Mustard

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Code: f89
Latin name: Brassica/Sinapis spp.
Source material: Black and white seeds
Family: Brassicaceae
Common names: Mustard (but see immediately below)
Mustards were originally identified as members of a small but widespread genus of European and Asiatic herbs named Sinapis, but they are now generally included in the Cabbage genus, Brassica.
 
The following should be distinguished: 
 
  • White Mustard (Brassica alba; syn.: Brassica hirta, Sinapis alba): 
    Known in the USA as Yellow Mustard; Eurasian Mustard cultivated for its pungent seeds; a common source of table Mustard
     
  • Black Mustard (Brassica nigra; syn.: Sinapis nigra, Brassica sinapioides):
    Widespread Eurasian annual plant cultivated for its pungent seeds; a common source of table Mustard and Mustard oil
     
  • Brown Mustard (Brassica juncea; syn.: Br. integrifolia): 
    Also known as Oriental Mustard, Chinese Mustard, Indian Mustard, Leaf Mustard, Sarepta Mustard, and Asiatic Mustard; used as a spice and a potherb, and for Mustard oil
Spice
A spice, which may result in allergy symptoms in sensitised individuals.

Allergen Exposure

Geographical distribution
Mustard is one of the oldest and most common spices. The Chinese have used it for thousands of years, and the ancient Greeks used it routinely, as well as holding it in very high esteem as a medicine. For the Romans, it was a condiment and pickling spice, and it got its modern English name when they brought it north in mixtures with new wine (mustum, which was combined with the word ardere, "to burn"). (Mixing with vinegar, wine, grape juice or some other liquid has been the traditional method of activating Mustard’s flavour, which depends on volatile compounds that are released by the plant for defense purposes. This defense system is similar to that found in cyanide-producing plants like Almond.) Today, world consumption of Mustard exceeds 400 million pounds.
 
All of the Mustard varieties come from species of annually flowering bushes or small trees, which are often experienced as weeds or even destructive pests. The leaves, Mustard greens, are used as a vegetable. If leaves are not harvested, strange seed stalks are sent up by the plants, and the condiment is made from the seeds. White Mustard is a round, hard seed, beige or straw-coloured. Black Mustard is a round, hard seed, varying in colour from dark brown to black, smaller and much stronger in taste than the White. Brown Mustard is similar in size to the Black variety and varies from light to dark brown. It is more pungent than the White, less than the Black, and its leaves can be a potherb.
 
Environment
Mustard pastes are a common condiment for meat in the West, and are also used in sauces. Mild, American styles of Mustard paste, and the mild European Bordeaux Mustard, tend to contain white Mustard seeds only. Several varieties of hot Mustard pastes contain either Brown or Black Mustard or combine seeds of different species. German (the variety, not the place of origin) and Meaux Mustard pastes generally use Black Mustard seeds only. British Mustard paste is mostly of the Colman variety, combining Black Mustard and White Mustard. The classic Dijon is made from Brown or Black Mustard. Mustard paste is usually composed of crushed or ground Mustard seeds and vinegar and wine or wine vinegar.
 
Frequently sugar or honey, salt, fresh herbs and dried spices are added to modify the taste; most common is the addition of Tarragon. Other spices such as Cinnamon, Cloves and Pepper may also be included in the recipe. Some types of Mustard (most commonly American “Ballpark” Mustard) contain Turmeric, which gives a bright yellow colour. Wheat flour, water, starch, stabilisers, preserving agents, and colourants other than Tumeric may be added as well.
 
Mustard powder usually combines Black and White Mustard seeds and is used in a variety of recipes and processed foods, especially sausages. Black and Brown Mustard seeds are often used directly as a spice or condiment in the East. Because of its erucic acid and isothiocynanate content, Mustard oil (the term Mustard oil is used both for the fatty oil and for the pure isothiocyanates) cannot be legally traded as a foodstuff in most Western countries, but it is a characteristic ingredient of some Eastern cuisines (especially Bengali). The oil also has cosmetic uses in India, and in the West features in soaps, liniments and lubricants, and in a non-volatile state in some food products such as salad oil.
 
Historically, Mustard has always been important in medicine. Although the volatile oil of Mustard is a powerful irritant, in dilution as a liniment or poultice it soothes, creating warmth and drawing blood to the surface. Over the years Mustard has been prescribed for a huge variety of ailments, from scorpion stings and snake bites to constipation and respiratory troubles. Mustard derivatives, such as nitrogen Mustard (mechlorethamine) have been used as antineoplastic drugs. The internal use of the seeds can be problematic because of the possibility of retention in the intestines, and the volatile compounds that can be released from Mustard necessitate caution in applications of all sorts.
 
