← The Dr. Gabrielle Lyon Show
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Here's a fascinating piece of the puzzle that most people don't know. You eat a steak at 7, you go to bed at 10. At 1 in the morning, you wake up with severe abdominal pain, hives everywhere, maybe vomiting, maybe difficulty breathing. You go to the er, they treat you for an allergic reaction of unknown origin and send you home. Nobody asks what you ate six hours ago. This can happen again and again before anyone connects the dots. Alpha GAL syndrome, or ags, is is one of the most remarkable discoveries in immunology in the last two decades. Reactions don't happen every time you eat meat. A sensitized person can eat a burger one day and be fine, then eat one the next day and wake up in the er. Why? Well, because there are CO factors that can amplify the reaction. But it goes beyond just the obvious cuts of meat. And here's something that makes it even more confusing. People with blood type B likely have immune tolerance to Alpha Gal because of that structural similarity, which reduces their capacity to produce anti Alpha GAL antibodies. This blood type connection has a real clinical implication beyond diet. Here is what surprised me the most. And beyond food, there's a whole category of Alpha GAL exposure that most people and many doctors don't think about. Imagine this. You eat a steak for dinner, go to bed feeling fine. Three hours later, you wake up covered in hives. Your throat is tightening and you have no idea why. See, you didn't connect it to the steak you had at dinner because why would you? You've eaten red meat your entire life. But six weeks ago, on a hike, a tiny tick latched onto your ankle. And that tick just about rewired your immune system. This, my friends, is Alpha Gal syndrome. And it is one of the most fascinating and misunderstood conditions, I think, in modern medicine. Let's start with the basics. What is the Lone Star tick? The adult female is easy to identify. She has a single white dot on her back, and that's the Lone Star Star. The males, smaller, molted, brown, no dot. All stages of this tick, larva and sex, male or female, transmit Alpha GAL syndrome. Now, here's what makes this tick different from others. Most ticks are ambush predators. They sit on a blade of grass and wait for you to walk by. But the Lone Star tick, man, she's super crabby. And she hunts, she actively pursues you. She detects your carbon dioxide, your body heat, your movement. And this tick, let's just call her Sarah, she comes to you. All life stages bite humans, the larvae, the nymphs, the adults, and the season runs from early spring through late fall. Historically, this tick was concentrated in southeastern United States. But over the last several decades, it its range expanded significantly into the Northeast, westward into the Central States. We're now seeing established populations in areas that we've never had them before. Before we get into conspiracy theory. Why did this happen? Well, warmer temperatures, milder winters, longer seasons of tick activity, the recovery of white tailed deer populations because these are the primary host, and changes in land use that bring humans closer to tick habitat. And this matters because the Lone Star tick transmits real disease. And then there's the big one that we're hearing so much about. That's Alpha Gal syndrome. Here's what you need to know. You eat a steak for dinner. You go to bed feeling fine. Three hours later, you wake up covered in hives. Your throat is tightening, and you have no idea why you didn't connect it to the steak you had at dinner. And why would you? You've eaten red meat your entire life. But six weeks ago on a hike, a tiny little tick latched onto your ankle. And that tick, my friend, just rewired your immune system. This is Alpha Gal syndrome. And in my opinion, it's one of the most fascinating and misunderstood conditions in modern medicine. Welcome. I'm Dr. Gabrielle Lyon. And today we're going to go deep on the Lone Star tick, the creature behind this syndrome. What it does to your body, how it is diagnosed, what makes reactions worse, which is fascinating, the treatments that can help, and most importantly, what you can do right now to protect yourself and your family. What is the Lone Star tick? The adult female is easy to identify. She has a single white dot on her back. That's the Lone Star. The males are smaller, molted brown, and have no dot. All forms transmit disease, and at any stages. Now, here's what makes this tick different from others. Most ticks, I don't know if you knew this, are ambush predators. They sit on a blade of grass and wait for you to walk by. The Lone Star tick, man, she's aggressive. She hunts and she actively pursues you, detects your body heat, your movement, and all life stages bite humans, the larvae, the nymph, the adults. And the season runs from early spring through late fall. And this is an aggressive bug, which is one reason why I dislike bugs. Historically, this tick was concentrated in the southeastern United States. But over the last several