Reactivity of the immunoglobulin E in bovine gelatin-sensitive children to gelatins from various animals

Intraoperative Anaphylaxis to the Bovine Flowable Gelatin Matrix: A Report of 2 Cases

CASE

We present 2 cases of life-threatening intraoperative anaphylaxis to the bovine flowable gelatin matrix during pediatric spinal deformity surgery for kyphoscoliosis. Both patients had no known bovine or gelatin allergies. Anaphylaxis occurred shortly after pressurized injection into the first cannulated pedicle tract and was successfully treated with epinephrine, diphenhydramine, and methylprednisolone infusion. The allergic reaction was confirmed with tryptase levels and serum-specific immunoglobulin E for beef, pork, bovine collagen, and porcine collagen.

CONCLUSION

In patients with beef, pork, or gelatin intolerance, a significant atopic history or childhood vaccine reaction, preoperative allergy consultation, and testing should be performed to prevent this life-threatening complication.

Preventing iatrogenic gelatin anaphylaxis

OBJECTIVE

To assess the iatrogenic risks of gelatin allergy and identify resources for patient management.

DATA SOURCES

A literature review was performed using PubMed and public databases provided by the National Library of Medicine.

STUDY SELECTIONS

Reports of iatrogenic gelatin allergy associated with vaccines, hemostatic agents, intravenous colloids, medicinal capsules, and intraoperative surgical supplies.

RESULTS

Gelatin ingredients may not be identified by electronic medical record safeguards, and an exhaustive listing of potential iatrogenic exposures is elusive. The National Library of Medicine AccessGUDID (https://accessgudid.nlm.nih.gov/) can be a useful resource in evaluating medical devices for gelatin content. Unexpected sources of iatrogenic gelatin exposure include hemostatic agents, vascular grafts, intravascular cannulas, bone replacement implants, and emergency resuscitation fluids.

CONCLUSION

Vigilance is important within medical systems to avoid inadvertent gelatin exposure when caring for patients with gelatin allergy. Additional safeguards are needed to remove latent health care system errors that fail to prevent gelatin administration in this at-risk population.

Protease resistance of food proteins: a mixed picture for predicting allergenicity but a useful tool for assessing exposure

Background

Susceptibility to pepsin digestion of candidate transgene products is regarded an important parameter in the weight-of-evidence approach for allergenicity risk assessment of genetically modified crops. It has been argued that protocols used for this assessment should better reflect physiological conditions encountered in representative food consumption scenarios.

Aim

To evaluate whether inclusion of more physiological conditions, such as sub-optimal and lower pepsin concentrations, in combination with pancreatin digestion, improved the performance of digestibility protocols used in characterization of protein stability.

Methods

Four pairs of established allergens and their related non/weakly-allergenic counterparts (seed albumins, muscle tropomyosins, plant lipid transfer proteins [LTP] and collagens) plus fish parvalbumin, were subjected to nine combinations of pH (1.2-2.5-4.0) and pepsin-to-protein ratio (PPR: 10-1-0.1 U/µg) for pepsin digestion, followed by pancreatin digestion in the presence of bile salts. Digestion was monitored by SDS-PAGE in conjunction with Coomassie staining and immunoblotting using rabbit antisera and human IgE.

Results

At pH 4.0 and at PPR 0.1 most proteins, both allergen and non-allergen, were highly resistant to pepsin. Under conditions known to favor pepsin proteolysis, the established major allergens Ara h 2, Pru p 3 and Pen a 1 were highly resistant to proteolysis, while the allergen Cyp c 1 was not. However, this resistance to pepsin digestion only made Ara h 2 and to a lesser extent Pen a 1 and Pru p 3 stand out compared to their non-allergenic counterparts. Largely irrespective of preceding pepsin digestion conditions, pancreatin digestion was very effective for all tested proteins, allergens and non-allergens, except for Cyp c 1 and bovine collagen.

Conclusions

Sub-optimal pH, low pepsin-to protein ratio, and sequential pepsin and pancreatin digestion protocols do not improve the predictive value in distinguish allergens from non-allergens. Digestion conditions facilitating such distinction differ per protein pair.

Potential food allergens in medications

Excipients are substances in pharmaceuticals other than the active ingredients. Some excipients are foods or substances derived from foods, raising the possibility that these substances would pose a hazard to patients with food allergy. This review describes which food-derived substances are used as pharmaceutical excipients in which medications and reviews published data regarding the safety of the administration of these medications to recipients with food allergy. Such reactions are rare, usually because the amount of food protein is not present in a large enough quantity to elicit a reaction. When a food protein appears as an unintentional contaminant, the amount, if any, that is present might be variable and might elicit reactions only from some lots of medication or only in some patients. In most circumstances these medications should not be routinely withheld from patients who have particular food allergies because most will tolerate the medications uneventfully. However, if a particular patient has had an apparent allergic reaction to the medication, potential allergy to the food component should be investigated.

