Emergency department anaphylaxis: A review of 142 patients in a single year.

BACKGROUND: There are few data on the incidence, clinical features, and management of patients with acute anaphylaxis presenting to the emergency department. We investigated all presentations to one department during the course of a year to improve current awareness of this medical emergency. OBJECTIVE: The purpose of the study was to describe the clinical features, management, and outcome of anaphylaxis presentations to a single Australian adult emergency department in a single year, 1998-1999. METHODS: This was a retrospective, case-based study of adult patients (>or=13 years of age) attending a single emergency department in Brisbane, Australia, during the year 1998-1999. The medical records of 304 patients satisfying the relevant discharge diagnostic codes were studied. We determined incidence, sex ratio, age, clinical features, management, disposal, asthma prevalence, and causes in patients presenting with acute allergic reactions and anaphylaxis. RESULTS: In all, 162 emergency department patients with acute allergic reactions and 142 emergency department patients with anaphylaxis, including 60 whose anaphylaxis was severe, were seen during the year, for an anaphylaxis presentation incidence of 1 in 439. One patient died; this gave a case fatality rate of 0.70%. Cutaneous features were present in 94% of the patients with anaphylaxis. Of those with severe anaphylaxis, 35% had dizziness/syncope before hospital presentation, 25% laryngeal edema, and 21.7% systolic hypotension on hospital presentation. A cause was recognized in 73% of the anaphylaxis cases; most commonly, the causative agent was a drug, insect venom, or food. Adrenaline was used in 57% of the severe cases before hospital presentation or in the hospital. The emergency department alone definitively cared for 94% of all patients, though only 43% severe anaphylaxis cases were referred for follow-up. CONCLUSION: The emergency department anaphylaxis presentation incidence of 1 in 439 cases is greater than previously recognized, though death remains rare. In three fourths of cases, a precipitant was identified, a fact that emphasizes the need for a detailed initial history. Definitive management in the emergency department alone is possible in most cases, provided that the appropriate use of adrenaline and the need for allergy clinic follow-up are appreciated.     

Clinical predictors for biphasic reactions in children presenting with anaphylaxis

Background One of the main reasons for hospital admission once a child has been stabilized following anaphylaxis is to monitor for a biphasic reaction. However, only a small percentage of anaphylactic episodes involve biphasic reactions that would benefit from admission. Identification of predictive factors for a biphasic reaction would assist in determining who may benefit from prolonged observation.
Objective To determine predictive factors for biphasic reactions in children presenting with anaphylaxis.
Methods This was a retrospective study of children presenting with anaphylaxis to a major paediatric emergency department over a 5-year period.
Results There were 95 uniphasic (87%), 12 (11%) biphasic and two protracted reactions (2%). One child with a protracted reaction died. For the management of the primary anaphylactic reaction, children developing biphasic reactions were more likely to have received >1 dose of adrenaline (58% vs. 22%, P =0.01) and/or a fluid bolus (42% vs. 8%, P =0.01) than those experiencing uniphasic reactions. The absence of either factor was strongly predictive of the absence of a biphasic reaction (negative predictive value 99%), but the presence of either factor was poorly predictive of a biphasic reaction (positive predictive value of 32%). All biphasic reactors, in which the second phase was anaphylactic, received either >1 dose of adrenaline and/or a fluid bolus.
Conclusions Children who received >1 dose of adrenaline and/or a fluid bolus for treatment of their primary anaphylactic reaction were at increased risk of developing a biphasic reaction.     

Epidemiologic and clinical features of anaphylaxis in Korea.

BACKGROUND: Little is known about the characteristics of anaphylaxis in Korea or even in Asia. OBJECTIVE: To evaluate the incidence of anaphylaxis and the clinical features of patients with anaphylaxis in a Korean tertiary care hospital. METHODS: We performed a retrospective review from January 1, 2000, through July 31, 2006, of 138 patients with anaphylaxis, including inpatients, outpatients, and emergency department visitors, in the Seoul National University Hospital. RESULTS: Among 978,146 patients, 138 (0.014%) had anaphylaxis. Two cardiopulmonary resuscitations were performed and 1 death occurred. The total mortality rate of anaphylactic patients was 0.0001%. The causes of anaphylaxes were drug (35.3%), food (21.3%), food-dependent exercise-induced (13.2%), idiopathic (13.2%), insect stings (11.8%), exercise induced (2.9%), blood products (1.5%), and latex (0.7%). Radiocontrast media and buckwheat were the leading causes of drug and food anaphylaxis, respectively. The organs most frequently involved in the anaphylaxis were cutaneous (95.7%), cardiovascular (76.8%), and respiratory (74.6%). The most common manifestations were dyspnea (71.3%), urticaria (81.9%), and angioedema (69.4%). Three of 138 patients (2.2%) had biphasic reactions. CONCLUSIONS: The incidence, mortality rate, and clinical features of Korean patients with anaphylaxis were similar to rates for patients from other countries, despite some differences in causative agents.     

