Non-IgE Mediated Food Allergy Development after Liver Transplantation?

Abstract

Background: The acquisition of new-onset food allergy after organ transplantation or transplant-acquired food allergy (TAFA) has been usually reported in adults and rarely in children. TAFA is described mainly after solid organ (e.g., liver, intestine, pancreas, kidney, lung and heart) or cord blood transplantations. In various reported studies, the male/female ratio seems to be equal. And literature data suggest that children with TAFA typically present within the first year after solid organ transplantation and they are typically allergic to multiple foods. Aim: TAFA is generally characterized with allergy to multiple foods and increased level of total and/or spesific IgE. Here, a patient with TAFA who had normal total and specific IgE test results plus minimal reaction to skin prick test for cow's milk is presented and his clinical presentation is discussed. Case Presentation: 15 month-old- boy came to our allergy clinic with complaints of vomiting after drinking cow's milk and skin rush on the area where contacted with chocolate. In his past medical history: Extrahepatic biliary atresia was diagnosed at 3 weeks age with conjugated hyperbilirubinemia (according to scintigraphy and biopsy results). Left lateral segment of liver (donor was his mother) was transplanted to him when he was at 5 months. The liver donor was not recorded as having a history of allergic disease. Methylprednisolone and tacrolimus immunosuppression were used after the transplantation, and tacrolimus therapy was continued for prophylaxis of chronic rejection. When he was at 7 months, family fed the patient with cow's milk but 3 hours later he began to vomit. He vomited five times in two hours. Then, he developed constipation. Rectal irrigation was used. Then oral intake stopped for two days. He was thought to be having food protein induced enterocolitis. His vomiting complaints repeated after intake of formula and baby food which includes grain. So he fed with special formula including short-chain peptides and free aminoacids and his symptoms improved. Family history: His father has penicillin allergy and his aunt has asthma. Physical examination revealed normal examination findings. Height and weight were within normal percentiles. Laboratory findings: WBC was 4.420/mm3, with 21% neutrophils, 6% eosinophils and 69% lymphocytes. His hemoglobin was 8.2 g/dl, platelet count was 280.000/mm3. Total IgE : <5 and ImmunoCAP specific IgE against milk, grain and other six classic foods was <0.35. Skin prick test results: saline: 0x0mm, histamine 4x4mm, Fresh cow's milk: 2x2mm, other food allergens (peanut, egg, fish, soybean, wheat): 0x0mm. Conclusion: Our patient seemed to have TAFA, cow's milk allergy with gastrointestinal manifestations (FPIES), after liver transplantation. Transplant-acquired new allergy needs to be considered after solid organ transplantation, especially when tacrolimus is used as immunosuppressive agent.