Intraoperative anaphylaxis to gelatin in topical hemostatic agents during anterior spinal fusion: a case report

BACKGROUND CONTEXT

The use of topical hemostatic agents is widespread and has been shown to reduce bleeding during a wide variety of surgical procedures. Nonetheless, as biologically active agents, there is potential for allergic reactions to these products.

PURPOSE

This is a report of intraoperative anaphylaxis to gelatin associated with the use of two topical hemostatic agents.

STUDY DESIGN

Case report. There is no outside funding or potential conflict of interest.

PATIENT SAMPLE

A patient with anaphylaxis during anterior spinal fusion.

OUTCOME MEASURES

Laboratory assays for tryptase, gelatin-specific immunoglobulin E (IgE), and total IgE.

METHODS

A 14-year-old male with myelomeningocele and scoliosis was treated with anterior spinal fusion from T12 to L3. Gelfoam sponges were applied during the preparation of the disc spaces. Approximately 1 hour later, Floseal hemostatic matrix was applied to a briskly bleeding screw hole in the L3 vertebral body, and the patient experienced an abrupt onset of hypotension and ventilatory difficulty. Epinephrine, dexamethasone, and blood products were administered for hemodynamic support while the surgical site was closed. Removal of the drapes revealed a widespread erythematous rash, and the patient was then transferred to the intensive care unit. When stable 3 days later, he returned to the operating room for completion of the spinal fusion.

RESULTS

Postoperative laboratory assays were sent that revealed elevated levels of tryptase, total IgE, porcine, and bovine gelatin-specific IgE. The patient was counseled to avoid gelatin-containing products. At 6-month follow-up, his instrumented spine was radiographically fused and he reported no further allergic issues.

CONCLUSIONS

Anaphylaxis may occur because of animal gelatin components of topical hemostatic agents. Previous reports have focused on the thrombin components. Care should be taken in the administration of these products, particularly in the atopic individual.

Relationship between red meat allergy and sensitization to gelatin and galactose-α-1,3-galactose

BACKGROUND

We have observed patients clinically allergic to red meat and meat-derived gelatin.

OBJECTIVE

We describe a prospective evaluation of the clinical significance of gelatin sensitization, the predictive value of a positive test result, and an examination of the relationship between allergic reactions to red meat and sensitization to gelatin and galactose-α-1,3-galactose (α-Gal).

METHODS

Adult patients evaluated in the 1997-2011 period for suspected allergy/anaphylaxis to medication, insect venom, or food were skin tested with gelatin colloid. In vitro (ImmunoCAP) testing was undertaken where possible.

RESULTS

Positive gelatin test results were observed in 40 of 1335 subjects: 30 of 40 patients with red meat allergy (12 also clinically allergic to gelatin), 2 of 2 patients with gelatin colloid-induced anaphylaxis, 4 of 172 patients with idiopathic anaphylaxis (all responded to intravenous gelatin challenge of 0.02-0.4 g), and 4 of 368 patients with drug allergy. Test results were negative in all patients with venom allergy (n = 241), nonmeat food allergy (n = 222), and miscellaneous disorders (n = 290). ImmunoCAP results were positive to α-Gal in 20 of 24 patients with meat allergy and in 20 of 22 patients with positive gelatin skin test results. The results of gelatin skin testing and anti-α-Gal IgE measurements were strongly correlated (r = 0.46, P < .01). α-Gal was detected in bovine gelatin colloids at concentrations of approximately 0.44 to 0.52 μg/g gelatin by means of inhibition RIA.

CONCLUSION

Most patients allergic to red meat were sensitized to gelatin, and a subset was clinically allergic to both. The detection of α-Gal in gelatin and correlation between the results of α-Gal and gelatin testing raise the possibility that α-Gal IgE might be the target of reactivity to gelatin. The pathogenic relationship between tick bites and sensitization to red meat, α-Gal, and gelatin (with or without clinical reactivity) remains uncertain.