decades, its range has expanded significantly to the north, northeast, westward into the central states. We're now seeing established populations in areas that we've never seen them Before? Why? Well, warmer temperatures, milder winters except in Texas. Longer seasons of tick activity and the recovery of white tailed deer populations, which are a primary host. And changes in land use that bring humans closer to tick habitat. Lone Star tick transmits real diseases like tularemia, heartland virus, bourbon virus, and a condition called starry Southern tick associated rash illness. S, T, A, R, I. And then there is the big one. Alpha Gal syndrome. Alpha Gal syndrome, or ags, is one of the most remarkable discoveries in immunology in the last two decades. And the story of how it was discovered is itself fascinating. Alpha Gal is a sugar molecule found on the cells of virtually every mammal except humans and other primates. It's in beef and pork, lamb, venison, bison, all of it, except for us. All humans naturally produce antibodies to Alpha gal. We make IgM, IgG, IgA, that's normal. But we do not normally make IgE antibodies to alpha gal. IgE is the antibody class that drives allergic reactions. What happens? Well, a Lone Star tick bites you. Its saliva, which contains high concentrations of Alpha Gal, gets injected into your skin. Something about that tick saliva in that context flips a switch in your immune system. Your body starts producing IgE antibodies specific to alpha gal. That's sugar. And those IGE levels climb dramatically, or can climb dramatically over the weeks following the bite. Now you're sensitized. And the next time you eat a burger, a pork chop, a lamb shank, your immune system recognizes the Alpha Gal in that meat and mounts a full allergic response. Here's what makes Alpha Gal syndrome so difficult to catch. The reaction is delayed. Most food allergies hit you within minutes. Alpha Gal reactions take two to six hours. And the leading theory is that this delay reflects the time it takes your gut to digest the glycolipids in meat and process them into chylomicrons and eventually low density lipoproteins that then enter circulation and activate mast cells. Mast cells are in part why you have this big reaction. So picture this. You eat a steak at 7, you go to bed at 10, especially if you're going to bed on time. At 1 in the morning, you wake up with severe abdominal pain, hives everywhere, maybe vomiting, maybe difficulty breathing. You go to the error. Nobody asks what you ate six hours ago. Why would they? They treat you for an allergic reaction of unknown origin and send you home. This can happen again and again before anyone connects the dots. And here's something that makes it even more confusing. Reactions don't happen every time you eat meat. A sensitized person can eat a burger one day and be fine, then eat one the next day and wake up in the er. Why? Well, because there are CO factors that can amplify the reaction. I don't like this one and I don't think you're going to like it either. Exercise after eating meat, alcohol consumption and potentially non steroidal anti inflammatory drugs like ibuprofen. All of these can increase both the likelihood and severity of a reaction. Fattier cuts of meat also tend to trigger worse reactions and here's why. Because Alpha GAL is concentrated in the glycolipids associated with fat, so it's concentrated in the fat. Here's a fascinating piece of the puzzle that most people don't know your blood type may influence your risk Research has shown that individuals with blood type B appear to have a lower risk of developing Alpha GAL syndrome. Why? Because the B blood group antigen is structurally very similar to Alpha gal. People with blood type B likely have immune tolerance to Alpha GAL because of that structural similarity, which reduces their capacity to produce anti Alpha GAL antibodies. Conversely, people with blood type A and O who lack the B antigen appear to be at a higher risk. A case control study out of North Carolina confirmed this Patients with Alpha GAL or AGS were significantly more likely to have A or O blood types compared to controls. They were also more likely to have a history of childhood allergies, a family history of Alpha GAL syndrome and a family history of food allergies, suggesting that both genetic and shared environmental factors contribute to who develops this condition. This blood type connection has a real clinical implication beyond diet. Alpha GAL is structurally similar to the B blood group antigen, which means that blood transfusions of group B plasma or platelets to group O recipients with Alpha GAL syndrome can trigger severe, even fatal anaphylactic reactions. And there have been documented cases, including one fatality in in Washington, D.C. area where group O patients with undiagnosed Alpha GAL syndrome received group B blood type products and went into anaphylaxis. Getting Diagnosed the blood test you need to know about how do you actually get diagnosed? And this is critical because the CDC estimates that between 96,000 and 450,000 people in in the