This serious tick-borne illness remains unfamiliar to most nurses.
- Many nurses and other healthcare professionals aren’t aware of the increasing frequency of alpha-gal syndrome (AGS), a tickborne illness.
- A bite from a lone star tick can result in serious allergic reactions, including anaphylaxis, to eating the meat of four-legged animals.
- Nurses with knowledge of this condition can serve as care coordinators among emergency service personnel and healthcare providers.
Lydia Ryan*, a 67-year-old woman, arrives at the ED in distress. She tells Jason, the ED triage nurse, that about 3 hours after eating beef nachos, she began experiencing stomach discomfort, headache, an extremely itchy raised rash “all over,” and swollen lips and tongue.
Other than arthritis, Ms. Ryan has no significant medical history. She sometimes takes 1,000 mg of acetaminophen in the early morning for her arthritis. She walks in a wooded park several times a week. Ms. Ryan reports that about 2 weeks ago, she found a tick on the back of her neck, which she fully removed.
History and assessment
During his assessment, Jason observes Ms. Ryan’s flushed skin, hives, and extreme itching. Ms. Ryan tells Jason that she took a 25 mg diphenhydramine pill before coming to the ED.
Ms. Ryan’s vital signs are temperature 100.5° F (38° C), HR 140 bpm, RR 22 breaths per minute, BP 90/50 mmHg (her normal is 130/80), and oxygen saturation 94% on room air. Jason notes audible wheezing.
Taking action
Jason notifies the attending ED provider of Ms. Ryan’s allergic/anaphylactic reaction. The patient tells the provider that she rarely eats meat, but that she did that evening. When the provider asks about recent tick bites, Ms. Ryan recalls the tick from 2 weeks ago. The provider notes a full body erythematous rash, hypotension, and tachycardia. He diagnoses Ms. Ryan with alpha-gal syndrome (AGS) and orders stat epinephrine IM and other adjuvant therapies. Ms. Ryan is monitored for several hours.
Anaphylaxis emergency treatment
Anaphylaxis requires prompt and simultaneous implementation of the following steps:
- ABCs. As in all emergencies, monitor the patient’s airway, breathing, and circulation.
- Stat epinephrine (1 mg/mL preparation). Administer 0.3 mg to 0.5 mg IM in the patient’s mid-outer thigh. Repeat the injection every 5 to 15 minutes (or more frequently) as needed.
- Recumbent position. If the patient can tolerate, have them lie down with the lower extremities elevated.
- Oxygen. Administer, if needed, via nonrebreather mask.
- Normal saline rapid bolus. If the patient is hypotensive, treat them with a rapid I.V. bolus of 1 to 2 liters of normal saline. Monitor intake and output.
- Albuterol. If the patient experiences bronchospasm, even after epinephrine administration, give 2.5 mg to 5 mg of albuterol in 3 mL of saline via a nebulizer (or 2 to 3 puffs by metered dose inhaler). Repeat this step every 1 to 4 hours needed.
- Adjunctive therapies.
- H1 antihistamine—Diphenhydramine 25 mg to 50 mg I.V. (given over 5 minutes) for relief of urticaria and itching. In conjunction with diphenhydramine, cetirizine 10 mg I.V. can be given over 2 minutes. Diphenhydramine offers faster onset for acute reactions; cetirizine provides longer lasting effects.
- H2 antihistamine—Consider famotidine 20 mg I.V. (given over 2 minutes) if the patient experiences significant skin itching (hives) and gastric discomfort (nausea, abdominal pain).
- Corticosteroids. Providers can order methylprednisolone 125 mg I.V. at their discretion to prevent possible delayed inflammatory reactions.
- Monitor. For at least 4 hours after treatment, monitor the patient for biphasic anaphylaxis (a rebound event).
Patient education
Provide thorough education regarding diet and tick bite avoidance.