A reliable enzyme linked immunosorbent assay for the determination of bovine and porcine gelatin in processed foods

Since gelatin-containing foods pose a risk for eliciting allergic reactions in sensitized individuals, a novel sandwich enzyme linked-immunosorbent assay (ELISA) for the detection and quantification of bovine and porcine gelatin in processed foods was developed. Rabbits and goats were immunized with bovine gelatin, and three antisera (pAb1 and pAb2 from rabbits, and pAb3 from goats) were obtained. We established a sandwich ELISA method based on a combination of these antibodies. In this study, two sandwich ELISA methods, rabbit pAb2-pAb1 and goat pAb3-pAb3, were evaluated for sensitivity, specificity, cross-reactivity, and applicability. Both ELISA methods were highly specific for bovine and porcine gelatin but had little reactivity with fish gelatin. The detection and quantification limits for porcine gelatin were found to be 0.78 ng/mL and 1.56 ng/mL, respectively. The established sandwich ELISA methods produced no false-positives, except for heated meat products or false negatives when various commercial foods were analyzed for their gelatin content. The rabbit pAb2-pAb1 ELISA cross-reacted with boiled squid, while the goat pAb3-pAb3 ELISA did not. Thus, the proposed goat pAb3-pAb3 ELISA method is a reliable tool for the detection of gelatin contaminants present in processed foods.

A randomized, double-blinded, placebo-controlled oral challenge study to evaluate the allergenicity of commercial, food-grade fish gelatin

BACKGROUND

Recent interest in the labeling of foods and food proteins derived from allergenic sources necessitates determination of the potential allergenicity of such food ingredients. Fish gelatin is extracted from the skin of fish species known to elicit allergic reactions in sensitized individuals.

OBJECTIVE

To determine the allergenicity of fish gelatin by double-blinded, placebo-controlled food challenges (DBPCFC) in clinically fish-allergic individuals.

METHODS

Thirty fish-allergic patients diagnosed according to the EAACI Guidelines were included (age 9-50 years). Skin prick tests (SPT) and Histamine Release tests (HR) were performed with fish gelatin and codfish, and codfish-specific IgE was measured. All patients underwent DBPCFC with a cumulative dose of 14.61 g fish gelatin.

RESULTS

In all 30 patients SPT, HR, and specific IgE to codfish were positive. SPT and HR with fish gelatin were positive in 3/30 and 7/30, respectively. One patient showed mild reaction to placebo and no reaction to the active challenge. Two patients reported mild subjective reactions to active challenge. Upon re-challenge one of them described subjective symptoms again to the active challenge (7.61 g cumulated dose of fish gelatin) with no reaction to placebo, while the other experienced very mild subjective symptoms to placebo and nothing to the active. The proportion of truly sensitive patients was estimated to 0.03 in the total study group.

CONCLUSION

None of 30 fish allergic patients reacted adversely to the ingestion of 3.61 g cumulative dose of fish gelatin. In this study fish gelatin presents no risk to fish-allergic patients at the doses typically used. Statistically, these results indicate that there is 95% certainty that 90% of fish-allergic consumers will not react to ingestion of a 3.61 g cumulative dose of fish gelatin.

Addressing parents' concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals?

Vaccines often contain preservatives, adjuvants, additives, or manufacturing residuals in addition to pathogen-specific immunogens. Some parents, alerted by stories in the news media or information contained on the World Wide Web, are concerned that some of the substances contained in vaccines might harm their children. We reviewed data on thimerosal, aluminum, gelatin, human serum albumin, formaldehyde, antibiotics, egg proteins, and yeast proteins. Both gelatin and egg proteins are contained in vaccines in quantities sufficient to induce rare instances of severe, immediate-type hypersensitivity reactions. However, quantities of mercury, aluminum, formaldehyde, human serum albumin, antibiotics, and yeast proteins in vaccines have not been found to be harmful in humans or experimental animals.

Gelatin prepared from tuna skin: a risk factor for fish allergy or sensitization?

BACKGROUND

Although fish gelatin may represent a useful alternative to bovine or porcine gelatin, the clearly recognized high prevalence of fish allergy could increase the risk of anaphylaxis to gelatin. The rationale for investigating tuna gelatin rather than gelatin from more allergenic fishes is the availability of an industrial gelatin under development. The infrequent occurrence of tuna allergy should influence the safety of a derived product. The present study investigated IgE antibodies to tuna-skin-derived gelatin in adults and children with documented fish allergy or sensitization.

METHODS

Serum samples were taken from 100 consecutive patients with fish allergy or sensitization and tested for IgE antibodies against hydrolyzed or nonhydrolyzed gelatin extracted from tuna skin as compared to extracts from tuna flesh, tuna skin as well as bovine or porcine gelatin. Patients with tuna allergies or sensitization were sensitive to the same tuna species (yellowfin) as that from which the gelatin was obtained. IgE antibodies to these various extracts were analyzed using SDS-PAGE and immunoblotting.

