Gastrointestinal-predominant alpha-gal syndrome with severe eosinophilia in a child: a case report from Sri Lanka

Alpha-gal syndrome (AGS) is an emerging IgE-mediated allergy caused by sensitisation to galactose-α-1,3-galactose following tick bites. Although AGS typically presents with delayed urticaria or anaphylaxis after ingestion of mammalian meat, gastrointestinal-predominant presentations remain under-recognised, particularly in children, often resulting in delayed diagnosis. Reports in children, especially from South Asia, remain limited. To our knowledge, this is the first reported paediatric case of gastrointestinal-predominant AGS associated with severe eosinophilia from Sri Lanka. A previously healthy 4-year-old girl from Western Province, Sri Lanka presented with recurrent abdominal pain for three months and vomiting undigested food particles with associated gastrointestinal manifestations. Further evaluation revealed a previous episode of delayed anaphylaxis occurring approximately three hours after pork ingestion and a history of multiple tick bites, both of which became important diagnostic clues for AGS. Investigations revealed marked peripheral eosinophilia (8,506/mm³). Abdominal ultrasonography and serological testing for toxoplasmosis, toxocariasis and filariasis were unremarkable. Symptoms persisted despite empirical anti-helminthic therapy and symptomatic treatment. Skin prick testing demonstrated positive reactions to fresh raw beef, fresh raw pork, gelatine, and cow’s milk, while alpha-gal-specific IgE was strongly positive (29 kUA/L), supporting the diagnosis of AGS. Following elimination of alpha-gal-containing foods, her gastrointestinal symptoms resolved completely with normalization of eosinophil counts within one month. This case highlights gastrointestinal-predominant AGS as an important but under-recognised differential diagnosis in children presenting with unexplained chronic gastrointestinal symptoms.