Q:

3/4/2014
I have a 60yo female patient with eosinophilic esophagitis, food allergy, asthma, and allergic rhinitis, who is planning on undergoing spinal surgery with INFUSE (recombinant human bone morphogenetic protein-2, or rh-BMP-2). Among other food allergies, she is allergic to beef, which causes increased symptoms of eosinophilic esophagitis as well as a local contact reaction if beef is touched. This has been confirmed by a positive skin test to beef.

One of the contraindications to receiving INFUSE is allergy to bovine type I collagen. Upon discussion with a medical rep at Medtronic, there are some reports of allergy to this product, sometimes as long as 30 days after placement- though she was unable to give me any recommendations regarding whether known beef allergy is a specific contraindication.

I have been unable to find an ImmunoCAP specific for bovine type I collagen. Would this patient be more likely to react if INFUSE is used, given her history? Are there any specific skin test reagents that could be used to provide further information?

A:

Thank you for your inquiry.

I cannot give you a definitive answer, but in short, based upon available data (see reference and abstracts copied below), your patient is at risk of an allergic reaction to recombinant human bone morphogenetic protein-2 (rh-BMP-2). The reasoning underlying this conclusion is, once again, based on the references below which show the following:

1. Patients have exhibited IgE-mediated events to bovine collagen which is a component of the scaffolding used in rh-BMP2.

2. Bovine collagen type 1 has been found to be an allergen in beef.

3. This collagen is an allergen found in gelatin as well, and a significant number of patients allergic to gelatin are also allergic to beef.

I know of no definitive way to refine the risk assesment. I, like you, could not find a commercially available in vitro test to detect IgE anti-bovine collagen, but you could contact one of the authors of the references below, who developed, for research purposes, a specific IgE anti-bovine collagen to see if they are still performing the test in their laboratory. You could also consider skin testing to gelatin as well as the INFUSE itself. The results would not give you a definitive answer to the question of whether or not your patient would react to rh-BMP-2, but a negative test would give you some assurance; and a positive test would be evidence that she is at strong risk.

Thank you again for your inquiry and we hope this response is helpful to you.

J Allergy Clin Immunol. 1999 Sep;104(3 Pt 1):695-9.
IgE reactivity to alpha1 and alpha2 chains of bovine type 1 collagen in children with bovine gelatin allergy.
Sakaguchi M1, Hori H, Hattori S, Irie S, Imai A, Yanagida M, Miyazawa H, Toda M, Inouye S.
Author information
1Department of Immunology, National Institute of Infectious Diseases, Tokyo, Japan.
Abstract
Background: Anaphylactic reactions to measles, mumps, and rubella vaccines, including gelatin as a stabilizer, have been reported. It had been found that most of these reactions to live vaccines are caused by the bovine gelatin included in these vaccines. Gelatin mainly includes denatured type I collagen, which consists of alpha1 and alpha2 chains.
Objects: The current study was designed to investigate the IgE reactivity to alpha1 and alpha2 chains of bovine type I collagen in gelatin-sensitive children.
Methods: Serum samples were taken from 10 children who had anaphylaxis to the vaccines and high levels of specific IgE to bovine gelatin. Bovine type I collagen was isolated from bovine skin and then separated to alpha1 and alpha2 chains by column chromatography. IgE reactivity to denatured type I collagen and its alpha1 and alpha2 chains was analyzed by immunoblotting, ELISA, and histamine release from the mast cells passive sensitized with IgE antibodies in pooled serum of the children.
Results: All children had specific IgE to bovine type I collagen. Furthermore, IgE antibodies in their sera reacted with the alpha;2 chain but not with the alpha1 chain. Similarly, the mast cells sensitized with pooled sera in the children showed alpha2 chain-specific histamine release but not alpha1 chain-specific histamine release.
Conclusion: In gelatin allergy denatured bovine type I collagen is a major allergen and IgE-binding sites exist in the alpha2 chain of type I collagen.