RESULTS

Only 3 of the 100 serum samples tested gave evidence of reactivity to gelatin extracted from tuna skin. Cross-reactivity between bovine/porcine and fish gelatin was not observed.

CONCLUSION

The risk of adverse reactions to tuna skin gelatin seems to be significantly lower than the risk of fish allergy. Fish gelatin may represent a valuable alternative to bovine or porcine gelatin.

Stability of bovine allergens during food processing

OBJECTIVE

The primary objective of this review was to summarize reported findings about the influence of various food manufacturing processes on the potential alteration of bovine allergens in cow's milk, beef, and related food products.

DATA SOURCES

This review was based on literature research in two German databases.

STUDY SELECTION

The expert opinion of the authors was used to select the relevant data for the review.

RESULTS

Changes in allergenic activity during food processing are attributable to inactivation or destruction of epitope structures, formation of new epitopes, or improved access of previously hidden epitopes. The allergenic potency of food could be altered by several food manufacturing procedures--such as mechanical, purification, thermal, biochemical, and chemical processes. The main processing steps studied by investigators were heating (dry heating, boiling, or cooking) and enzymatic digestion. A review of the available literature on the alteration of bovine allergens in cow's milk, meat, and related food products revealed reduction (but not elimination) of allergenicity by heating of cow's milk for 10 minutes. Although homogenization did not change the allergenic potency of cow's milk, it decreased the allergenicity of beef, as did freeze-drying. Digestion studies showed varied results.

CONCLUSIONS

The allergenicity of some food products decreased during certain processing steps, but the results of other investigations differed. Therefore, more systematic research on the influence of food processing on allergenicity should be undertaken.

Hydrocolloids in wound management: pros and cons

Hydrocolloids are interactive dressings which are well established in wound management. Because of their sophisticated composition, they can be used to manage a variety of wound types, from clean and granulating to sloughy and necrotic. While they may be more expensive per item than many other modern dressings, if used correctly they can be cost-effective, as they have a longer wear time. Hydrocolloid formulations appear to be changing and improving with ongoing research by manufacturers, but a significant limitation appears to be sensitivity reactions. Dressings that would benefit from improvement are those containing gelatin, and those containing colophony within the adhesive matrix. These known sensitizers are largely unpublicised, but can produce serious side effects in some individuals.

Contribution of conformational stability of hen lysozyme to induction of type 2 T-helper immune responses

It is important to identify characteristics that confer on proteins the potential to induce allergenic sensitization and allergenic disease. Protein allergens carry T-cell epitopes that are capable of inducing a type 2 T helper (Th2) cell response. There is limited information regarding factors that govern the allergenicity of proteins. We previously reported that a decrease in the conformational stability of hen-egg lysozyme (HEL) enhanced its capacity to activate HEL-specific T cells owing to the increased susceptibility to intracellular antigen processing. To determine whether the conformational stability of HEL makes for a critical contribution to allergenic sensitization in vivo, we immunized BALB/c mice with HEL derivatives of different conformational stability, but which retained a similar three-dimensional structure. The magnitude of in vivo T-cell responses, evaluated by ex vivo proliferative responses of lymph node T cells from mice primed with various HEL derivatives, was inversely correlated with conformational stability, as was interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) production by splenic T cells in response to HEL. Immunization of the least stable derivative led to a potent IL-4 response and to immunoglobulin E (IgE) antibody production. We propose that the intrinsic allergenicity of proteins can be determined by the degree of conformational stability.

Stability of food allergens and allergenicity of processed foods

The allergenicity of food could be altered by several processing procedures. For various foods of animal and plant origin the available literature on this alteration is described. Investigations on hidden allergens in food products are also dealt with.

Identification of collagen as a new fish allergen

This study was intended to identify a high molecular weight allergen that had been detected in fish. Analyses by ELISA of five protein fractions prepared from bigeye tuna muscle showed that the high molecular weight allergen was contained in the myostromal protein fraction. Based on the results of SDS-PAGE, immunoblotting and amino acid analysis of the myostromal protein fraction, the high molecular weight allergen was judged to be collagen. Five of the eight patient sera used were found to react to the bigeye tuna collagen. In competitive ELISA inhibition experiments, the bigeye tuna collagen almost completely inhibited the IgE reactivity to the heated extracts from five species of fish, suggesting that collagen is commonly allergic regardless of fish species. However, no antigenic cross-reactivity was observed between collagens from fish and other animals.