United States may have developed Alpha Gal since 2010, and many of them don't know about it. Now the diagnosis relies on three things a clinical history of delayed allergic reactions after eating mammalian meat, which is very challenging a positive blood test for alpha GAL specific ige and number three, an improvement on a mammalian restricted diet. Skin prick testing can also be used, but the blood test is the primary diagnostic tool. Importantly, oral food challenges where you eat the suspected food under obviously or not, but you should. Medical supervision are not always reliable for alpha GAL reactions because of what we spoke about before. Alpha GAL syndrome is dependent. Those reactions are dependent on cofactors. You might pass the challenge in clinic, but react at home after, say, a glass of wine and a hard workout. If you're having unexplained allergic reactions, especially GI symptoms like the following. Abdominal pain, nausea, diarrhea, especially if you spend time outdoors in tick country, ask your doctor to test for alpha GAL specific ige. I will mention it is a simple blood draw. We have an online clinic called Strong Medical where you can come visit us in person in New York at the Forever Strong Center. And it could change everything for you because you know what you are dealing with. Treatment and management. What do you do now? Let's talk about what you do once you have the diagnosis. And I will say the diagnosis is the hardest part. I remember looking at some data and According to the CDC, it was something like 43% of healthcare providers didn't even know it existed. So once you understand that, you get the diagnosis. What is the treatment? The cornerstone is dietary avoidance. All symptomatic patients should avoid mammalian meat. Beef, pork, lamb, venison, bison, essentially any animal with hair. But it goes beyond just the obvious cuts of meat. And this is pretty crazy. Somewhat disappointing because you also need to watch for things that are derived from gelatin foods like marshmallows, gummy bears, gelatin desserts, lard in biscuits, pork casing used for poultry, sausages, beef broth, gravy drippings, bacon fat used in vegetable dishes. So that is a hidden source. And some patients have even reported reactions from inhaling aerosolized alpha Gal like fumes from the grill. The good news is that Most patients, about 80%, can continue to eat small to moderate amounts of low fat dairy, like skim milk and hard cheeses without problems. Dairy contains less alpha Gal, particularly in lower fat forms, but for roughly 20% whose symptoms persist despite avoiding meat, the next step is eliminating high fat dairy. Okay, what else? Poultry, fish, seafood are completely fine, which that's crazy. Chicken, turkey, salmon, shrimp, all fine. Now for managing symptoms. And this is where pharmacology comes in. And there are tools that can help. Again, this is not medical advice. The goal is how do we raise awareness so that you or your provider recognizes these symptoms. For acute allergic reactions and anaphylaxis, this is serious. The treatment mirrors any severe food allergy epinephrine first. Every patient with Alpha Gal syndrome or AGS who has a significant reaction should carry an EpiPen. In the case of accidental exposure, the American Gastroenterological association or AGA, recommends taking one or two Benadryl 25 milligram tablets immediately and having EPI ready if symptoms worsen, especially if there's any concern for respiratory compromise. Again, this is not medical advice. Please check with your physician. Here is what surprised me the most. There are hidden triggers and beyond food, there's a whole category of Alpha Gal exposure that most people and many doctors don't think about in terms of medication and medical products. Cetuximab, the cancer drug that led to the discovery of of AGs, is the most well known. But other monoclonal antibodies produced in the same mouse cell line also contain Alpha Gal, including infliximab, which is widely used for Crohn's disease and rheumatoid arthritis. And there's at least one documented case of first dose anaphylaxis with infliximab caused by cross reactive Alpha Gal ige. Here's another one that really surprised me. Gelatin containing vaccines are another concern and this really surprised me. Vaccines for measles, mumps, rubella, varicella and zoster often contain hydrolyzed gelatin as a stabilizer and research has shown that these vaccines can activate basophils in AGS patients. The general recommendation is to avoid gelatin containing vaccines when possible, but if one is absolutely required and there is no alternative, it can potentially be administered under the supervision of an allergy specialist. Medications in gelatin capsules should be switched to tablet form when available. Porcine derived thyroid supplements and this surprises a lot of people like Armour, thyroid should be avoided and here's one that also surprises people including myself. Heparin Heparin is used for blood clots. Porcine derived heparin contains detectable Alpha Gal and studies show that about 24% of Alpha