Diagnostic dilemma: A woman got a lung transplant — and ended up with a peanut allergy, too

The patient: A 47-year-old woman in Canada

The symptoms: The woman underwent a lung transplant to treat interstitial lung disease, which involves harmful inflammation and scarring of lung tissue. While recovering in the hospital, she ate a bowl of breakfast cereal, which activated a nearly two-hour episode of flushing, itching, shortness of breath and low blood pressure.

This severe, life-threatening allergic reaction is known as anaphylaxis. A report of the woman's case does not mention specific treatment she received for this reaction, but it notes that it resolved after two hours.

(Treatment for anaphylaxis involves epinephrine (also called adrenaline), and it can also require antihistamines, cortisone, oxygen and beta-agonists, such as albuterol, which help improve breathing.)

What happened next: The woman experienced the same symptoms in the weeks after being discharged from the hospital — after eating a coconut cream pie and after having an almond candy bar.

The diagnosis: Two months after her lung transplant, the woman underwent a skin-prick allergy test, which revealed a sensitivity to peanut and pine nut allergens. She did not have an allergic response to tree nuts, such as the almonds in the candy bar, nor to coconut. None of the foods that triggered her symptoms were known to contain peanuts, but none were certified as peanut-free, either.

Notably, the woman's lung donor had been a 12-year-old boy with a known peanut allergy but no history of anaphylaxis. Her doctors theorized that the transplanted lung tissue contained immune cells from the donor that were sensitized to nut allergens.

The treatment: The woman did not receive a specific treatment to get rid of this new allergic response. However, the sensitivity subsided in follow-up skin-prick tests, and they had disappeared completely by a year after her surgery. She ate peanuts in a supervised setting a few months after the one-year mark and had no reaction.

The doctors reasoned that the sensitized immune cells from the donor must have cleared from her body.

What makes the case unique: Only one other case of peanut allergy following a lung transplant had been documented before the woman's case was published in 2011.

Scientists had only recognized the risk of allergies being passed from organ donors to recipients a little over a decade before the report, according to a 2025 review of such instances. Doctors had previously reported allergy transfer linked to bone marrow transplants, which makes sense given that bone marrow produces immune cells. But the first known donor-acquired allergy from a solid-organ transplant was observed in 1997 following a combined kidney-liver transplant from a donor who was allergic to peanuts.

The authors of the 2025 review noted that donor-acquired allergies are more commonly associated with lung and liver transplants than with transplants of other solid organs. That could be because these organs are rich in a type of immune cell that produces allergen-specific antibodies, called B lymphocytes.

Other potential culprits for donor-acquired allergies are mast cells and basophils, two types of immune cell that bind to those allergen-specific antibodies. The cells hold onto the antibodies, and when they encounter an allergen, they release the inflammatory compounds responsible for anaphylaxis.

In the woman's case, a blood test for peanut-specific antibodies came back negative. This suggested that her body was not continually generating the antibodies. That could serve as possible evidence that her reaction was caused by antibodies bound to mast cells or basophils within the donor tissue, rather than antibodies produced by lymphocytes.

That said, the woman's reaction to the skin-prick test could imply that lymphocytes were still involved in the allergic reaction, the doctors added, as they did not know whether mast cells or basophils could migrate to the skin the way circulating antibodies could.

Regardless of the cell type behind the woman's peanut allergy, the sensitivity faded after a year, consistent with other cases described in the 2025 review. Still, the review authors called for better donor allergy labels to inform allergy testing and treatment for organ recipients. The doctors in the case report came to a similar conclusion, noting that detailed donor allergy histories and skin-prick testing after organ transplant could help identify donor-acquired allergies.

For more intriguing medical cases, check out our Diagnostic Dilemma archives.