Oculogyric dystonic reaction to escitalopram with features of anaphylaxis including response to epinephrine

Dystonia-associated features of anaphylaxis, including tongue swelling, and chest and throat tightness, have been rarely reported with selective serotonin reuptake inhibitor (SSRI) use. The patient is a 44-year-old woman who presented with palpitations, diaphoresis, dyspnea, swelling of the lips and tongue, and fixed upward deviation of her right eye following inadvertent ingestion of 20 mg of escitalopram in addition to her usual 10-mg dose. She reported transient resolution of all symptoms after autoinjector aqueous epinephrine administration (0.3 mg), with recurrence of symptoms after 35 min. The patient presented with one prior episode of anaphylactic symptoms and dystonia. She also reported one episode with purely anaphylactic features of swelling of lips and tongue, difficulty breathing and syncope. This case represents a unique dose-dependent episode of escitalopram-associated oculogyric dystonia with anaphylactic features. The transient resolution of the associated features of dystonia with intramuscular epinephrine administration is unique and suggests a common pathophysiology of the dystonic and anaphylactic symptoms.     

Anaphylaxis after contact with a jellyfish

We report a case of an anaphylactic reaction to a jellyfish sting. The episode was manifested by hypotension and bronchospasm. The patient's basophils released histamine in response to nematocyst venom from the Chesapeake Bay sea nettle; this sensitivity could be passively transferred by a heat labile serum factor. This appears to be the first case report of such a reaction.     

Evaluation of bee sting allergy by skin tests and serum antibody assays.

We studied 55 subjects who had had anaphylactic reactions to bee stings within the previous 3 years. 38 out of 54 tested had IgE antibody to honey bee venom (HBV) as measured by radioallergosorbent test (RAST). On skin testing, 30 out of 34 had a positive test to HBV. Of these, 26 had a positive RAST. A positive skin test to HBV at high dilution or else a high anti-HBV RAST score appeared to identify those who, in a 6-month follow-up period, were at risk of developing further anaphylaxis following bee stings or immunotherapy. Of the two tests, RAST appeared to be the less sensitive. Measurements of IgG antibody to phospholipase A were seldom available for the period immediately preceding an anaphylactic episode and proved to be a poor means of predicting the liability to bee sting anaphylaxis in subsequent months.     

An Internet-based survey of anaphylactic reactions to foods

BACKGROUND: A favorable outcome of anaphylaxis depends on the rapidity of adequate initial management and epinephrine injection. However, few data on the management of anaphylactic reactions are available. The aim of this study was to investigate the management and awareness of anaphylaxis to foods by mean of an Internet-based survey. METHODS: Visitors to a website with information on food allergy were invited to join the survey. Items in the survey included the management of anaphylactic reactions, investigations done by the diagnosing physician, and information given to the responder in anticipation of a new anaphylactic reaction. RESULTS: Almost all of the 264 responders were from North America, Europe, Australia, or New Zealand (263/264). The most recent reaction was treated by epinephrine injection in 68.7% (180/262) of cases, or by antihistamines in 14.1% (37/262). Epinephrine was the first treatment for the most severe reaction in only 43.9% (101/230), while antihistamines were given first in 43.5% (100/230). One-third (62/210 = 29.5%) of the responders diagnosed by a physician received neither a diagnostic blood test nor a skin test. Responders diagnosed by an allergist were more often investigated (91/105 = 86.7%) than those diagnosed by a pediatrician or an internist (29/44 = 65.9%), a general practitioner (22/45 = 48.9%), or another physician (6/16 = 37.5%) (P < 0.001). Most responders had received instructions on how to deal with a new episode of anaphylaxis (244/263 = 92.8%). Responders instructed by an allergist were most frequently satisfied with the instructions (115/131 = 87.8%). CONCLUSION: A large number of responders did not receive epinephrine for treatment of their most severe, or most recent anaphylactic reaction, and did not undergo allergy tests. The conventional management of anaphylaxis might still be improved.     