The pungent and irritating allyl isothiocyanate (“Mustard gas”) that is released from Brown and Black Mustard, Horseradish and other pungent vegetables of the same family has been used in war gas products and other weapons. The plant source of the active chemicals is sinigrin (or allylglucosinolate, which is also known as potassium myrosinate). Besides allyl isothiocyanate, in Romanian Brown Mustard another related compound is found, namely crotylisothiocyanate (2-butenylisothiocyanate). Capsaicin, the irritant ingredient of capsicum, can also be found in Mustard. An irritant in White Mustard is sinalbin.
 
Unexpected exposure
See under Environment. Mustard is a dangerous "hidden" allergen. Contact with Mustard is frequent in infancy and Mustard is considered a hidden allergen in the usual infant diet (1) in some countries.
 
Anaphylaxis occurred as a result of ingestion of Mustard as a masked allergen in "chicken dips" (2).
 
Allergens
Brassica alba
Sin a 1, a 14 kDa protein and a 2S albumin, a major and very potent allergen, possesses a high resistance to trypsin digestion (3-7). Sin a 1 resists heating and degradation by proteolytic enzymes (8).
 
Two isoforms of Sin a 1 have been isolated:
  • Sin a 1.1, a 2S albumin/amylase inhibitor;
  • Sin a 1.2, a 2S albumin/amylase inhibitor.
  • rSin a 1, the recombinant form of Sin a 1 (3).
Five new low-molecular-mass trypsin inhibitors belonging to the RTI/MTI-2 family have been identified from White Mustard seed (9). A serine proteinase inhibitor, Mustard trypsin inhibitor 2 (MTI-2), has been isolated from White Mustard (10). The antigenicity of these compounds was not determined.
 
Brassica nigra
No allergens have been characterised.
 
Brassica juncea
Bra j 1, a 2S albumin, a major allergen, closely related to Sin a 1, the major allergen from White Mustard seeds (11).

Potential Cross-Reactivity

Cross-reactivity between Brassicaceae is rare (12). However, an extensive cross-reactivity among the different individual species of the genus could be expected, in particular among the various Mustards (13). For instance, the amino acid sequence obtained for Brown Mustard, Bra j 1, and its structure, are closely related to those of Sin a 1 (11, 14).
 
Other studies have indicated similar reactivity. Amino acid sequences of 2S seed storage proteins of 5 Brassica species, namely B. campestris, B. oleracea, B. nigra, B. juncea, and B. carinata, showed more than 85% homology amongst each other (and considerable homology with some other crucifer 2S protein coding sequences) (7). The 2S storage protein in Rape seed exhibits great sequence similarity with 2S albumins from different seeds, and cross-reactivity between Mustard and Rape seed flours can be explained by this close sequence homology (15). Sunflower seed contains a 2S albumin, and inhibition experiments demonstrated complete cross-reactivity between Sunflower seed and Mustard 2S albumins. The authors concluded that skin- specific IgE determination for Mustard should always be carried out in Sunflower seed-allergenic patients (16).
 
Amino acid sequence comparison of the 2S albumin from Ricinus communis (Castor bean) with other 2S albumin was reported to show shared allergenicity with the 2S albumins from Brassica juncea and Sin a 1 (17).
 
Nonetheless, cross-reactivity may not necessarily be absolute. In a report of 3 cases of anaphylactic reactions to ingestion of a small amount of Mustard sauce, skin- and serum-specific IgE for Mustard were positive in all 3 patients but negative for other vegetables belonging to the same family. The authors concluded that they did not detect cross-sensitivity with other vegetables of the same family (18).

Clinical Experience

IgE-mediated reactions
Allergy to Mustard has been known for some time, and researchers have emphasised the antigenic potency of this vegetable and have compared the severity of reactions to Mustard with those to Penicillin (19-21). Mustard may commonly induce symptoms of food allergy, including severe anaphylactic reactions, in sensitised individuals, including infants and children (8, 18, 22).
 
In scratch tests performed with common spices in 1,120 atopic patients, positive results were seen most frequently to Curry and Paprika, and when the components of Curry were tested separately, Coriander, Caraway, Cayenne and Mustard were responsible for the vast majority of the skin reactions (23).
 
