S., Cuevas, M., Olaguibel, J.M. & Tabar, A.I. (1993) Clinical and immunologic studies of carmine-exposed workers [Abstract]. J. Allergy Clin. Immunol., 91, 219.
Quirce, S., Cuevas, M., Olaguibel, J.M. & Tabar, A.I. (1994). Occupational asthma and immunologic responses induced by inhaled carmine among employees at a factory making natural dyes. J. Allergy Clin. Immunol., 93, 44–52.
Sarkany, I., Meara, R.H. & Everall, J. (1961) Cheilitis due to carmine in lip salve. Trans. St John’s Hosp. Dermatol. Soc., 48, 39–40.
Tenabene, A., Bessot, J.C., Lenz, D., Kofferschmitt-Kubler, M.C. & Pauli, G. (1987) [Occupational asthma due to cochineal carmine]. Arch. Mal. Prof., 48, 569–571.
Wüthrich, B., Kägi, M.K. & Stücker, W. (1997) Anaphylactic reactions to ingested carmine (E120). Allergy, 52, 1133–1137.
See Also: Toxicological Abbreviations