Journal Information
Vol. 111. Issue 2.
Pages 178-180 (March 2020)
Vol. 111. Issue 2.
Pages 178-180 (March 2020)
Case and Research Letters
DOI: 10.1016/j.adengl.2018.09.021
Open Access
When a Gin And Tonic Can Mean Trouble: Fixed Drug Eruption Due to Quinine
Cuando tomarse un gin-tonic se convierte en una mala experiencia: exantema fijo medicamentoso por quinina
Visits
...
M. Castellanos-Gonzáleza,
Corresponding author
, B. Díaz-Leya, B. Huertas-Barbudob, M.A. Segurado Rodrígueza
a Servicio de Dermatología y Venereología, Hospital del Sureste, Arganda del Rey, Madrid, Spain
b Servicio de Alergia, Hospital del Sureste, Arganda del Rey, Madrid, Spain
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Tables (1)
Table 1. Summary of cases of FDE published to date.a
Full Text
To the Editor:

A fixed drug eruption (FDE) may be caused by different drugs, especially NSAIDs, paracetamol, and antibiotics. In recent years, cases due to the quinine in tonic water have been reported. We report a case of FDE caused by quinine after drinking a gin and tonic and we review the cases published to date. We analyze the current legislation on the amount of quinine allowed in drinks and the differences between the different brands sold in Spain.

A 32-year-old woman visited our department with repeated outbreaks of erythematous-violaceous lesions with irregular, edematous margins in the perioral region, the 5th finger of the left hand, and the lateral surface of the right hand, compatible with FDE (Fig. 1). The patient occasionally took diclofenac and metamizole but did not improve. On examining the patient’s full medical history, we discovered that the lesions coincided with the consumption of gin and tonic; quinine was therefore suspected.

Figure 1.

Clearly defined brownish-erythematous lesions.

(0.14MB).

A skin-patch test performed with Schweppes® tonic water was negative, and epicutaneous tests with the tonic, with quinine in petrolatum at 20%, and in aqueous solution at 1%, were also negative after 48 and 96 h. An oral provocation test was positive, with appearance of the lesions a few hours after consumption. The patient has remained asymptomatic since removing tonic water from her diet.

FDE is characterized by the appearance of erythematous-violaceous, eczematous or bullous lesions that cause pruritus or a burning sensation, always in the same locations, after exposure to a specific agent in sensitized patients. It is considered to be a type of delayed hypersensitivity and is caused by many drugs. On rare occasions, foods may be involved, such as strawberries, green beans, asparagus, and cashews.1In these cases, it is called fixed food eruption. FDE due to quinine was first reported in 20032 and 11 cases have since been published, coinciding with the increased consumption of tonic water, particularly in combination with gin (Table 1).

Table 1.

Summary of cases of FDE published to date.a

Author  Year  Age  Sex  Location  Biopsy  Patch tests  Oral provocation test  Tonic water brand 
Asero2  2003  23  Female  Upper lip, arm, neck, back, and chest  No  Negative   
Muso et al.3  2007  24  Female  Lip, fingers  No  Positive  − 
Muso et al.3  2007  37  Male  Fingers and elbow  No  Positive  − 
Gázquez et al.4  2009  34  Male  Right hand, tongue, and oral mucosa  Yes  Positive  − 
Bel et al.5  2009  57  Female  Hand, fingers, wrists, ear  Yes  Positive  No  Schweppes® 
Gonzalo Garijo et al.6  2012  32  Female  Lip, hand  No  Negative  − 
Ohira et al.1  2013  26  Male  Perioral region, lumbar region, penis  No  Positive  Schweppes® 
Lonsdale-Eccles et al.7  2014  20  Male  Tongue, lip, penis  Yes  No  − 
Genest et al.8  2014  25  Male  Palate, finger, penis  No  Negative  No  Canada Dry® 
Castellanos González et al.  2018  32  Female  Lip, hand, and fingers  Yes  Negative  Schweppes® 
a

Two more cases exist, for which we could find no data.

Quinine is a natural alkaloid obtained from the bark of the Cinchona officinalis tree, of the Rubiaceae family. It was used traditionally to treat malaria, but its current principal use is as an aroma in tonic water, due to its bitter flavor; this is now considered to be the main source of quinine in the diet. It is considered toxic at doses of greater than 1 g per day and causes gastrointestinal, visual, and auditory problems. Nevertheless, the legislation governing its use as a food is heterogeneous at the national level. Thus, in the US, the FDA limits its concentration in tonic water to 83 mg/L, whereas in Japan, quinine is classed as a drug and its use as a food additive is not permitted. The European Union, in Regulation (CE) 872/2012, of 1 October 2012, establishes a maximum limit of quinine in soft drinks of 100 mg/L. Furthermore, it must be indicated on the list of ingredients.9

The lesions in our patient appeared on consuming Schweppes® tonic water but not Nordic Blue®. This fact led us to wonder whether differences exist in the amount of quinine present in different tonic waters.