In a Spanish study of 29 patients with a history of Mustard allergy, skin-specific IgE tests for Mustard were positive in all patients. Serum-specific IgE to Mustard was positive in all patients (0.7 to > 100 kU/L). Of the 29 patients, 19 (66%) had a systemic reaction after consumption of Mustard, and 10 (34%) had a local reaction; 14 (48%) had anaphylaxis. Fifteen patients (52%) had symptoms after ingestion of other vegetable foods, and 15 also had typical symptoms of pollen allergy. No significant differences were found in age, sex, atopic family history, total IgE, and specific IgE to Mustard among the various subgroups studied (14).
 
In particular, French studies report Mustard to be a prominent allergen in that population (24).  In a group of 580 patients in France with reactions to food, of which 60 presented with severe, near-fatal reactions, the foods most frequently incriminated in anaphylactic reactions were Celery (30%), crustacea (17%), fish (13%), Peanuts (12%), Mango (6%), and Mustard (3%). The authors comment that the frequency of sensitisation to different foods has changed; and that sensitisation to Mustard, among others, is definitely increasing (25).
 
Children and adolescents appear to also be especially often affected (26). A recent French study reports that about 20% of French schoolchildren have allergic diseases, that food allergy has been steadily increasing for the last 20 years, and that in France, the most common food allergens are the following: Hen's egg (35%), Peanut (24%), Cow's milk (8%), Mustard (6%), and fish (4%) (27-29).
 
Similar findings were reported by the same researchers in a prospective study at medical centres in Nancy and Toulouse (France), where 378 children with food hypersensitivity were studied; 5 allergens accounted for 82% of confirmed food hypersensitivity: egg (51.8%), Peanut (34.3%), milk (11.6%), Mustard (8.9%) and Codfish (7.1%). The clinical features experienced were atopic dermatitis (46.5%), urticaria (17.9%), oedema (14.2%), asthma (8.4%), anaphylaxis (5.2%), gastro-intestinal symptoms (2.1%), oral allergy syndrome (1.8%) and rhino-conjunctivitis (0.5%) (28).
 
In evaluating 163 asthmatic French children with food allergy for food-induced asthma, using DBPCFC, the most frequent offending foods were found to be (sometimes in association with each other) Peanut (30.6%), egg (23.1%), Cow's milk (9.3%), Mustard (6.9%), Codfish (6%), Shrimp (4.5%), Kiwi fruit (3.6%), Hazelnut (2.7%), Cashew nut (2.1%), Almond (1.5%), and Garlic (1.2%) (30).
 
Clinical features of Mustard allergy in 36 French children were described and included atopic dermatitis (51.8%) and urticaria and/or angioedema (37%). Symptoms after Mustard ingestion started under 3 years of age in 53.3% of the subjects. Skin-specific IgE was tested with a White/Black Mustard mix and was positive in all. Positive oral challenges occurred from ingestion of 1 to 936 mg (1).
 
Other French researchers have determined, utilising DBPCFC, that Mustard allergy accounts for 1.1% of food allergies in children (31).
 
Furthermore, allergic reactions to Mustard start very early in life, usually below 3 years of age. Frequent contact with Mustard in infancy could be explained by the presence of Mustard in baby foods in glass pots for babies and commercial foods for toddlers. Positive skin-specific IgE has been determined to Mustard in 3 infants aged 12-18 months of age, who were breastfed until the age of 11 months and who had never consumed Mustard before (32). Unlike in adults with Mustard allergy, clinical symptoms were not severe in children (1).
 
Mustard is a potent allergen and may result in anaphylaxis (2, 8, 33-34) or idiopathic anaphylaxis (35). Two cases of anaphylactic reactions set off by the ingestion of a small amount of Mustard sauce have been reported (36), and similarly, an anaphylactic reaction from a very small amount of Mustard included in pizza (37). Similarly, two patients are described who developed severe reactions to small amounts of Mustard: a 47-year-old woman developed 3 episodes of acute severe urticaria, facial angioedema, nausea, vomiting, dyspnoea, wheezing, chest tightness, and hoarseness shortly after ingestion of sandwiches made with mayonnaise and Mustard. In the second incident, a 15-year-old female developed generalised urticaria, swelling of the face and throat, followed by chest tightness, 45 minutes after the ingestion of salad containing Mustard. In both patients, serum-specific IgE to Mustard was positive (34). In 2 of 5 cases, Mustard exposure came from the accidental contamination of the food by cooking utensils (36, 37).
 
