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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Moringa is a plant native to the southern Himalayas that belongs to the Moringaceae family&#46; The most common species is <span class="elsevierStyleItalic">Moringa oleifera</span>&#46; It is widely used in traditional medicine in developing countries owing to its empirical nutritional&#44; antioxidant&#44; and therapeutic properties&#46; Although its active principles and its effects remain unknown&#44; the moringa market in developed countries is booming&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> We present a case of a rarely described adverse effect&#58; cutaneous toxicity due to moringa&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 57-year-old woman with a personal history of hypertension&#44; dyslipidemia&#44; and fibromyalgia was referred to the emergency department for a generalized pruritic rash that had appeared 3 days earlier and was accompanied by mild respiratory distress and edema of the tongue&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed a morbilliform rash on the face&#44; trunk&#44; and upper limbs that consisted of confluent erythematous papules that disappeared with diascopy and was interspersed with areas of healthy skin&#46; There were no vesicles or blisters and the mucous membranes were spared &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">During the interview&#44; the patient denied having consumed any new medication or food&#44; but reported that for 2 weeks she had been taking moringa in powder form in order to lose weight&#44; adding unspecified amounts to salads and taking daily infusions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A biopsy showed dotted and confluent necrotic keratinocytes with a perivascular inflammatory infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the suspected diagnosis of cutaneous toxicity due to moringa&#44; use of moringa powder was discontinued and the patient was prescribed symptomatic treatment with antihistamines and a topical corticosteroid&#44; which resulted in progressive resolution of the condition over the following 10 days&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Moringa&#44; like any medicinal plant&#44; can cause harm due to the direct pharmacological effects of some of its components&#44; interactions with commonly used drugs&#44; or the presence of unknown contaminants&#46; The exact mechanism of action of moringa is unknown and most studies have exclusively investigated its anti-inflammatory properties&#44; although its effects in our patient were precisely the opposite&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The reported adverse effects of moringa include alterations in liver and kidney function&#44; miscarriage&#44; alterations in hematologic parameters&#44; diarrhea&#44; insomnia&#44; and lithiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> No frequent cutaneous adverse effects have been reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several studies of <span class="elsevierStyleItalic">M oleifera</span> have been published in recent years&#44; mainly in rodents&#44; and have shown that these harmful effects appear to increase in correlation with dose and duration of consumption&#46; However&#44; little effort has been made to standardize the moringa extracts studied&#44; and it is therefore difficult to compare and contrast results between studies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">No adverse effects were reported in a human study conducted with whole leaf powder at a single dose of 50&#8239;g or in another study in which participants received a dose of 8&#8239;g per day for 40 days&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; higher concentrations of toxic substances have been detected in the seeds&#44; root&#44; and bark of the plant&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">One case of urticaria was described in an article published in the journal of the Spanish Society of Allergology and Immunology&#46; The authors described a 54-year-old man who presented with urticaria after taking a food supplement consisting of powdered moringa leaves&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> An article recently published by the Sri Lankan medical association described Stevens&#8211;Johnson syndrome in a 53-year-old man who had consumed moringa leaves&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Rash and urticaria are the most frequently reported immediate adverse reactions associated with herbal medicines&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The few published studies of moringa have demonstrated that it contains the potentially toxic agents moringin and moringinin&#44; plant alkaloids that are structurally very similar to ephedrine&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Both ephedrine and pseudoephedrine exert adverse cutaneous effects&#44; which include eruption&#44; fixed drug eruption&#44; acute generalized exanthematous pustulosis&#44; and erythroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Descriptions of lesion histology are absent from most of these reports and&#44; if included&#44; tend to consist of variable&#44; nonspecific changes&#46; Reported findings include hydropic changes in the basement membrane and perivascular infiltrate&#44; but not necrosis as intense as that observed in our patient&#8217;s biopsy&#44; the results of which were compatible with Stevens&#8211;Johnson syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">These types of plants are classified as dietary foods or supplements&#44; and therefore do not require evidence of quality&#44; efficacy&#44; or safety prior to commercialization&#46; Due to the large number of components that a single plant can contain&#44; evaluation of efficacy and safety is much more complex than for conventional drugs&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We wish to highlight the importance of monitoring the consumption and adverse effects of <span class="elsevierStyleItalic">M oleifera</span>&#44; given the growing market for this plant in Europe&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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Case and Research Letters
Cutaneous Toxicity Due to Moringa oleifera
Toxicodermia por Moringa oleifera
A. Sagreraa,
Corresponding author
anasagreraguedes@gmail.com

Corresponding author.
