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The case report by Phan et al¹ of transfer of nut allergy is interesting from the phenomenological standpoint and also serves as a haunting lesson in the proper management of patients with food allergy. It has been suggested that some transplantation drugs (tacrolimus) play an immunopathogenetic role in the development of food allergy by driving a T_H2 response.² It appears from this case as well that aggressive immunosuppression does not temper the clinical manifestations of anaphylaxis.

Aside from avoiding the sensitizing food, was the death of the donor otherwise preventable? This child had at least one, if not both, of the 2 main risk factors implicated in fatal food anaphylaxis: delay in administration of epinephrine and poorly controlled asthma.³ The recipient likewise had anaphylaxis with hypotension, yet did not initially receive epinephrine.

In my own experience, epinephrine is often omitted from the emergency care of the anaphylactic patient. Pumphrey⁴ . . . [Full Text of this Article]

Gary Stadtmauer, MD
New York, NY