Two cases of transplant-acquired food allergy who developed resensitization after a negative oral food challenge

A 1-year-and-10-month-old boy who was diagnosed with Alagille syndrome received a live-donor liver transplant from his nonallergic father. His food allergy was diagnosed by immunoglobulin E (IgE) associated immediate symptoms related to food ingestion, such as vomiting with wheat, and vomiting and systemic urticaria with soybean (Table 1). No allergic history except for the food allergy had been reported at the transplantation. His transplantation was uneventful, and tacrolimus has been used as a preventive agent for rejection. Egg allergy, which is the most common food allergy in this age group in Japan, was suspected because he experienced allergic reactions to wheat and soybean; he also had sensitization to hen’s egg white (EW) (Table 1). As he had avoided to eat hen’s egg completely, initial consumption of EW was planned in our hospital when he was 2 years and 5 months old. Consequently, the OFC was negative with 15 g of boiled EW, and he was initiated on daily consumption of boiled EW by adding stepwise doses (1 g every 3 days). The consecutive daily consumption was unremarkable until he encountered systemic urticaria with 26 g of boiled EW about 1 month after the negative OFC. His systemic urticaria was reproducible with lower doses of boiled EW for a few days without contamination of wheat and soybean, and respiratory symptoms including wheezing from consuming 9 g of boiled EW finally gave him up to continue eating. High titers of EW-specific IgE were accompanied by allergic reactions, and the titers gradually decreased with the complete elimination of hen’s egg consumption (Table 1). Regarding wheat and soybean, daily consumption without any concern has been accomplished in his natural course of food allergy.

A 51-year-old male without any history of allergic disease was diagnosed with anaplastic large cell lymphoma (ALCL), and he received cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy as an induction regimen. Although salvage-intensive treatment, including a CBT, was required for CHOP-refractory ALCL, the CBT had achieved a complete response. Unfortunately, despite the prophylactic use of tacrolimus, grade 3 intestinal graft-versus-host disease (GVHD) characterized by vomiting and watery diarrhea (> 1500 mL per day) was diagnosed based on histological GVHD findings 2 months after. Refractory diarrhea forced him to consume ingredient nutrition with small amounts of snacks. GVHD therapy using systemic steroids and mesenchymal stem cell therapy was effective.

Six months after the CBT, he was finally allowed to consume solid food. On the next day, he unexpectedly experienced fever, frequent vomiting, diarrhea, and refractory hypotension with unknown mechanism that required continuous noradrenaline injection. Many kinds of food antigen could be contaminated in the solid foods because no attention had been paid for his possible food allergy. But Baumkuchen, that is a desert containing egg, milk, and wheat, and yogurt were critical to cause immediate severe hypotension in the episode. Blood examination revealed that he was sensitized to multiple antigens (Table 2), including hen’s egg, milk, and wheat. After the diagnosis of FA, he never experienced allergic reactions by avoiding these diets. OFC was conducted after 1 year and 9 months of the CBT, and his negative allergic status was proven through the boiled egg challenge with one whole egg. Daily consumption of one whole egg was started without any allergic symptoms, but it finally caused vomiting and watery diarrhea on the seventh day. The symptoms were reproducible with the next boiled egg challenge with one whole egg after 1 week of the first episode, and resensitization to EW supported his allergic reaction to it (Table 2). Although specific IgE assays (i.e., MAST and CAP assay) were used for the assessment, because MAST assay is useful for screening and CAP assay is quantitative for management of diagnosed food allergy, his sensitization was obvious in the same assay [8]. Limited information related to food allergy of the donor was available in a CBT setting.