Anaphylaxis due to succinylcholine

The antigen non-specific release of histamine by synthetic neuromuscular blocking agents is well known, though our review of thirty-two cases reported in the literature of anaphylactoid reactions to succinylcholine, shows that there is insufficient evidence to determine whether the signs are due to anaphylactic or to anaphylactoid reactions. We have examined thirteen cases in whom evidence of anaphylactic sensitization was examined by direct skin tests (in eleven cases) Prausnitz-Küstner tests (in five), rabbit basophil degranulation, Shelley test (in twelve) and human basophil degranulation (in seven). These tests were done on two to four occasions, and the optimal period for the first test ascertained to be 6 to 12 weeks after the episode. All eleven patients examined by direct skin tests showed evidence of anaphylactic sensitivity, and in three of five cases the sensitivity could be transferred by the Prausnitz-Küstner procedure. In one of these P-K tests there was evidence of both IgE and of IgG S-TS antibodies (heat-stable antibody conferring sensitivity for 2 hr). Particular susceptibilities to adverse reactions to this drug appear to be prior drug allergy (in 50% of cases), several previous anaesthetics, and atopy.     

Anaphylactic reactions in children--a questionnaire-based survey in Germany

BACKGROUND: Severe anaphylactic reactions are medical emergencies requiring immediate recognition and treatment. Despite this, little is known on their clinical features, especially in infants and children. OBJECTIVE: To evaluate trigger factors, patterns of clinical reaction, site of occurrence and treatment modalities of reported reaction in infants and children below 12 years of age in Germany. METHODS: Paediatricians throughout Germany were asked by questionnaire to report accidental anaphylactic reactions over the previous 12 months. Severity of reported reactions was classified in grades I-IV according to reported symptoms. RESULTS: Hundred and three cases of anaphylaxis were evaluated. Median age was 5 years, 58% were boys. Site of occurrence was the child's home in the majority of cases (58%). Foods were the most common causative allergen (57%), followed by insect stings (13%) and immunotherapy (SIT) (12%); in 8% anaphylactic agent was unknown. Among foods, peanuts and tree nuts were the most frequent allergens (20% of food allergens in each case). Severe reactions with cardiovascular involvement occurred in 24% of cases. No fatal reaction was observed. Recurrent episodes of anaphylaxis were reported in 27% of cases, half of these caused by the same allergen again. For treatment, 20% of children received adrenaline, in 8% of cases intravenously. Thirty-six per cent of patients with grade-IV reactions received adrenaline, 24% intravenously. In 17% of all children an adrenaline self-injector was prescribed after the episode. CONCLUSION: Our data: (i) shows an uncertainty of physicians in diagnosing anaphylaxis, (ii) reveals remarkable under-treatment of the majority of children with anaphylaxis, (iii) reflects the need for guidelines and training for physicians in managing children with anaphylaxis and (iv) should encourage the development of self-management programmes for patients and families.     

Effect of homogenization and pasteurization on the allergenicity of bovine milk analysed by a murine anaphylactic shock model

In a factorial design study a murine anaphylactic shock model was used to analyse the effect of homogenization, pasteurization, and fat content on the ability of bovine milk to induce anaphylactic reactions. Mice were sensitized by either oral or subcutaneous immunizations with various types of bovine milk. In spite of a significantly higher antibody titre in the mice sensitized subcutaneously, there was no difference in the sensitivity between orally and subcutaneously immunized mice with respect to anaphylactic reactions. Pasteurization did not seem to change the ability of milk to induce anaphylactic reactions. However, increasing fat contents in combinations with homogenization resulted in an increase of the ability of the milk to induce anaphylactic reactions.     

Rat tumour allografts evoke anaphylactic antibody responses.

In vitro assays of release of histamine from peritoneal mast cells showed that Wistar rats produced anaphylactic antibody in response to a single immunization with an allogeneic sarcoma. The response occurs early after immunization, and no adjuvant is needed. The thermolability of the anaphylactic antibody suggests that it is IgE.     

