Source: Nakayama T, Aizawa C, Kuno-Sakai H. A clinical analysis of gelatin allergy and determination of its causal relationship to the previous administration of gelatin-containing acellular pertussis combined with diphtheria and tetanus toxoids. J Allergy Clin Immunol. 1999;103:321–5.To determine the incidence of gelatin allergy as a cause of allergic reactions to the monovalent measles, mumps, and rubella vaccines, and to identify factors that may contribute to the development of gelatin allergy, Nakayama et al recruited 366 children in Japan from 1994 to 1997 who had a history of a possible allergic reaction to these vaccines. The children were evaluated with regard to the nature of their reaction, immunization history, and the presence of IgE antibodies to gelatin.The vaccine reactions were categorized as follows: 34 had anaphylaxis, 76 had urticaria, 215 had a nonurticarial rash, and 41 had local reactions only. Serum was available for 206 children, revealing IgE antibodies against gelatin in 25 of 27 (93%) with anaphylaxis, 27 of 48 (56%) with urticaria, 8 of 90 (9%) with nonurticarial rash, and 0 of 41 with a local reaction. When the children’s immunization histories were reviewed, it was found that there was a higher incidence of gelatin allergy in children who had received prior DTaP vaccinations with a gelatin-containing product compared to those who had received a non-gelatin-containing product. (Four of 6 Japanese DTaP vaccines contain a gelatin stabilizer.)The authors conclude that most anaphylactic reactions and some urticarial reactions to the measles, mumps, and rubella vaccines are due to IgE-mediated gelatin allergy. Patients with non-IgE-mediated reactions may have cell-mediated reactions. Prior vaccination with other gelatin-containing vaccines may be important in the development of this allergy.Allergic reactions to vaccines, though not terribly common, are usually a great source of confusion. Gelatin allergy was first reported as a cause of MMR reactions in 1993 by Kelso et al who cared for a 17-year-old who reported that her symptoms following MMR—rhinorrhea, total body itching, hives, and throat swelling—were similar to those she experienced after eating Jell-O.1 This study provides a great deal of new information and documents the critical role of gelatin allergy in a majority of these vaccine reactions.The subjects of Nakayama et al’s study were immunized with monovalent measles, mumps and rubella vaccines between 1994 and 1997. Interestingly, there were no reports of anaphylaxis following immunization with a trivalent MMR vaccine from 1989 to 1993 despite the fact that the manufacturer (Kitsato Institute) used the same lot of gelatin and in the same concentration as in the monovalent preparations. The authors state they cannot explain the difference in the incidence of anaphylactic reactions based on an increased consumption of gelatin-containing foods by Japanese infants and children from 1994 to 1997, but note that around 1994 most children began to receive DTaP vaccines, some of which contained gelatin, before measles or rubella vaccines.A paper by Ohsaki et al in the same journal sheds light on the immune mechanism of gelatin allergy.2 They studied 8 patients with immediate and 8 patients with non-immediate reactions to gelatin-containing vaccines. All patients with immediate responses had gelatin-specific IgE antibodies, whereas the others did not. All patients in both groups had positive T lymphocyte responses specific to gelatin.In an accompanying editorial, Kelso3 observes that all reports of gelatin-related allergic reactions to vaccines have come from Japan and that the subject of his original report was of Japanese descent, suggesting a role of ethnicity in susceptibility to gelatin allergy, perhaps related to HLA types. He also reports that a group of allergists are cooperating with the CDC and FDA to determine the incidence of gelatin allergy among US patients who have had an anaphylactic reaction to MMR.These studies suggest we should think first of gelatin when confronted by an allergic reaction to a gelatin-containing vaccine—which, in the United States, include MMR and its monovalent component vaccines and some DTaP vaccines. (Acel-Imune and Tripedia contain gelatin; Infanrix and Certiva do not.)One perspicacious clinician’s attention to his patient’s history—that her vaccine reaction was similar to what happened when she ate Jell-O—began this fascinating cascade of studies. This serves to reinforce the lesson taught in your medical school’s introduction to clinical medicine course but sometimes forgotten in this technologic age: if you listen to your patients, they will often tell you their diagnosis!Note that allergic reactions to “gummy bears”4 and gelatin plasma expanders5 have also been linked to gelatin hypersensitivity. So, a history of reaction to gummy candies might also be a tip-off to gelatin allergy.
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Oct 1, 2002
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