Wheat anaphylaxis in children

Food anaphylaxis is now the leading known cause of anaphylactic reactions treated in emergency departments, and wheat is one of the most common causes of anaphylaxis. Wheat is an important source of food worldwide. Wheat anaphylaxis is increasingly observed in our clinic. The purpose of this study was to describe the clinical features of wheat-induced anaphylaxis in 19 children for better elucidation of this disease. Children with severe reactions after ingestion of small amounts of wheat were referred to our clinic during a 4-year period. A detailed clinical history was recorded for each of the patients and a skin prick test was performed with wheat allergen extracts. The wheat-specific IgE and total IgE were measured. Grading of anaphylaxis episodes was performed according to a specific grading system. We identified 36 episodes of wheat anaphylaxis in 19 patients. All of the first attacks of wheat anaphylaxis occurred in the first-time ingestion. The most frequent manifestations of the reactions were skin and respiratory symptoms. In this study 78.9% of reactions were moderate and 21.1% of them were severe. All of our patients had positive skin prick tests to wheat. Mean total IgE level was 853.4 ± 455.27 IU/ml, and mean wheat-specific IgE was 70 ± 14.61 Ucs/ml. We conclude that wheat-induced anaphylaxis is a disease that is sufficiently severe, and. prevention of first wheat-induced anaphylaxis episodes is almost impossible. It would, however, probably be good practice to educate physicians to recognize the common clinical manifestations of this disease for early management.     

Paediatric anaphylaxis: a 5 year retrospective review

Objective:  To describe the demographic characteristics, clinical features, causative agents, settings and administered therapy in children presenting with anaphylaxis.
Methods:  This was a retrospective case note study of children presenting with anaphylaxis over a 5-year period to the Emergency Department (ED) at the Royal Children's Hospital, Melbourne.
Results:  One-hundred and twenty-three cases of anaphylaxis in 117 patients were included. There was one death. The median age of presentation was 2.4 years. Home was the most common setting (48%) and food (85%) the most common trigger. Peanut (18%) and cashew nut (13%) were the most common cause of anaphylaxis. The median time from exposure to anaphylaxis for all identifiable agents was 10 min. The median time from onset to therapy was 40 min. Respiratory features were the principal presenting symptoms (97%). Seventeen per cent of subjects had experienced anaphylaxis previously.
Conclusions:  This is the largest study of childhood anaphylaxis reported. Major findings are that most children presenting to the ED with anaphylaxis are first-time anaphylactic reactions and the time to administration of therapy is often significantly delayed. Most reactions occurred in the home. Peanut and cashew nut were the most common causes of anaphylaxis in this study population, suggesting that triggers for anaphylaxis in children have not changed significantly over the last decade.     