IgE antibody to fish gelatin (type I collagen) in patients with fish allergy

BACKGROUND

Most children with anaphylaxis to measles, mumps, and rubella vaccines had shown sensitivity to bovine gelatin that was included in the vaccines. Recently, it was found that bovine type I collagen, which is the main content in the gelatin, is a major allergen in bovine gelatin allergy. Fish meat and skin also contain type I collagen.

OBJECTIVE

The present study was designed to investigate IgE antibody to fish gelatin in children with fish allergy.

METHODS

Serum samples were taken from patients in 3 groups: (1) 10 patients with fish allergy and specific IgE to fish meat; (2) two patients with allergies to both fish meat and bovine gelatin and specific IgE to fish meat and bovine gelatin; and (3) 15 patients with atopic dermatitis and specific IgE to fish meat. Various fish gelatins (type I collagen) were prepared from fish skin. IgE antibody to fish gelatin was analyzed by using ELISA and immunoblotting.

RESULTS

Of 10 patients with fish allergy, 3 had specific IgE to fish gelatin. Of two patients with fish allergy and bovine gelatin allergy, all had specific IgE to fish gelatin. Of 15 patients with atopic dermatitis and specific IgE to fish meat, 5 had specific IgE to fish gelatin. Furthermore, IgE from pooled serum of the patients reacted with both the alpha1 and alpha2 chains of fish type I collagen in immunoblots. There is cross-reactivity among gelatins from various fishes, but there is little cross-reactivity between fish and bovine gelatins.

CONCLUSION

Some fish-sensitive patients possessed IgE antibody to fish gelatin. Fish gelatin (type I collagen) might be an allergen in subjects with fish allergy.

Sensitization to gelatin in children with systemic non-immediate-type reactions to varicella vaccines

BACKGROUND

We recently found that four children who experienced systemic immediate-type reactions to varicella vaccine with gelatin had anti-gelatin IgE. We also found systemic non-immediate-type allergic reactions, which mainly consist of systemic cutaneous signs, appearing several hours or more after the vaccination.

OBJECTIVE

To investigate the relationship between immune responses to gelatin and non-immediate-type reactions to gelatin-containing varicella vaccines, we measured anti-gelatin IgE and IgG in the sera of the children with these allergic reactions.

METHODS

Serum samples were taken from 21 children who showed non-immediate-type reactions to varicella vaccines. As a positive control, serum samples were taken from 33 children who showed immediate-type reactions to varicella vaccine and had anti-gelatin IgE. As a negative control, serum samples were taken from 50 children who showed no reaction to the vaccine. We then examined anti-gelatin IgE and IgG in sera of the children.

RESULTS

Of 21 children with non-immediate-type reactions, two (10%) had anti-gelatin IgE and six (29%) had anti-gelatin IgG. In the positive control group, all 33 children with immediate-type reactions had anti-gelatin IgG as well as IgE. In the negative control group, all 50 children who showed no allergic reaction to varicella vaccines had neither anti-gelatin IgE nor IgG.

CONCLUSIONS

These results suggest that the possibility exists that some non-immediate-type reactions to varicella vaccine are caused by immune reactions to gelatin.

IgE reactivity to alpha1 and alpha2 chains of bovine type 1 collagen in children with bovine gelatin allergy

BACKGROUND

Anaphylactic reactions to measles, mumps, and rubella vaccines, including gelatin as a stabilizer, have been reported. It had been found that most of these reactions to live vaccines are caused by the bovine gelatin included in these vaccines. Gelatin mainly includes denatured type I collagen, which consists of alpha1 and alpha2 chains.

OBJECTIVE

The current study was designed to investigate the IgE reactivity to alpha1 and alpha2 chains of bovine type I collagen in gelatin-sensitive children.

METHODS

Serum samples were taken from 10 children who had anaphylaxis to the vaccines and high levels of specific IgE to bovine gelatin. Bovine type I collagen was isolated from bovine skin and then separated to alpha1 and alpha2 chains by column chromatography. IgE reactivity to denatured type I collagen and its alpha1 and alpha2 chains was analyzed by immunoblotting, ELISA, and histamine release from the mast cells passive sensitized with IgE antibodies in pooled serum of the children.

RESULTS

All children had specific IgE to bovine type I collagen. Furthermore, IgE antibodies in their sera reacted with the alpha;2 chain but not with the alpha1 chain. Similarly, the mast cells sensitized with pooled sera in the children showed alpha2 chain-specific histamine release but not alpha1 chain-specific histamine release.

CONCLUSION

In gelatin allergy denatured bovine type I collagen is a major allergen and IgE-binding sites exist in the alpha2 chain of type I collagen.