Gal sensitized patients undergoing cardiac surgery had allergic reactions to IV unfractionated heparin compared to essentially zero percent with low molecular weight heparin. Even surgical implants, bovine or porcine heart valves, cardiac patches, vascular grafts contain Alpha Gal and may serve as a long term source of chronic inflammation in sensitized patients. The big takeaway if you have Alpha Gal syndrome, your allergist and your entire medical team need to know because it affects decisions first, far beyond what you eat. Okay, so what do you do? How do you treat it? Well The American Gastroenterological Association. Again, the AGA states there is no definitive cure for Alpha GAL syndrome. But it's a syndrome. But the condition is dynamic and can resolve spontaneously over time. If, and this is really important, further tick bites are avoided. Alpha Gal Ige levels may be rechecked 6 to 12 months after diagnosis. As levels decrease or become negative, patients may be able to gradually reintroduce. First, dairy, that's what we start with in our clinic. Then mammalian meat in small portions. Now, they say there is no cure and I agree with it. But I have seen spontaneous remission. They say that the mainstay of treatment is avoidance. And I'm going to take you through the tiers of evidence as to how people typically clinically approach this. Tier 1, remove all mammalian meat, beef, pork, lamb, venison and hidden sources like lard, beef broth, pork casing. This alone resolves symptoms in roughly 80% of patients. Again, which is important to understand. Chicken, turkey and fish and seafood are all still fine. Now I will tell you, this is exactly how my first patient, roughly 10 years ago presented with Alpha Gal. They couldn't eat any mammalian products. And he kept saying every time I eat a burger or steak, he was a bodybuilder, that he would get sick and he was like, doc, I can tolerate fish and I can tolerate turkey. I just don't understand it. I was convinced he had a parasite. I was convinced that he had some inflammation in his intestines. I mean, I was wrong. He ended up having Alpha Gal. We treated him without knowing that it was Alpha Gal. So we removed all mammalian products. And this is where a food diary comes in really handy because you get to know yourself and you get to in real time understand what works for yourself. Tier 2, second level here. If symptoms persist, cut out high fat dairy, whole milk ice cream, heavy cream, soft cheeses. Most people can still tolerate skim milk and hard cheeses. This gets you to about 95% of symptom resolution. Tier 3 for the most sensitive patients. Also, eliminate gelatin containing foods and certain medications. This gets you close to about 99%. Now what about medications? We talked about food, we're taking that off the table. This is really an underappreciated issue. Some medications contain Alpha Gal like we mentioned, cetuximab, gelatin capsules, porcine derived thyroid supplements and even some vaccines. Patients should use tablet formulations when possible and flag this allergy with their pharmacy managing reactions. Every patient with Alpha Gal syndrome should carry a self injectable EpiPen for mild accidental exposures, Benadryl can help. For chronic low grade symptoms, we've already covered this like GI upset or itching. H1 and H2 antihistamines or oral chromalin sodium can be used now. What about the cofactors? Exercise alcohol and NSAIDs can lower the threshold for a reaction. So patients might tolerate a small exposure on one day but react to the same amount if they've been drinking or exercising. The good news is Alpha GAL syndrome can fade over time and we have seen this if patients avoid further tick bites. Tick prevention is a critical part of the management plan. Individuals use permethrin treated clothing and this is DEET d EET based repellents and they do regular tick checks. Now again the red flags. If a patient has a history of anaphylaxis and an elevated baseline tryptase, then you would consider evaluating for underlying mast cell disorder which can of course amplify reactions. The bottom line, Alpha GAL syndrome is increasingly more common and it's often under diagnosed and primarily managed through dietary avoidance. The tiered approach makes it practical. You start with meat avoidance, escalate if needed and always have an EPI pen on hand. And of course this is not medical advice. This is for your education. The trajectory is concerning. Climate models predict the range of this tick could expand and we have to be prepared for it. But there's reasons for optimism for ags. Oral immunotherapy is being explored. It's shown efficacy for other food allergies like peanuts. And case reports suggest desensitization may be feasible for Alpha Gal. But we still need clinical trials. The Lone Star tick is expanding. Alpha Gal syndrome is increasing. But you are not powerless. Knowledge and simple prevention habits are your best defense. And friends, it is not all in your head. If you think that you got bit, get tested. Until next time. Thank you for listening. Stay forever strong.