Shiitake flagellate dermatitis

Author: Emma Trowbridge, Registrar, Department of Dermatology, Christchurch Hospital, Christchurch, New Zealand, January 2016. Updated by Lauren Thomas, 3rd Year Postgraduate Medical Student, Flinders University, Northern Territory, Australia; Chief Editor: Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, September 2016. 


What is shiitake flagellate dermatitis?

Shiitake dermatitis is a distinctive rash that can occur following the ingestion of raw or undercooked shiitake mushrooms (Lentinula edodes). 

It is characterised by pruritic, erythematous, linear streaks that resemble whiplash marks, hence the name flagellate.

Shiitake dermatitis is also known as flagellate erythema and toxicodermia.

Who gets shiitake flagellate dermatitis?

China and Japan have the highest rates of consumption of shiitake mushrooms and the highest prevalence of shiitake dermatitis.  It affects about 2% of people that consume the mushrooms raw or only lightly cooked. It has been reported in people of all ages, who are more often male than female.

More cases of shiitake dermatitis are being diagnosed in other countries where the use of shiitake mushrooms is increasing.

What causes shiitake flagellate dermatitis?

Shiitake flagellate dermatitis is a toxic reaction to lentinan, found in fresh, powdered, or lightly cooked shiitake mushrooms. Lentinan is a thermolabile polysaccharide that activates interleukin 1 secretion, leading to vasodilation, haemorrhage and rash

This hypothesis is supported by the observation that shiitake dermatitis is not seen with the ingestion of thoroughly cooked at a temperature >145 C.

The flagellate dermatitis does not result from cutaneous contact with the mushrooms.

What are the clinical features of shiitake flagellate dermatitis?

The flagellate rash of shiitake dermatitis typically appears 24 hours after ingestion of raw or undercooked shiitake mushrooms.

  • Onset can occur within a few hours and up to 5 days after ingestion of the mushrooms.
  • Itchy erythematous papules and sometimes petechiae are arranged in linear streaks.
  • There may be localised swelling.
  • They most often affect the trunk, but may also affect limbs, neck and head.  It does not affect mucosal surfaces.
  • The rash can be worse on exposure to the sun.
  • Associated gastrointestinal symptoms can occur.

The rash spontaneously resolves within a few weeks.  

Shiitake flagellate dermatitis

See more images of shiitake flagellate dermatitis ...

Systemic symptoms

Some patients with shiitake flagellate dermatitis have other symptoms.

  • Localised oedema
  • Malaise
  • Fever
  • Lip tingling (has been reported 48 hours after eating)
  • Discomfort when swallowing
  • Diarrhoea
  • Tingling of hands and feet

How is shiitake flagellate dermatitis diagnosed?

The diagnosis is clinical, based on the characteristic history of recent mushroom ingestion and on the appearance of the rash.  There are no specific laboratory findings.  Usual tests may include:

  • Full blood count
  • Urea and electrolytes
  • Liver function test 

Histopathology is nonspecific, demonstrating focal hyperkeratosis, spongiosis, dermal oedema and perivascular lymphocytic infiltrate with eosinophils.

What is the differential diagnosis of shiitake flagellate dermatitis?

Flagellate erythema is also associated with

Raw shiitake mushrooms can also rarely induce contact allergic dermatitis in sensitised individuals.

What is the treatment of shiitake flagellate dermatitis?

Shiitake flagellate dermatitis is a self-limiting condition. It is unknown if treatment speeds up resolution of the rash.

What is the outcome for shiitake dermatitis?

There is generally improvement within 2 days and complete resolution after 3 weeks.

Prevent future attacks by ensuring that Shiitake mushrooms are thoroughly cooked before eating. 

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Related information

 

References:

  • Boels D, Landreau A, Bruneau C, Garnier R, Pulce C, Labadie M, de Haro L, Harry P. Shiitake dermatitis recorded by French Poison Control Centers – new case series with clinical observations. Clin Toxicol (Phila). 2014 Jul;52(6):625-8. PubMed 
  • Adriano AR, Acosta ML, Azulay DR, Quiroz CD, Talarico SR. Shiitake dermatitis: the first case reported in Brazil.  An Bras Dermatol.  2013 May-Jun;88(3):417-9. PubMed
  • Hamer S, Rabindranathnambi R.  A wide-spread flagellate dermatitis.   BMJ Case Reports [internet]. 2013 [cited 2016 Jan 13];[2 p.]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23291817. DOI: 10.1136/bcr-2012-007682.  
  • Corazza M, Zauli S, Ricci M, Borghi A, Pedriali M, Mantovani L, et al. Shiitake dermatitis: toxic or allergic reaction? Journal of the European Academy of Dermatology and Venereology. 2015;29(7):1449-51. PubMed
  • Adler MJ, Larsen WG. Clinical variability of shiitake dermatitis. Journal of the American Academy of Dermatology. 2012;67(4):e140-e1. PubMed
  • Karanovic S, George S, Topham E. Don’t miss shiitake dermatitis: a case report. British Journal of General Practice. 2014;64(625):426-7. PubMed

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