Correspondence

Anaphylaxis from Passive Transfer of Peanut Allergen in a Blood Product

N Engl J Med 2011; 364:1981-1982May 19, 2011

Article

To the Editor:

Anaphylactic reactions to blood transfusions are rare and their causes often remain elusive.1 The inducement of clinically relevant allergic reactions by means of the passive transfer of IgE in blood products has been well documented.2 In an editorial comment written in 2003, Erick speculated on the possibility that allergic transfusion reactions could be induced by the passive transfer of food allergens.3 We present such a case.

A 6-year-old boy with acute lymphoblastic leukemia had an anaphylactic reaction while receiving a leukoreduced pooled buffy-coat product with ABO-identical platelets. During transfusion, rash, angioedema, hypotension, and difficult breathing occurred. The patient recovered within 30 minutes after resuscitation with adrenaline. His serum level of mast-cell tryptase, measured directly after the reaction, was 24 μg per liter (normal level, <5), which confirmed the clinical picture of a type I allergic reaction. No conventional mechanism could explain this transfusion reaction. Detailed laboratory analyses ruled out the possibilities of deficiencies in IgA, C4, or haptoglobin, allergies to drugs or latex, the presence of HLA antibodies, and transfusion-related acute lung injury.

The patient's mother stated that her son had had a similar reaction after eating peanuts at the age of 1 year. Since that time, peanuts had been excluded from his diet. Three of the five blood donors, contacted shortly after the transfusion reaction, recalled eating several handfuls of peanuts the evening before donation. The major peanut allergen, Ara h2, is extremely resistant to digestion4; therefore, we investigated whether the peanut allergens ingested by the donors could have been administered in the transfusion. In contrast with the intact peanut protein, the digestion-resistant peptide from Ara h2 (DRP–Ara h2) can be detected in serum for up to 24 hours after ingestion,5 and it is sufficiently large (with a mass of 10 kD) to bind IgE and to elicit allergic reactions. We corroborated the recipient's peanut allergy with an ImmunoCAP assay (Phadia) that revealed a serum level of peanut-specific IgE of 72.5 kU per liter (normal level, <0.35). We also determined that IgE antibodies reactive to both Ara h2 and DRP–Ara h2 were present (Figure 1Figure 1IgE Reactivity of a 6-Year-Old Boy to Peanut Allergens.).

These data are consistent with the hypothesis that the consumption of peanuts by the donors before blood donation provided the trigger for this patient's transfusion reaction. It is possible that allergens transferred in blood products to other patients have led to reactions that have gone unexplained and unreported. This case highlights the need to consider donor-ingested allergens as a source of reactions in sensitized recipients.

Joannes F.M. Jacobs, M.D., Ph.D.
Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
h.jacobs@labgk.umcn.nl

Joseph L. Baumert, Ph.D.
University of Nebraska, Lincoln, NE

Paul P. Brons, M.D., Ph.D.
Irma Joosten, D.V.M., Ph.D.
Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands

Stef J. Koppelman, Ph.D.
HAL Allergy, Leiden, the Netherlands

Elisabeth C.M. van Pampus, M.D., Ph.D.
Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.

5 References

1. 1

   Gilstad CW. Anaphylactic transfusion reactions. Curr Opin Hematol 2003;10:419-423
   CrossRef | Web of Science | Medline

2. 2

   Johansson SG, Nopp A, van Hage M, et al. Passive IgE-sensitization by blood transfusion. Allergy 2005;60:1192-1199
   CrossRef | Web of Science | Medline

3. 3

   Erick M. Food allergens and blood transfusions: a cause for concern? Arch Intern Med 2003;163:1861-1861
   CrossRef | Web of Science | Medline

4. 4

   Koppelman SJ, Hefle SL, Taylor SL, de Jong GA. Digestion of peanut allergens Ara h 1, Ara h 2, Ara h 3, and Ara h 6: a comparative in vitro study and partial characterization of digestion-resistant peptides. Mol Nutr Food Res 2010;54:1711-1721
   CrossRef | Web of Science | Medline

5. 5

   Baumert JL, Bush RK, Levy MB, et al. Distribution of intact peanut protein and digestion-resistant Ara h2 peptide in human serum and saliva. J Allergy Clin Immunol 2010;123:S268-S268
   CrossRef | Web of Science

Citing Articles (6)

Citing Articles

1. 1

   Laurence H. Beck. (2012) Childhood Membranous Nephropathy and Dietary Antigens. American Journal of Kidney Diseases 59:2, 174-176
   CrossRef

2. 2

   Mindy Goldman, Sheila F. O'Brien. (2011) Frequency of severe allergies in blood donors. Transfusion 51:11, 2520-2521
   CrossRef

3. 3

   Nicholas G Kounis, Andreas Mazarakis, Grigorios Tsigkas, Sotiris Giannopoulos, John Goudevenos. (2011) Kounis syndrome: a new twist on an old disease. Future Cardiology 7:6, 805-824
   CrossRef

4. 4

   (2011) Anaphylaxis from Peanuts Ingested by Blood Donors?. New England Journal of Medicine 365:9, 867-868
   Full Text

5. 5

   William J. Savage, Jessica H. Savage, Aaron A.R. Tobian, Chris Thoburn, Robert G. Hamilton, John T. Schroeder, Paul M. Ness. (2011) Allergic agonists in apheresis platelet products are associated with allergic transfusion reactions. Transfusionno-no
   CrossRef

6. 6

   Joel Shuster. (2011) ISMP Adverse Drug Reactions - Bupropion-Induced Generalized Exanthematous Pustulosis; Azathioprine-Induced Fever; Reversible Posterior Leukoencephalopathy Syndrome With Sunitinib Therapy; Ketoprofen-Associated Nonalcoholic Fatty Liver Disease and Steatohepatitis; Glomerulosclerosis With Acute Renal Failure Associated With Eltrombopag; Anaphylaxis From Passive Transfer of Peanut Allergen in a Blood Product; Early Detection and Prediction of Cardiotoxicity in Chemotherapy-Treated Patients. Hospital Pharmacy 46:8, 561-564
   CrossRef

Letters