Dear Editor,

I have read the article titled “Alpha-gal syndrome: when treatment of hypovolemic shock can lead to anaphylaxis” by Nalin et al. with great interest.¹ However, there are a few points the author suggests where I had difficulty understanding, and clarification on these points would help me and also the readers understand this article better.

First, the case is about severe food and drug allergy,¹ and this patient does not actually have a drug allergy. Moreover, how can the principal drug be a plasma expander that contains gelatin when the patient’s perioperative medications and magnesium stearate were investigated; the patient was also found to be negative with the naproxen test. Second, while describing the clinical condition, “anaphylaxis with hypovolemic shock” is mentioned instead of anaphylactic shock,¹ but also stating later in the text that the patient experienced anaphylactic shock. There is also no mention of aneurysmal bleeding sufficient enough to cause hypovolemic shock in this patient¹—all leading to confusion. Maybe plasma expanders were used postprocedurally as a preventive measure for distributive shock?² Third, if the association between cow’s epithelium/dander sensitization and alpha-gal syndrome is mentioned, then why has it not been reported in the literature? However, this role on the occurrence or clinical recurrence of alpha-gal syndrome is not mentioned or discussed¹; the clinical significance and relevance of this should have been debated first.

Also, why was the patient put on a cow’s milk diet when there was no mention of positivity in the tests? Was it only the dander positivity that led to this conclusion? As is often the case, milk and dairy products cause a significant number of allergic signs and symptoms in these patients.³ Bovine γ-globulin, lactoferrin, and lactoperoxidase are known as alpha-gal found in proteins which are detected by alpha-gal syndrome patients’ immunoglobulin E (IgE).⁴ My guess is that allergy tests for these were not done in this patient, which should have been discussed as well.

In conclusion, I thank the author for this high-quality case report and its results. Of note, the diagnosis of alpha-gal allergy should be kept in mind in patients with urticaria-anaphylaxis of unknown origin or happening after the utilization of sera, vaccines, or products of bovine/pork origin.⁵