Paper Title
Alpha Gal Syndrome-The Milder Side

Abstract
Alpha gal syndrome, also known as alpha gal allergy, mammalian meat allergy, red meat allergy, and tick bite meat allergy, is an allergy to red meat, dairy products, and gelatin induced by the bite of the lone star tick in North America. Alpha gal disease is an allergic response to the glycan galactose-alpha-1,3-galactose, which is present in the glycoproteins from tick saliva and tissues of non-catarrhine mammals. The IgE antibodies to galactose-alpha-1,3-galactose mediate delayed anaphylaxis to red meat consumption, and immediate anaphylaxis to tick bites, xenotransplantation, and certain drugs such as cetuximab. Symptoms can include anaphylaxis, itching, skin erythema, urticaria, angioedema, wheezing or shortness of breath, abdominal pain, diarrhea, vomiting, and gastroesophageal reflux. There is a subset of patients with milder symptoms that are more difficult to diagnose. These patients may present to dermatologists with generalized itching with or without a rash, a butterfly rash similar to the presentation of systemic lupus with a negative antinuclear antibody, urticaria, and mild lower extremity edema. Patients can present to primary care or gastroenterology with irritable bowel symptoms, chronic gastroesophageal disease, or symptoms of eosinophilic esophagitis. The mechanism of action of alpha gal syndrome and the resulting sequelae, whether severe or mild, are discussed to help physicians recognize the milder symptoms and promptly diagnose patients to lessen morbidity.