Similarly, 3 individuals who experienced anaphylactic reactions to ingesting a small amount of Mustard sauce were described. A 43-year-old man developed 4 reactions following the ingestion of foods containing Mustard sauce. Symptoms included pruritis, swelling of the tongue, dysphagia, dysphonia, facial oedema, and progressive respiratory difficulty. One episode was accompanied by hypotension and the other by palpebral oedema. A second patient, a 17-year-old girl, experienced 2 episodes of pruritis, swelling of the lips and tongue, and facial oedema after eating a salad containing Mustard. A 19 year-old developed sysphonia, dysphagia, generalised urticaria and respiratory difficulty flowing the ingestion of Mustard sauce. Serum- and skin-specific IgE determination to Mustard were positive in all. In this instance, and contrary to expectations, tests with the rest of the vegetables belonging to the same family were negative (18).
 
Mustard may also result in food-dependant exercise-induced anaphylaxis (38-39).
 
Mustard was reported to result in angioedema of the face, generalised urticaria, dyspnoea without wheezing, sneezing, nasal itching and nasal obstruction in a 31-year-old man. Symptoms resolved 2-3 hours after treatment. The individual, on smelling Mustard sauce, developed sneezing, rhinitis, nasal itching and nasal obstruction lasting 60 minutes. Local contact on the lips resulted in lip oedema. Similarly, a 32-year-old man presented with generalised urticaria, angioedema of the neck, lips, eyelids and ears, with itching of the scalp and genital area, asthma, and dysphonia 2-3 minutes after having accidentally ingested Mustard. In both patients, skin- and serum-specific IgE were positive (22).
 
Mustard allergy may result in adverse cutaneous reactions, including angioedema and urticaria (8, 40-41). A young woman experienced recurrent urticaria and angioedema following ingestion of Mustard and mayonnaise. The presence of specific IgE to Mustard seeds and seeds of botanically related plants was confirmed by RAST (42). Contact urticaria from Mustard in Anchovy fillet sauce has been reported (43).
 
Contact urticaria from Mustard in occupational settings has been described. At a major fish processing plant in northern Norway, workers employed in fish-stick and fillet production participated in a survey on skin diseases. Sixteen cases of occupational dermatitis among workers in fish stick production were found, 3 of whom had contact urticaria from Mustard and 8 from fish (44).
 
Allergic contact dermatitis to Mustard (B. nigra) in a salad maker has been reported (45).
 
A prospective study conducted in 30 subjects aged 3-20 years presenting with positive skin-specific IgE to ground Mustard seeds (Brassica nigra), Mustard flour (B. juncea), metabisulfite-free strong Mustard seasoning (B. juncea) and a commercialised allergenic extract (B. nigra), reported that the mean diameter of the wheal induced by skin-specific IgE tests with the allergenic extract was lower than that induced by the native Mustard products: 5.8 mm (1.5-15) vs. 6.9 mm (0.5-18) for B. nigra ground seeds, 7.8 mm (1-20) for B. juncea flour and 9.7 mm (3-20) for the strong Mustard seasoning. The diameter of the wheal induced by the allergenic extract was significantly different from that induced by the Mustard seasoning. The mean of Mustard-specific IgE values was 8.7 KU/l (0.35-72.4).
 
Seven of 30 food challenges were considered positive. Mean prick test results in the positive and negative PCFC subgroups were 5.5 mm vs 5.9 mm for the commercialised extract, 10.9 mm vs 5.8 mm for B. nigra ground seeds (P < 0.01), 9.9 mm vs 7.1 mm for B. juncea flour (n.s. P > 0.25) and 11.5 mm vs 9.1 mm for the metabisulfite-free Mustard seasoning (n.s. P > 0.1). Mean serum-specific IgE values were higher but not significantly so in the subgroup with Mustard allergy (12.3 K/l vs 7.6 KU/l). The study concluded that about 23.3% of the sensitised subjects were allergic to a routine dose of Mustard. Positive skin- or serum-specific IgE tests were not predictive. SB PCFC or DB PCFC is required before recommending avoidance diets (31).
 
Other reactions
See also under Environment and Unexpected exposure. A 15-month-old healthy boy presented in acute, severe respiratory distress after ingesting and aspirating ground Black Mustard seeds. Ground Mustard seeds contain the toxic compound isothiocyanate, which causes airway irritation and oedema similar to symptoms caused by Black Pepper (which can be lethal with aspiration) (46).
 
A skin burn from culinary Mustard has been described (47).
 
Irritant contact dermatitis was induced by a Mustard compress (48).
 
Pancreatitis as a complication of Mustard-induced anaphylaxis has been reported (49).
 
Compiled by Dr Harris Steinman, harris@zingsolutions.com

References

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As in all diagnostic testing, the diagnosis is made by the physican based on both test results and the patient history.