Anaphylactic and non-anaphylactic murine IgG1 differ in their ability to bind to mast cells: relevance of proper glycosylation of the molecule

We have previously shown that murine IgG1 antibodies comprise two functionally distinct types regarding their ability to induce mast cell degranulation. In this work, we identified two IgG1-producing hybridomas, both with the same antigenic specificity (anti-DNP), but different in vivo anaphylactic activities. Whereas one of them secretes the anaphylactic IgG1 antibody, as assessed by passive cutaneous anaphylaxis, the other produces the non-anaphylactic IgG1 molecule. The evaluation of the ability of both types of IgG1 to bind to and activate a mouse mast cell line revealed that the anaphylactic IgG1 has a higher binding capacity and releases more beta-hexosaminidase from mast cells than the non-anaphylactic IgG1. Aglycosylated IgG1 obtained by treatment of the anaphylactic IgG1-producing hybridoma line with an inhibitor of N-glycosylation failed to elicit anaphylaxis. In addition, a goat anti-mouse IgG1 antibody reacted less with this aglycosylated IgG1 than with the glycosylated form. These results suggest that the anaphylactic activity of IgG1 antibodies is closely related to their structural conformation and the proper N-glycosylation of these molecules. Finally, the difference in the anaphylactic property between the two types of IgG1 seems to be primarily due to binding to the mast cell surface.     

Life-threatening inhalant allergy: typical anaphylaxis induced by inhalational allergen challenge in patients with idiopathic recurrent anaphylaxis

Eight patients, referred to an allergy service because of anaphylactic syndromes, were investigated for the usual causes (drugs, foods, insect stings etc.) without satisfactory results. All were atopic by history and/or allergy skin testing. Inhalation challenges, using nebulized common inhalant allergens to which the patients were positive by skin tests, were performed to test whether such inhaled allergens could be causing the anaphylactic episodes. Four of the eight patients developed anaphylactic episodes similar to the spontaneous attacks. Two of the other four patients developed precipitous asthma with some suggestion of non-pulmonary anaphylactic features. It is suggested that inhaled allergens may be a common cause of recurrent anaphylaxis where other recognized causes have been excluded.     

Effects of histamine H1-receptor blockade on respiratory and cardiac manifestation of systemic anaphylaxis

Summary In vivo anaphylaxis is associated with respiratory distress and cardiovascular failure. The present investigation was designed to further characterize respiratory and cardiac anaphylactic events. In guinea pigs, sensitization was produced by subcutaneous application of ovalbumin together with Freund's adjuvant. Fourteen days after sensitization, the effects of an intravenous infusion of ovalbumin were tested in the anesthetized artificially ventilated guinea pigs. The renewed application of the antigen induced an initial increase of left ventricular pressure which was followed by a rapid decrease 5 min after antigenic challenge. Enddiastolic left ventricular pressure increased within 3 min, thus indicating left ventricular pump failure. In the same time range, ECG recordings uniformly showed signs of acute myocardial ischemia. In addition, heart rate steadily decreased. All animals died within 15 min. Simultaneously with cardiac anaphylactic malfunction, severe arterial hypoxia and carbon dioxide retention occurred, revealing respiratory distress.Histamine is known as a potent bronchoconstrictor via histamine H₁-receptor stimulation. Administration of H₁-recpetor antagonists to improve respiration may therefore provide further information on the contribution of pulmonary malfunction to anaphylactic cardiovascular shock. Therefore, additional experiments were performed with sensitized guinea pigs pretreated with the histamine H₁-receptor blocker mepyramine. In these experiments the antigenic challenge induced a dissociation of cardiac and respiratory manifestation of anphylaxis. Despite inhibition of hypoxia and carbon dioxide retention, left ventricular pump failure and occurrence of myocardial ischemia were delayed but not suppressed.It is concluded that histamine is an important mediator of anaphylactic respiratory distress. However, vasoactive anaphylactic mediators other than histamine are primarily involved in anaphylactic cardiac malfunction occurring during the later phase of systemic anaphylaxis.Supported by grant Fe 250/1-1 from the Deutsche Forschungsgemeinschaft (DFG).     

