Anaphylaxis to succinylated gelatin in a patient with a meat allergy: galactose-α(1, 3)-galactose (α-gal) as antigenic determinant

doi:10.1016/j.jclinane.2014.04.014

Journal of Clinical Anesthesia

Volume 26, Issue 7, November 2014, Pages 574-576

https://doi.org/10.1016/j.jclinane.2014.04.014 Get rights and content

Abstract

Specific immunoglobulin E (sIgE) antibodies towards the galactose-α(1,3)-galactose (α-gal) moieties may elicit life-threatening and fatal anaphylactic reactions. Patients sensitized to α-gal moieties from mammalian meat may also react towards mammalian gelatins and gelatin-containing drugs such as bovine gelatin-based colloid plasma substitute. The case of a 56 year old woman with a meat allergy who suffered anaphylaxis to succinylated gelatin is reported.

Introduction

Specific immunoglobulin E (sIgE) antibodies towards the galactose-α(1,3)-galactose (α-gal) moieties coupled to the asparagine at position 88 in the murine heavy chain Fab portion of the chimeric mouse-human IgG1 mAb may elicit life-threatening and fatal anaphylactic reactions [1]. Alpha-gal is synthesized by α(1, 3)-galactosyltransferase that couples a terminal galactose residue in an α-linkage to another galactose. Alpha(1,3)-galactosyltransferase displays a peculiar pattern in mammals, as its expression is suppressed in primates including humans, apes, and Old World monkeys [2]. As α-gal is present on proteins of most nonprimate mammals, Chung et al. [1] also quantified sIgE to different cat, dog, beef, and pork proteins and identified several patients who had possibly suffered from delayed anaphylaxis or serious angioedema up to 3 to 6 hours after eating beef or pork. This observation was later confirmed by others [3], [4], [5], [6], [7] and it was demonstrated that α-gal sensitization and related mammalian meat allergies can result from tick bites [8].

Section snippets

Case report

A 56 year old woman was referred to our institution for an anaphylactic reaction with urticaria and severe bronchospasm during epidural anesthesia. She had no history of atopy or any previous drug allergies. For several years, she had suffered from intermittent urticaria related to consumption of dairy products and various meat species (eg, pork and beef). These episodes appeared to be late in onset (4–6 hrs after the meal).

Review of the anesthetic record showed exposure to chlorhexidine,

Discussion

Patients sensitized to α-gal moieties from mammalian meat might react towards mammalian gelatins and gelatin-containing drugs such as bovine gelatin-based colloid plasma substitute [5]. It appears that the α-gal-related gelatin allergy differs from genuine gelatin allergy and may easily be overlooked. Patients might tolerate oral challenges with 10 g of bovine gelatin, but present with urticaria and bronchospasm during intravenous challenges [5]. Second, diagnosis of α-gal-related gelatin

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As an active ingredient, gelatin has use in topically and intraoperatively applied hemostatic drugs.15 Gelatin is found in topical gelatin-based hemostatic products containing porcine16–19 or bovine18–21 gelatin. It is also found in gelatin-containing vaccines.9
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IgE-mediated anaphylaxis to gelatin is thought to be the predominant mechanism of immediate hypersensitivity.81 Intraoperative anaphylaxis is reported with topical gelatin-based hemostatic products (Floseal) or sponges (Gelfoam) due to porcine16-19 or bovine18-21 gelatin allergy. For this excipient, it is important to consider a previous history of meat allergy, as shown in 2 of these cases with reactions to canned pork meat with gelatin also known as aspic, a gelatin dish made with a meat stock or consommé in a mold to contain other ingredients, in which the authors recommended inquiring about gelatin allergy not only in drugs but also in food and gelatin-containing vaccines,81 as part of preoperative assessment.16,20
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This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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A Bull in a Pill Shop: Alpha-Gal Allergy Complicating Treatment Options for Postprocedural Hypothyroidism
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Alpha-gal allergy has been associated with other medications and medical products, besides thyroid replacement medications (Table 3) (13–19). The correct diagnosis of an alpha-gal allergy starts with a good history; making sure to ask about tick exposure and delayed reactions to nonprimate mammalian meat, gelatin injections, or heavy creams, and then likely includes an anti-alpha-gal IgE immunoassay and/or skin prick testing (15). Although the alpha-gal allergy was initially described as a red meat food allergy in 2009, we now know the alpha-gal moiety can be found in other mammalian-derived foods, medications, and medical devices.
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In this case of difficulty tailoring thyroid replacement therapy secondary to the alpha-gal allergy, the diagnostic studies included IgE immunoassays for alpha-gal as well as thyroid function tests.
A 45-year-old woman with postoperative hypothyroidism and a history of an alpha-gal allergy (diagnosed after an anaphylactic reaction to beef) could not be immediately started on any common thyroid hormone replacement formulation because of our concern regarding the possible presence of nonprimate mammalian meat byproduct components in the thyroid hormone medication. After consulting allergy and immunology specialists and compounding pharmacists and contacting multiple drug companies in an effort to confirm the nature of the inactive ingredients in their thyroid hormone products, she was prescribed a plant-based compounded levothyroxine preparation with good clinical results.
This case emphasizes the importance of recognizing various risk factors and common drugs which may be associated with the alpha-gal allergy. It is not known how to best tailor enteral medications for patients with an alpha-gal allergy. Further research and pharmaceutical attention to this allergy are needed.
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The galactose-α-1,3-galactose (α-Gal) syndrome has many novel features that are relevant to diagnosis and management. In most cases, the diagnosis can be made on a history of delayed allergic reactions to mammalian meat and the blood test for IgE to the oligosaccharide α-Gal. In general, the diagnosis also dictates the primary treatment, that is, avoiding mammalian meat and also dairy in some cases. In the United States, the lone star tick is the primary cause of this disease, but different ticks are responsible in other countries. Blood levels of IgE to α-Gal often drop in patients who avoid recurrent tick bites, but the rate of decline is variable. Similarly, the delay before reactions is variable and the severity of the allergic reactions is not predicted by the delay or the titer of specific IgE. Some mammalian-derived products such as heart valves, gelatin-based plasma expanders, and pancreatic enzymes are relevant to only select patient groups. A minority of cases may benefit from avoiding a wide range of products that are prepared with mammalian-derived constituents, such as gelatin. This review focuses on the nature of the syndrome, common challenges in diagnosis and management, and also gaps in our current knowledge that would benefit from additional investigation.
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Case ReportAnaphylaxis to succinylated gelatin in a patient with a meat allergy: galactose-α(1, 3)-galactose (α-gal) as antigenic determinant

Abstract

Introduction

Section snippets

Case report

Discussion

J Biol Chem

J Allergy Clin Immunol

Int J Cardiol

Spine J

Cetuximab-induced anaphylaxis and IgE specific for galactose-alpha-1,3-galactose

N Engl J Med

Case Report
Anaphylaxis to succinylated gelatin in a patient with a meat allergy: galactose-α(1, 3)-galactose (α-gal) as antigenic determinant