J Allergy Clin Immunol. 2002 Oct;110(4):652-7.
Analysis of the major epitope of the alpha2 chain of bovine type I collagen in children with bovine gelatin allergy.
Hori H1, Hattori S, Inouye S, Kimura A, Irie S, Miyazawa H, Sakaguchi M.
Author information
1Division of Adult Diseases, Medical Research Institute, Tokyo Medical and Dental University, Tokyo, Japan.
Abstract
Background: Anaphylaxis to measles, mumps, and rubella vaccines has been reported. It has been found that most of these reactions to live vaccines are caused by type I allergy with the bovine gelatin present in the vaccines as an allergen. Gelatin mainly includes denatured type I collagen, which consists of alpha1 and alpha2 chains. We previously reported that allergic reactions to gelatin are caused by the type I collagen alpha2 (alpha2[I]) chain.
Objective: To aid in the development of gelatin that has little or no allergenicity in human subjects, we investigated epitopes of bovine alpha2(I) chain with use of IgE in gelatin-sensitive children.
Methods: Serum samples were collected from 15 patients who had systemic allergic reactions to vaccines and high levels of specific IgE to bovine gelatin. Eleven overlapping recombinant proteins that cover bovine alpha2(I) were prepared with a bacterial expression vector. We examined IgE reactivity to these recombinant proteins by means of ELISA. Fifteen peptides covering a major reactive recombinant protein were synthesized. The IgE-reacting epitope was identified by means of IgE-ELISA inhibition with these synthetic peptides and pooled serum from the patients.
Restults: We found that of the 15 patients, 13 showed IgE reactivity to a recombinant protein (no. 3) spanning the central region of the collagenous domain ((418)Gly-(662)Pro). Furthermore, all 13 patients showed IgE reactivity to the 4-kd recombinant protein (no. 3a) spanning the region from (461)Pro to (500)Glu. In IgE-ELISA inhibition we found that a minimum IgE epitope of gelatin allergen was composed of the 10-amino-acid sequence (485)Ile-Pro-Gly-Glu-Phe-Gly-Leu-Pro-Gly-Pro(494). This sequence is not observed in the human type I collagen alpha1 and alpha2 chains, nor is it found in the bovine type I collagen alpha1 chain.
Conclusions: We found that Ile-Pro-Gly-Glu-Phe-Gly-Leu-Pro-Gly-Pro is a major IgE epitope of the alpha2 chain of bovine type I collagen in patients with gelatin allergy. The degree of anaphylaxis to gelatin in vaccines might be reduced by digestion of this IgE-binding site in gelatin.

J Allergy Clin Immunol. May 2012; 129(5): 1334-1342.e1.
Published online Apr 3, 2012. doi: 10.1016/j.jaci.2012.02.038
PMCID: PMC3340561
NIHMSID: NIHMS368366
The relationship between red meat allergy and sensitization to gelatin and galactose-alpha-1,3-galactose
Raymond James Mullins, MB BS, PhD, Consultant Physician, Clinical Immunology and Allergy, Hayley James, BS, Thomas A.E. Platts-Mills, MD, PhD, FRS, and Scott Commins, MD, PhD
Abstract
Background: We have observed patients clinically allergic to red meat and meat-derived gelatin.
Objective: We describe a prospective evaluation of the clinical significance of gelatin sensitization, the predictive value of a positive test and an examination of the relationship between allergic reactions to red meat and sensitization to gelatin and alpha-Gal.
Methods: Adult patients evaluated 1997-2011 for suspected allergy/anaphylaxis to medication, insect venom or food were skin tested with gelatin colloid. In vitro (ImmunoCap) testing was undertaken where possible.
Results: Positive gelatin tests were observed in 40/1335 individuals; 30/40 patients with red meat allergy (12 also clinically allergic to gelatin); 2/2 with gelatin colloid anaphylaxis; 4/172 with idiopathic anaphylaxis (all responded to intravenous gelatin challenge of 0.02 to 0.4g); 4/368 with drug allergy. Testing was negative in all patients with venom allergy (n=241), non-meat food allergy (n=222), and miscellaneous disorders (n=290). ImmunoCap was positive to alpha-Gal in 20/24 meat allergics and in 20/22 with positive gelatin skin tests. The results of gelatin skin testing and anti-alpha-Gal IgE were strongly correlated (r=0.46; P<0.01). Alpha-Gal was detected in bovine gelatin colloids at concentrations of ~ 0.44 to 0.52ug/gm gelatin by inhibition radioimmunoassay.
Conclusion: Most patients allergic to red meat were sensitized to gelatin and a subset was clinically allergic to both. The detection of alpha-Gal in gelatin and correlation between the results of alpha-Gal and gelatin testing raises the possibility that alpha-Gal IgE may be the target of reactivity to gelatin. The pathogenic relationship between tick bites and sensitization to red meat, alpha-Gal and gelatin (with or without clinical reactivity) remains uncertain.