Labeling does not mention quinine concentration in drinks sold in Spain. However, this has been studied by the scientific community and high-resolution liquid chromatography has shown that the quantity of quinine differs depending on the commercial brand. The concentration is higher in Schweppes® than in Nordic Mist® (60.3 mg/L vs 55.0 mg/L, respectively).10 Other authors found that some brands had twice as much quinine as others.11 Ohira et al.1 detected peaks in the chromatogram only in Schweppes® and Canada Dry®. Nevertheless, the levels of quinine in all the brands studied are below the maximum levels allowed by current technical health regulations, and, according to consumption data, estimated consumption is below the toxic dose. In our case, we exposed different brands to ultraviolet light and found that the only brand that did not fluoresce was precisely the brand that did not cause lesions in our patient (Fig. 2A and B). This is a drink without quinine and cannot therefore be considered a tonic water but rather a soft drink with extracts. It is bottled in a similar form and is sold in supermarkets alongside the tonic waters, which gives rise to confusion. It may, however, be an alternative to tonic water in cases of fixed food eruption due to quinine, as its flavor is similar.

Figure 2.

Three different commercial brands of tonic water (A) were exposed to ultraviolet light (B).

(0.24MB).

We highlight the importance of taking a thorough medical history to find the agent responsible for an FDE, as it is not always a drug. We also note that not all tonic waters on the market contain the same amount of quinine. We propose an alternative to tonic water, with a similar flavor, for patients with FDE due to quinine.

Conflicts of interest

The authors declare that they have no conflicts of interest.

References
[1]
A. Ohira, S. Yamaguchi, T. Miyagi, Y. Yamamoto, S. Yamada, H. Shiohira, et al.
Fixed eruption due to quinine in tonic water: a case report with high-performance liquid chromatography and ultraviolet A analyses.
J Dermatol, 40 (2013), pp. 629-631
[2]
R. Asero.
Fixed drug eruptions caused by tonic water.
J Allergy Clin Immunol, 111 (2003), pp. 198-199
[3]
Y. Muso, O. Kentarou, S. Itami, K. Yoshikawa.
Fixed eruption due to quinine: report of two cases.
J Dermatol, 34 (2007), pp. 385-386
[4]
V. Gázquez, C. Gómez, G. Daimau, P. Gaig, J. Landeyo.
A case of fixed drug eruption due to quinine.
Clin Exp Dermatol, 34 (2009), pp. 95-97
[5]
B. Bel, G. Jeudy, D. Bouilly, S. Dalac, P. Vabres, E. Collet.
Fixed eruption due to quinine contained in tonic water: positive patch-testing.
Contact Dermatitis, 61 (2009), pp. 242-244
[6]
M.A. Gonzalo-Garijo, M.A. Zambonino, R. Pérez-Calderón, I. Pérez-Rangel, S. Sánchez-Vega.
Fixed drug eruption due to quinine in tonic water: study of cross-reactions.
[7]
E. Lonsdale-Eccles, A. Wallett, A.M. Ward.
A case of fixed drug eruption secondary to quinine in tonic water presenting to a sexual health clinic.
Sex Transm Infect, 90 (2014), pp. 356-357
[8]
G. Genest, D.M. Thomson.
Fixed Drug eruption to quinine: a case report and review of the literatura.
J Alerrgy Clin Immunol Pract, 2 (2014), pp. 469-470
[9]
European Union. Regulation (EU) No 872/2012 of 1 October 2012 adopting the list of flavouring substances provided for by Regulation (EC) No 2232/96 of the European Parliament and of the Council, introducing it in Annex I to Regulation (EC) No 1334/2008 of the European Parliament and of the Council and repealing Commission Regulation (EC) No 1565/2000 and Commission Decision 1999/217/EC. Official Journal of the European Union L 267/1, of 2 October 2012.
[10]
A.B. González Reyes, A. Hardisson de la Torre, A.J. Gutiérrez Fernández, C. Rubio Armendáriz, I. Frías Tejera, C. Revert Gironés.
Valoración nutricional Cafeína y quinina en bebidas refrescantes; contribución a la ingesta dietética.
Nutr Hosp, 32 (2015), pp. 2880-2886
[11]
X. Féas Sánchez, J. Robert Brasíc, C.A. Fente Sampayo, A. Cepeda Sáez.
Nutr. Clín Diet Hosp, 28 (2008), pp. 20-25

Please cite this article as: Castellanos-González M, et al. Cuando tomarse un gin-tonic se convierte en una mala experiencia: exantema fijo medicamentoso por quinina. Actas Dermosifiliogr. 2020;111:178–180.

Copyright © 2019. AEDV
Idiomas
Actas Dermo-Sifiliográficas (English Edition)

Subscribe to our newsletter

Article options
    NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
    NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
    NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
    NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
  • Additional material
Tools
NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
NOTICE Undefined index: tipo (includes_ws_v2/librerias/html/item.php[1273])
Supplemental materials
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.