Alpha-gal syndrome: when treatment of hypovolemic shock can lead to anaphylaxis
Main Article Content
Keywords
alpha-gal syndrome, anaphylaxis, drug allergy, meat allergy
Abstract
Delayed anaphylaxis after ingestion of red meat because of galactose-alpha-1,3-galactose (alpha-gal) syndrome has increased in recent years. The mechanism involves an immunoglobulin E reaction to alpha-gal, a molecule found in mammalian meat, dairy products, medications and excipients containing mammalian-derived components, and tick salivary glycans. Sensitization occurs due to the bite of a lone star tick and the transmission of alpha-gal molecules into person's bloodstream. We describe a case of alpha-gal syndrome with severe food, drug, and perioperative allergy in which anaphylaxis with hypovolemic shock occurred immediately after an emergency surgical procedure, when a gelatin-containing drug was injected. This case study confirms that the clinical manifestations of alpha-gal syndrome could be different depending on the route of administration, with immediate reactions if an alpha-gal-containing drug is injected and delayed type allergic manifestations occurring several hours after oral intake. The purpose of this report is to highlight the importance of risk communication in case of exposure to medical products and surgical procedures of patients with alpha-gal syndrome and to encourage drug manufacturers to indicate clearly the origin of excipients in product literature.
References
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20. Stoltz LP, Cristiano LM, Dowling APG, Wilson JM, Platts-Mills TAE, Traister RS. Could chiggers be contributing to the prevalence of galactose-alpha-1,3-galactose sensitization and mammalian meat allergy? J Allergy Clin Immunol Pract. 2019 Feb;7(2):664–6. 10.1016/j.jaip.2018.07.014
21. Murangi T, Prakash P, Moreira BP, Basera W, Botha M, Cunningham S, et al. Ascaris lumbricoides and ticks associated with sensitization to galactose α1,3-galactose and elicitation of the alpha-gal syndrome. J Allergy Clin Immunol. 2022 Feb;149(2):698–707. 10.1016/j.jaci.2021.07.018
22. Commins SP, Jerath MR, Cox K, Erickson LD, Platts-Mills T. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016 Jan;65(1):16–20. 10.1016/j.alit.2015.10.001
23. Chung CH, Mirakhur B, Chan E, Le QT, Berlin J, Morse M, et al. Cetuximab-induced anaphylaxis and IgE specific for galactose-alpha-1,3-galactose. N Engl J Med. 2008 Mar 13;358(11):1109–17. 10.1056/NEJMoa074943
24. Commins SP, James HR, Kelly LA, Pochan SL, Workman LJ, Perzanowski MS, et al. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. J Allergy Clin Immunol. 2011 ,May;127(5):1286–93.e6. 10.1016/j.jaci.2011.02.019
25. Stone CA Jr, Hemler JA, Commins SP, Schuyler AJ, Phillips EJ, Peebles RS Jr, et al. Anaphylaxis after zoster vaccine: Implicating alpha-gal allergy as a possible mechanism. J Allergy Clin Immunol. 2017 May;139(5):1710–13. 10.1016/j.jaci.2016.10.037
26. Stone CA Jr, Commins SP, Choudhary S, Vethody C, Heavrin JL, Wingerter J, et al. Anaphylaxis after vaccination in a pediatric patient: Further implicating alpha-gal allergy. J Allergy Clin Immunol Pract. 2019 Jan;7(1):322–4. 10.1016/j.jaip.2018.06.005
2. Galili U, Shohet SB, Kobrin E, Stults CL, Macher BA. Man, apes, and Old World monkeys differ from other mammals in the expression of alpha-galactosyl epitopes on nucleated cells. J Biol Chem. 1988;263(33):17755–62.
3. Platts-Mills TAE, Schuyler AJ, Hoyt AEW, Commins SP. Delayed anaphylaxis involving IgE to galactose-alpha-1,3--galactose. Curr Allergy Asthma Rep. 2015;15(4):12. 10.1007/s11882-015-0512-6
4. Kersh GJ, Salzer J, Jones ES, Binder AM, Armstrong PA, Choudhary SK, et al. Tick bite as a risk factor for alpha-gal-specific immunoglobulin E antibodies and development of alpha-gal syndrome. Ann Allergy Asthma Immunol. 2023 Apr;130(4):472–8. 10.1016/j.anai.2022.11.021
5. Steinke JW, Platts-Mills TAE, Commins SP. The alpha-gal story: Lessons learned from connecting the dots. J Allergy Clin Immunol. 2015;135(3):589–96. 10.1016/j.jaci.2014.12.1947
6. Božan M, Vukičević Lazarević V, Marković I, Morović-Vergles J, Mitrović J. Alpha-gal syndrome–food or drug allergy: A case report. Clin Case Rep. 2023 Aug 24;11(9):e7830. 10.1002/ccr3.7830
7. Kutlu A, Unal D. Mammalian meat allergy accompanied by venom allergy: A review of 12 cases. Iran J Allergy Asthma Immunol. 2019 Oct 23;18(5):584–8. 10.18502/ijaai.v18i5.1928
8. Commins SP. Diagnosis & management of alpha-gal syndrome: Lessons from 2,500 patients. Expert Rev Clin Immunol. 2020 Jul;16(7):667–77. 10.1080/1744666X.2020.1782745
