SESSION TYPE: Miscellaneous Cases III
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: This case describes a patient who developed a nut allergy after lung transplantation.
CASE PRESENTATION: A 71 year-old man with idiopathic pulmonary fibrosis underwent bilateral lung transplantation in August 2011. The donor was an 15 year-old male with a history of asthma and peanut allergy and died of anaphylaxis after eating a food that contained nuts. After transplantation, the patient underwent induction immunosuppression with methylprednisolone, basiliximab and azathioprine followed by an oral regimen of predisone, tacrolimus and azathioprine. The recipient had no history of food allergy prior to transplantation. He was discharged after an uncomplicated postoperative course on day seven. Two weeks after discharge the patient experienced a syncopal event at home. Bradycardia and expiratory wheezing were present on initial examination. He was admitted to the hospital, stabilized, and discharged the following day. Two days later the patient experienced a respiratory arrest at home after eating a pastry that contained a nut crust. He was intubated in the field and was again noted to have diffuse wheezing. He was treated for status asthmaticus which resolved with bronchodilators and corticosteroids. Additional food history was obtained after extubation and revealed that the patient had eaten the same dessert immediately prior to both episodes. Specific IgE titers were performed and positive for pistachio (1.49 kU/L) and cashew (0.84 kU/L). Peanut specific IgE was negative. Upon discharge, the patient was advised to avoid all nuts and was given a prescription for intramuscular epinephrine. Three months after transplantation repeat titers were undetectable except for pistachio (0.49kU/L). Five months after transplantation skin prick testing for nut allergens was positive for cashews.
DISCUSSION: To our knowledge, this is only the fourth reported case of passive transfer of a nut allergy in a lung transplant recipient. In all cases, the donor allergy was documented prior to transplantation. Passive transfer of nut allergy is hypothesized to occur by one of two mechanisms. Donor lungs may contain previously sensitized B lymphocytes that produce nut-specific IgE. Alternatively, transfer of sensitized mast cells harboring nut-specific IgE may also occur with subsequent migration of mast cells into host tissues.
CONCLUSIONS: Knowledge of donor allergies should be considered prior to lung transplantation. If an allergy is identified, transplant recipients should be educated prior to discharge.
1) Bhinder, S et al. Development of transient peanut allergy following lung transplantation: a case report. Canadian Respiratory Journal 2011; 18(3):154-6.
DISCLOSURE: The following authors have nothing to disclose: Carmen Polito, David Neujahr, Remzi Bag, Umbreen Lodi, Timothy Sullivan, Seth Force, E. Clinton Lawrence
No Product/Research Disclosure InformationEmory University, Decatur, GA