Fatal anaphylactic sting reaction in a patient with mastocytosis

We report on a 33-year-old female patient with indolent systemic mastocytosis and urticaria pigmentosa who died of an anaphylactic reaction after a yellow jacket sting. As she had no history of previous anaphylactic sting reaction, there was no testing performed in order to detect hymenoptera venom sensitization. But even if a sensitization had been diagnosed, no venom immunotherapy (VIT) would have been recommended. It is almost certain that VIT would have saved her life and it is most likely that VIT is indicated in some patients with mastocytosis with no history of anaphylactic sting reaction. However, no criteria have been established in order to allow a selection of mastocytosis patients eligible for such a 'prophylactic' VIT.     

Immunologic response to different determinants of benzylpenicillin, amoxicillin, and ampicillin. Comparison between urticaria and anaphylactic shock

BACKGROUND: Subjects with IgE-mediated allergic reactions to penicillins can develop urticaria or anaphylactic shock. Urticaria is mainly associated with positivity to the major determinant of benzylpenicillin (BPO), and anaphylactic shock with minor determinants (MDM). The presence of IgG antibodies to BPO is thought to be mainly associated with urticaria, possibly protecting from anaphylactic shock. We aimed to study the skin test response to BPO and MDM, amoxicillin (AX), and ampicillin (AMP) in a group of subjects allergic to penicillins, and to evaluate the role of specific IgG. METHODS: We studied a group of patients with immediate allergic reactions to penicillins, comparing urticaria and anaphylactic shock. Skin tests were done with BPO, MDM, AX, and AMP. Specific IgE and IgG antibodies to benzylpenicilloyl-poly-L-lysine (BPO-PLL) and amoxicilloyl-poly-L-lysine (AXO-PLL) were determined by RAST and ELISA, respectively. RESULTS: Fifty-nine patients were studied (30 with anaphylactic shock and 29 with urticaria). Skin test positivity to BPO was associated with urticaria (P<0.001), and positivity to MDM, AX, and AMP with anaphylactic shock (P=0.006, P<0.001, and P=0.002, respectively). Specific anti-BPO-PLL and AXO-PLL IgG values were higher in patients than controls (P<0.001), but no differences were observed between urticaria and anaphylactic shock. CONCLUSIONS: Positivity to minor determinants of penicillins is associated more with anaphylactic shock than urticaria, but the role of IgG antibodies in helping to prevent the development of anaphylactic shock could not be confirmed.     

Effect of leaves of Eriobotrya japonica on anaphylactic allergic reaction and production of tumor necrosis factor-α

Leaves of Eriobotrya japonica Lindl. (Rosaceae) (LEJL) have been used as traditional medicines for inflammatory diseases and chronic bronchitis. However, its effect on mast cell-mediated anaphylactic reaction is not known. The anaphylactic allergic reaction is involved in many allergic diseases such as asthma and allergic rhinitis. In this report, we investigate the effect of LEJL on the anaphylactic allergic reaction and studied its possible mechanisms of action. LEJL inhibited compound 48/80-induced systemic anaphylactic reactions and serum histamine release in mice. LEJL dose-dependently decreased the IgE-mediated passive cutaneous anaphylaxis and histamine release from mast cells. Furthermore, LEJL decreased the production of tumor necrosis factor-α in phorbol 12-myristate 13-acetate and A23187-stimulated human mast cells. These findings provide evidence that LEJL could be a candidate as an anti-allergic agent.     