, T. Montenegrob, L. Borregoa
a Servicio de Dermatología, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain
b Servicio de Anatomía Patológica, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain
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trunk&#44; and upper limbs that consisted of confluent erythematous papules that disappeared with diascopy and was interspersed with areas of healthy skin&#46; There were no vesicles or blisters and the mucous membranes were spared &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">During the interview&#44; the patient denied having consumed any new medication or food&#44; but reported that for 2 weeks she had been taking moringa in powder form in order to lose weight&#44; adding unspecified amounts to salads and taking daily infusions&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A biopsy showed dotted and confluent necrotic keratinocytes with a perivascular inflammatory infiltrate &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the suspected diagnosis of cutaneous toxicity due to moringa&#44; use of moringa powder was discontinued and the patient was prescribed symptomatic treatment with antihistamines and a topical corticosteroid&#44; which resulted in progressive resolution of the condition over the following 10 days&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Moringa&#44; like any medicinal plant&#44; can cause harm due to the direct pharmacological effects of some of its components&#44; interactions with commonly used drugs&#44; or the presence of unknown contaminants&#46; The exact mechanism of action of moringa is unknown and most studies have exclusively investigated its anti-inflammatory properties&#44; although its effects in our patient were precisely the opposite&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The reported adverse effects of moringa include alterations in liver and kidney function&#44; miscarriage&#44; alterations in hematologic parameters&#44; diarrhea&#44; insomnia&#44; and lithiasis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> No frequent cutaneous adverse effects have been reported&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Several studies of <span class="elsevierStyleItalic">M oleifera</span> have been published in recent years&#44; mainly in rodents&#44; and have shown that these harmful effects appear to increase in correlation with dose and duration of consumption&#46; However&#44; little effort has been made to standardize the moringa extracts studied&#44; and it is therefore difficult to compare and contrast results between studies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">No adverse effects were reported in a human study conducted with whole leaf powder at a single dose of 50&#8239;g or in another study in which participants received a dose of 8&#8239;g per day for 40 days&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; higher concentrations of toxic substances have been detected in the seeds&#44; root&#44; and bark of the plant&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">One case of urticaria was described in an article published in the journal of the Spanish Society of Allergology and Immunology&#46; The authors described a 54-year-old man who presented with urticaria after taking a food supplement consisting of powdered moringa leaves&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> An article recently published by the Sri Lankan medical association described Stevens&#8211;Johnson syndrome in a 53-year-old man who had consumed moringa leaves&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Rash and urticaria are the most frequently reported immediate adverse reactions associated with herbal medicines&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The few published studies of moringa have demonstrated that it contains the potentially toxic agents moringin and moringinin&#44; plant alkaloids that are structurally very similar to ephedrine&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Both ephedrine and pseudoephedrine exert adverse cutaneous effects&#44; which include eruption&#44; fixed drug eruption&#44; acute generalized exanthematous pustulosis&#44; and erythroderma&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Descriptions of lesion histology are absent from most of these reports and&#44; if included&#44; tend to consist of variable&#44; nonspecific changes&#46; Reported findings include hydropic changes in the basement membrane and perivascular infiltrate&#44; but not necrosis as intense as that observed in our patient&#8217;s biopsy&#44; the results of which were compatible with Stevens&#8211;Johnson syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">These types of plants are classified as dietary foods or supplements&#44; and therefore do not require evidence of quality&#44; efficacy&#44; or safety prior to commercialization&#46; 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Article information
ISSN: 15782190
Original language: English
DOI:10.1016/j.adengl.2021.09.008
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