Development of macro-aspartate aminotransferase in a patient undergoing specific allergen injection immunotherapy

Macro-aspartate aminotransferase (macro-AST), a complex between normal AST and an immunoglobulin, is recognized as a cause of isolated elevation of AST. Though its pathogenesis is unknown, previous reports have been suggestive of an autoimmune process. We describe a case of macro-AST formation in a patient with previously normal liver enzymes in whom an isolated AST elevation was discovered after initiation of specific allergen injection immunotherapy (SIT) for allergic rhinitis. We propose that SIT in this otherwise healthy patient led to the formation of macro-AST as a consequence of antibody cross-reaction (molecular mimicry). Awareness of this possible mechanism of macroenzyme development may be helpful to physicians evaluating patients with isolated elevations in AST.