Outcome
After full resolution of symptoms, the ED provider discharges Ms. Ryan home with a prescription for an epinephrine pen; he advises her to carry it at all times and stresses the importance of seeing an allergist as soon as possible.
The provider explains to Ms. Ryan that her symptoms are consistent with AGS, a meat allergy triggered by a lone star tick bite. The tick deposits a chemical sugar known as alpha gal into the bloodstream of an individual who then becomes sensitized to it. When the person consumes meat from four-legged animals, which also have this chemical, they can experience serious allergic reactions.
Education and follow-up
AGS is an IgE-mediated hypersensitivity response, which can result in a drop in blood pressure, difficulty breathing, wheezing, stridor, cough, flushing, rashes, itching, and swelling of the lips, throat, tongue or eyelids. This swelling serves as a sign of the severity of the reaction, which may cause respiratory compromise.
Individuals with AGS require education about avoiding anaphylactic reactions. They should see an allergist who can perform diagnostic blood tests to verify the presence of AGS. They also should receive education about reading food labels and how to avoid future bites. Providers should advise patients to carry an epinephrine pen at all times and to call 911 if they experience signs and symptoms of anaphylaxis. Fatality occurs usually within the first hour of the onset of anaphylaxis.
Diet
Patients with alpha-gal syndrome should avoid the following foods. However, they also should check with their provider since sensitivities for individual patients can vary.
- Mammalian meat (for example, beef, pork, lamb, goat, and rabbit)
- Dairy products for some, but not all patients
- Foods made with gelatin, which comes from mammal collagen (for example, Jell-O, medication in gel capsules, and gummy candies)
- Certain other medications, including some vaccines (MMR, yellow fever), heparin, pancreatic enzymes, and cetuximab (a chemotherapy drug)
AGS is on the rise, but many healthcare professionals are unaware. To ensure comprehensive patient management, nurses can serve as excellent coordinators of care among emergency services and healthcare providers.
Tick bite avoidance
- Avoid wooded areas, especially during high tick season (typically spring through early fall).
- Wear long sleeves in wooded areas.
- Treat clothing with permethrin.
- Use insect repellant.
- Routinely perform complete body checks.
- If bitten, save the tick in a zip-lock plastic bag and call your provider to discuss next steps.
*Name is fictitious.
To access references and learn more about alpha gal, anaphylaxis monitoring and treatment, and patient education, visit bit.ly/anjsep25alphagal.
Stacen Keating is a clinical associate professor, New York University Rory Meyers College of Nursing in New York City. Theresa Bucco is a clinical assistant professor, NYU College of Nursing in New York City.
American Nurse Journal. 2025; 20(9). Doi: 10.51256/ANJ092577
References
Campbell RL, Kelso JM. Anaphylaxis: Emergency treatment. UpToDate. June 24, 2023. uptodate.com/contents/anaphylaxis-emergency-treatment
Carpenter A, Drexler NA, McCormick DW, et al. Health care provider knowledge regarding alpha-gal syndrome—United States, March–May 2022. Morb Mortal Wkly Rep. 2023;72:809-14. doi:10.15585/mmwr.mm7230al
Centers for Disease Control and Prevention. About alpha-gal syndrome. May 15, 2024. cdc.gov/alpha-gal-syndrome/about/index.html
Leder J, Diederich A, Patel B, Bowie M, Renwick CM, Mangunta V. Perioperative considerations in alpha-gal syndrome: A review. Cureus. 2024;16(1):e53208. doi:10.7759/cureus.53208
Macdougall JD, Thomas KO, Iweala OI. The meat of the matter: Understanding and managing alpha-gal syndrome. ImmunoTargets Ther. 2022;11:37–54. doi:10.2147/ITT.S276872
McLendon K, Sternard BT. Anaphylaxis. StatPearls. January 26, 2023. ncbi.nlm.nih.gov/books/NBK482124
Key words: alpha-gal syndrome, anaphylaxis, tickborne illness, serious food allergy