Anaphylactic reaction induced by Toxoplasma gondii-derived heat shock protein 70

Toxoplasma gondii-derived heat shock protein 70 (T.g.HSP70) is a virulent molecule specific for tachyzoites of T. gondii. The expression of T.g.HSP70 rapidly increases just before death of the host, indicating that T.g.HSP70 functions as a danger signal during lethal acute T. gondii infection. In the present study, T.g.HSP70 was proven to be capable of inducing lethal anaphylactic reaction in T. gondii-infected wild-type (WT) mice. Anaphylactic reaction appeared within the first hour after intraperitoneal injection of T.g.HSP70 and was characterized by a series of consequent symptoms until death. T.g.HSP70-induced anaphylactic reaction was not observed in IFN-gamma knockout (GKO) mice, indicating the involvement of IFN-gamma in the reaction. The anaphylactic reaction was transferable to GKO mice by splenocytes but not serum from infected WT mice. Also, this reaction occurred in B cell-deficient mice, indicating that T.g.HSP70-induced anaphylactic reaction occurred through an Ig-independent pathway. The messenger RNA (mRNA) expression of IFN-gamma increased significantly in splenocytes from T. gondii-infected WT mice after T.g.HSP70 injection. Furthermore, the mRNA expression of platelet-activating factor (PAF) acetylhydrolase in WT, but not GKO mice, distinctly increased during the occurrence of T.g.HSP70-induced anaphylactic reaction, indicating the involvement of PAF in T.g.HSP70-induced anaphylactic reaction. Treatment with PAF receptor antagonist rescued WT mice from the anaphylactic reaction. These data demonstrated the involvement of IFN-gamma-dependent PAF activation in T.g.HSP70-induced anaphylactic reaction.     

Inhibition of anaphylactic histamine releasein vitro by GABA

Inhibitory effect of GABA on anaphylactic histamine releasein vitro is not mimicked by 2-aminoethansulphonic acid (taurine), an aminoacid unrelated to GABA neurotransmission.Tetrodotoxin (TTX) 6×10^–7 M, a concentration known to block neuronal mechanism but not to modify muscle membrane and anaphylactic histamine release, strongly prevented the inhibition caused by GABA in the Schultz-Dale reaction and in anaphylactic histamine release.The inhibitory effect of GABA on anaphylactic reactionin vitro thus appears to be specific for this aminoacid and is neurogenic in nature, in that it requires integrity of neuronal mechanisms.     

Studies on monovalent anaphylactogens with carbohydrate auxiliary groups: exclusion of an artefact

N1-DNCP-N6-lactobionoyl-1,6-hexanediamine is an elicitor of anaphylactic reactions in the guinea pig passively sensitized by antisera raised with a DNCP-bovine gammaglobulin conjugate. If the antisera contained anticarbohydrate antibodies against the carbohydrate residues of the globulin, significantly cross-reacting with the lactobionoyl moiety, anaphylactogenic cell triggering would be by classical hetero-specific bridging which involved the DNCP- and the lactobionoyl residues as ligands. This possibility was excluded by showing that a bis-lactobionoyl conjugate is unable to elicit anaphylactic reactions.     

Anaphylaxis induced by lentil inhalation

Anaphylaxis is a rapid onset serious allergic reaction which may be fatal. Foods are the most common allergens leading to anaphylaxis especially for childhood. Most of the food-induced anaphylactic reactions take place after ingestion of the allergic food and only a few cases exist with anaphylactic reactions induced by inhalation of foods such as peanut, soybean and lupine. The case we present is unusual in that an 8 1/2-year-old boy developed anaphylaxis with the inhalation of steam from boiling lentils.     

烧伤后期过敏性紫癜的诱发

目的 烧伤后期由于存在各种致敏的因素，寻求并发过敏性紫癜的原因及防治方法。方法 通过近4年来20例烧伤后期出现过敏性紫癜的病例分析。结果 寻得烧伤与过敏性紫癜的关系，总结了烧伤后并发过敏性紫癜的病因、预后及防治。结论 烧伤可引起过敏性紫癜，但是可以预防和治疗。