Friday, March 18, 2011

Lung recipient developed her donor’s allergy

In the months after her surgery, a Toronto patient suffered four anaphylactic attacks. Doctors were stumped because she had never had allergies.

Tom Blackwell, National Post

For a 47-year-old woman with dangerously scarred lung tissue, the double-lung transplant she underwent a couple of years ago was a life saver. It came, though, with an unwelcome bonus.

In the months after her surgery, the Toronto patient suffered four anaphylactic attacks, according to her doctors’ 2009 study of the case. Physicians were stumped by the mysterious affliction in a woman who had never experienced serious allergies before. Then they discovered that the 12-year-old boy whose lungs she received had himself suffered from an acute peanut sensitivity, while the woman’s anaphylactic shock had occurred after she ate foods that likely contained nut traces.

It appeared the young donor’s allergy had been passed on along with his organs.

“When it’s transplanted, everything in the organ is transplanted,” said Dr. Susan Tarlo, a University of Toronto asthma and allergy expert who treated the woman.

Now a string of such unusual cases has prompted medical experts to make plans to start screening potential organ and stem-cell donors for serious allergies - a piece of medical background they had never paid much heed to before.

Draft guidelines prepared at the request of Health Canada call for doctors to ask whether organ donors had a history of anaphylactic shock triggered by allergens like peanuts and shellfish, and whether cell donors have any kind of allergy.

In fact, the organs in such cases often become available when the donors die themselves from allergy-caused shock.

“The transplant recipient may be unaware of the risk for potentially life-threatening hypersensitivity reactions,” says a Health Canada document urging the change in protocol.

The guidelines being developed by expert committees of the Canadian Standards Association say allergic donors should not necessarily be excluded, but that doctors can suggest, at least, that recipients get allergy testing and, if necessary, make lifestyle changes to avoid specific allergens.

Doctors say the “intriguing” problem is described in the medical literature relatively rarely, though Health Canada has suggested it is likely under-reported.

There are reports, nonetheless, of transplant recipients developing allergies to various nuts, seafood, eggs, beans, bananas and avocado, as well as drugs like penicillin, substances like latex, plus dust mites and pet dander, according to Health Canada’s proposal to the CSA for new standards. The allergy can persist for at least 14 years, and symptoms have developed as early as eight days after the transplant.

In one case reported in 2008, a 42-year-old, allergy-free Detroit woman received two donor lungs from someone who had died of anaphylactic shock after eating peanuts. “Seven months later, she ate a peanut-butter cookie at a transplant support group meeting,” they recounted. “Immediately thereafter, she developed an anaphylactic reaction, but survived with prompt treatment.”

There is evidence that the process can work in reverse, as well. In one case, a young patient’s serious peanut allergy disappeared after a bone-marrow transplant from an allergy-free donor. Others have ceased being asthmatic.

Allergies occur when people develop so-called immunoglobulin E antibodies to the particular food or other substance, causing the body’s immune system to react against the allergen. Experts say it is likely that those antibodies are implanted in the transplant recipient, either on their own or on the surface of Mast cells, which release the histamine and other chemicals that contribute to the allergic reaction.

Dr. Tarlo reported on the case of the 47-year-old lung-transplant recipient, who eventually tested strongly positive for peanut allergy herself, according to the physician’s presentation to an American College of Chest Physicians conference. It was likely the cereal, coconut cream pie and chocolate she ate just before the reactions were contaminated with peanut, Dr. Tarlo and colleagues said.

The woman’s test results for peanut allergy gradually disappeared, likely because the transplanted cells carrying the antibodies had died, she said.

The CSA standards, which hospitals implement voluntarily, are likely to be published early in 2012, said Anthony Toderian, a spokesman for the non-profit organization.

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