9. Gilstad CW, Conry-Cantilena K, Zarpak R, Eder AF. An outbreak of anaphylactic transfusion reactions to group B plasma and platelets and its possible relationship to alpha-gal syndrome. Transfusion. 2023 Oct;63(10):1997–2000. 10.1111/trf.17521
10. Wilson JM, Platts-Mills TAE. Red meat allergy in children and adults. Curr Opin Allergy Clin Immunol. 2019;19(3):229–35. 10.1097/ACI.0000000000000523
11. Platts-Mills TAE, Li R chi, Keshavarz B, Smith AR, Wilson JM. Diagnosis and management of patients with the α-gal syndrome. J Allergy Clin Immunol Pract. 2020;8(1):15–23.e1. 10.1016/j.jaip.2019.09.017
12. Fischer J, Lupberger E, Hebsaker J, Blumenstock G, Aichinger E, Yazdi AS, et al. Prevalence of type I sensitization to alpha-gal in forest service employees and hunters. Allergy. 2017;72(10):1540–7. 10.1111/all.13156
13. Orhan F, Sekerel BE. Beef allergy: A review of 12 cases. Allergy. 2003;58(2):127–31. 10.1034/j.1398-9995.2003.00021.x
14. Brestoff JR, Zaydman MA, Scott MG, Gronowski AM. Diagnosis of red meat allergy with antigen-specific IgE tests in serum. J Allergy Clin Immunol. 2017;140(2):608–10.e5. 10.1016/j.jaci.2017.01.032
15. Commins SP, Satinover SM, Hosen J, Mozena J, Borish L, Lewis BD, et al. Delayed anaphylaxis, angioedema, or urticaria after consumption of red meat in patients with IgE antibodies specific for galactose-alpha-1,3-galactose. J Allergy Clin Immunol. 2009;123(2):426–33. 10.1016/j.jaci.2008.10.052
16. Kim MS, Straesser MD, Keshavarz B, Workman L, McGowan EC, Platts-Mills TAE, et al. IgE to galactose-α-1,3-galactose wanes over time in patients who avoid tick bites. J Allergy Clin Immunol Pract. 2020 Jan;8(1):364–7.e2. 10.1016/j.jaip.2019.08.045
17. Ledward DA. Animal by-product processing by Ockerman H.W. & Hansen C.L.. Ellis Horwood Series in Food Science and Technology, VCH Verlagsgesellschaft, Weinheim, 1988. 366 pp. Price: (DM 250) £88. Meat Sci. 1989;26(2):163–4. 10.1016/0309-1740(89)90039-9
18. Muglia C, Kar I, Gong M, Hermes-DeSantis ER, Monteleone C. Anaphylaxis to medications containing meat byproducts in an alpha-gal sensitized individual. J Allergy Clin Immunol Pract. 3(5):796–7. 10.1016/j.jaip.2015.04.004
19. Dunkman WJ, Rycek W, Manning MW. What does a red meat allergy have to do with anesthesia? Perioperative management of alpha-gal syndrome. Anesth Analg. 2019 Nov 129(5):1242–8. 10.1213/ANE.0000000000003460
20. Stoltz LP, Cristiano LM, Dowling APG, Wilson JM, Platts-Mills TAE, Traister RS. Could chiggers be contributing to the prevalence of galactose-alpha-1,3-galactose sensitization and mammalian meat allergy? J Allergy Clin Immunol Pract. 2019 Feb;7(2):664–6. 10.1016/j.jaip.2018.07.014
21. Murangi T, Prakash P, Moreira BP, Basera W, Botha M, Cunningham S, et al. Ascaris lumbricoides and ticks associated with sensitization to galactose α1,3-galactose and elicitation of the alpha-gal syndrome. J Allergy Clin Immunol. 2022 Feb;149(2):698–707. 10.1016/j.jaci.2021.07.018
22. Commins SP, Jerath MR, Cox K, Erickson LD, Platts-Mills T. Delayed anaphylaxis to alpha-gal, an oligosaccharide in mammalian meat. Allergol Int. 2016 Jan;65(1):16–20. 10.1016/j.alit.2015.10.001
23. Chung CH, Mirakhur B, Chan E, Le QT, Berlin J, Morse M, et al. Cetuximab-induced anaphylaxis and IgE specific for galactose-alpha-1,3-galactose. N Engl J Med. 2008 Mar 13;358(11):1109–17. 10.1056/NEJMoa074943
24. Commins SP, James HR, Kelly LA, Pochan SL, Workman LJ, Perzanowski MS, et al. The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. J Allergy Clin Immunol. 2011 ,May;127(5):1286–93.e6. 10.1016/j.jaci.2011.02.019
25. Stone CA Jr, Hemler JA, Commins SP, Schuyler AJ, Phillips EJ, Peebles RS Jr, et al. Anaphylaxis after zoster vaccine: Implicating alpha-gal allergy as a possible mechanism. J Allergy Clin Immunol. 2017 May;139(5):1710–13. 10.1016/j.jaci.2016.10.037
26. Stone CA Jr, Commins SP, Choudhary S, Vethody C, Heavrin JL, Wingerter J, et al. Anaphylaxis after vaccination in a pediatric patient: Further implicating alpha-gal allergy. J Allergy Clin Immunol Pract. 2019 Jan;7(1):322–4. 10.1016/j.jaip.2018.06.005
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Published
May 1, 2024
Article Details
How to Cite
Nalin, F., Scarmozzino, R., Arcolaci, A., Olivieri, B., Tommasi, M., Bonadonna, P., & Zanoni, G. (2024). Alpha-gal syndrome: when treatment of hypovolemic shock can lead to anaphylaxis. Allergologia Et Immunopathologia, 52(3), 60-64. https://doi.org/10.15586/aei.v52i3.1082
Section
Case Report
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
How to Cite
Nalin, F., Scarmozzino, R., Arcolaci, A., Olivieri, B., Tommasi, M., Bonadonna, P., & Zanoni, G. (2024). Alpha-gal syndrome: when treatment of hypovolemic shock can lead to anaphylaxis. Allergologia Et Immunopathologia, 52(3), 60-64. https://doi.org/10.15586/aei.v52i3.1082