Mullins RJ et al: Allergic reactions to oral, surgical and topical bovine collagen: Anaphylactic risk for surgeons
Australian and New Zealand Journal of Ophthalmology
Volume 24, Issue 3, pages 257-260, August 1996
Abstract
Background: Two cases of allergic (IgE-mediated) reaction to bovine collagen are described. Both patients developed conjunctival oedema in response to the topical application of highly purified bovine collagen to the eye during opthalmic surgery (corneal shields and catgut suture material). One patient developed periocular angioedema and angioedema of the throat after the ingestion of bovine collagen in the form of gelatin-containing foods.
Methods: The presence of allergen-specific IgE was evaluated by skin prick testing with collagen-derived products, and by topical challenge with a highly purified bovine collagen-derived corneal shield.
Results: In both patients, application of collagen to the eye reproduced the original subconjunctival oedema. In one patient, skin testing with purified and crude extracts of bovine collagen in the form of a corneal shield, catgut suture material and edible gelatin demonstrated evidence of collagen-specific IgE.
Conclusions: Clinical reactions to collagen are rare. Neverthless, patients with a history of allergic reactions to bovine collagen-derived products should be investigated because of the widespread use of collagen-derived therapeutic devices, the potential for immunological cross-reactivity with dietary collagen (gelatin) and the potential for anaphylaxis.

Takahishi et al:Laminin γ-1 and collagen α-1 (VI) chain are galactose-α-1,3-galactose-bound allergens in beef.
Allergy
Volume 69, Issue 2, pages 199-207, February 2014
Abstract
Background: Sensitization to the carbohydrate galactose-α-1,3-galactose (α-Gal) has been reported in patients with beef allergy. However, the proteins responsible for this allergy have not yet been identified. This study aimed to identify beef proteins that predominantly react with serum IgE in Japanese patients with beef allergy.
Methods: Sera were collected from 29 patients with beef allergy who had allergic reaction(s) such as urticaria, abdominal pain, vomiting, and anaphylactic shock after ingestion of beef and pork; the sera tested positive for IgE against beef and pork. IgE-binding proteins were detected by immunoblotting sera from the patients and identified using a combination of two-dimensional gel electrophoresis and peptide mass fingerprinting techniques. The involvement of carbohydrate in the binding of IgE to allergens was examined by periodate treatment and an inhibition assay with cetuximab by immunoblotting. Specific IgE binding to cetuximab was measured using the CAP-fluorescent enzyme immunoassay.
Results: Two IgE-binding proteins (240 kDa and 140 kDa) were detected in beef extract and identified as laminin γ-1 and the collagen α-1 (VI) chain fromBos taurus, respectively. Periodate treatment or the inhibition assay resulted in the loss of IgE binding to these proteins. Immunoblotting with anti-α-Gal antibody revealed the presence of α-Gal on the 240- and 140-kDa beef proteins. The amount of IgE bound to cetuximab was significantly correlated with that to beef in the patients with beef allergy.
Conclusion: The carbohydrate moiety (α-Gal) on laminin γ-1 and collagen α-1 (VI) chain are possibly common IgE-reactive proteins in the Japanese patients with beef allergy.

J Allergy Clin Immunol. Author manuscript; available in PMC Nov 1, 2010.
Published in final edited form as:
J Allergy Clin Immunol. Nov 2009; 124(5): 1108-1110.
Published online Aug 8, 2009. doi: 10.1016/j.jaci.2009.06.021
PMCID: PMC2784137
NIHMSID: NIHMS128015
Bovine and Porcine Gelatin Sensitivity in Milk and Meat-Sensitized Children
Jelena Bogdanovic, Ph.D.,a Neal A. Halsey, M.D.,b Robert A. Wood, M.D.,a and Robert G. Hamilton, Ph.D.

Sincerely,
Phil Lieberman, M.D.

Close-up of pine tree branches in Winter Close-up of pine tree branches in Winter