Biphasic systemic anaphylaxis: An inpatient and outpatient study

We attempted to ascertain the incidence of systemic biphasic anaphylactic reactions in both outpatients and inpatients. Madigan Army Medical Center is a large teaching facility. The Allergy Clinic staff sees approximately 20,000 patients per year, and an average of 27,000 allergy immunotherapy injections are administered each year. During the years 1988 to 1991 we collected data from a total of 35 patients who had experienced, during the 30-minute waiting period in the clinic, symptoms and signs consistent with anaphylaxis. A total of 44 anaphylactic reactions were noted, with only two (5%) involving a biphasic systemic pattern. All patients were observed and treated within the clinic until symptoms and signs had resolved. None of the patients were treated with or were presently using glucocorticosteroids during the time of their reactions. Of the reactions noted, 25 (57%) involved only cutaneous manifestations of anaphylaxis, three (7%) involved the laryngeal/upper airway area, eight (18%) involved bronchospasm alone, three (7%) involved the rhinoconjunctivae, and five (11%) involved more than one site or type. None of the patients experienced any symptoms or signs of cardiovascular compromise or collapse after allergy extract injections. During the years 1986 to 1992 a total of 59 patients were admitted to the medical ward or intensive care unit with the diagnosis of systemic anaphylaxis. Of 59 patients, four (7%) experienced a recurrent (biphasic) anaphylactic reaction without reexposure to the initial inciting agent. The remaining 55 patients (93%) did not experience any further systemic anaphylaxis after initial hospital admission and treatment. Two of the patients with biphasic anaphylaxis were first seen with hypotension and generalized urticaria. Of the remaining two patients, one had lip and tongue angioedema, and the other had urticaria only. The biphasic reaction involved antibiotics in two cases and food (shrimp) in the remaining two cases. Forty-two male patients and 17 female patients were included in the study. The age range of male patients was 6 months to 77 years and that of the female patients was 10 to 81 years. There were no deaths in this study. Of the causes for anaphylactic episodes 20 (34%) were drug- or medication-related, 12 (20%) were idiopathic, 13 (22%) were related to food, six (10%) were secondary to exercise, two (3%) were related to vaccine administration and three (3%) were secondary to Hymenoptera stings. The four remaining episodes were secondary to contrast dye administration, allergen skin test extract administration, horse serum administration, and allergen extract injection. We conclude that the incidence of biphasic anaphylactic events is lower than that reported in previously published studies. (J ALLERGY CLIN IMMUNOL 1994;93:977-85.)     

Wheat Anaphylaxis in Children

Food anaphylaxis is now the leading known cause of anaphylactic reactions treated in emergency departments, and wheat is one of the most common causes of anaphylaxis. Wheat is an important source of food worldwide. Wheat anaphylaxis is increasingly observed in our clinic. The purpose of this study was to describe the clinical features of wheat-induced anaphylaxis in 19 children for better elucidation of this disease. Children with severe reactions after ingestion of small amounts of wheat were referred to our clinic during a 4-year period. A detailed clinical history was recorded for each of the patients and a skin prick test was performed with wheat allergen extracts. The wheat-specific IgE and total IgE were measured. Grading of anaphylaxis episodes was performed according to a specific grading system. We identified 36 episodes of wheat anaphylaxis in 19 patients. All of the first attacks of wheat anaphylaxis occurred in the first-time ingestion. The most frequent manifestations of the reactions were skin and respiratory symptoms. In this study 78.9% of reactions were moderate and 21.1% of them were severe. All of our patients had positive skin prick tests to wheat. Mean total IgE level was 853.4 ± 455.27 IU/ml, and mean wheat-specific IgE was 70 ± 14.61 Ucs/ml. We conclude that wheat-induced anaphylaxis is a disease that is sufficiently severe, and. prevention of first wheat-induced anaphylaxis episodes is almost impossible. It would, however, probably be good practice to educate physicians to recognize the common clinical manifestations of this disease for early management.     

Food-induced anaphylaxis and repeated epinephrine treatments.

BACKGROUND: Research on the use of more than 1 dose of epinephrine in the treatment of food-induced anaphylaxis is limited. OBJECTIVE: To perform a medical record review to examine the frequency of repeated epinephrine treatments in patients presenting with food-induced anaphylaxis to the emergency department (ED). METHODS: We reviewed 39 medical records of patients who presented with food-induced allergic reactions to the Massachusetts General Hospital ED during a 1-year period. The analysis focused on the timing of the onset of symptoms and on the number of epinephrine treatments given before and during the ED visit. RESULTS: Of the 39 patients, 34 had an acute food-induced allergic reaction. Nineteen had anaphylaxis. Twelve patients with anaphylaxis (63%; 95% confidence interval, 38%-84%) received at least 1 dose of epinephrine, and 3 (16%; 95% confidence interval, 3%-40%) were given 2 doses. Although statistical analysis was not possible, repeated epinephrine treatment occurred in patients with anaphylaxis to peanut or tree nut and hypotension. There was no apparent association between time from ingestion of the causative agent to epinephrine treatment(s). CONCLUSIONS: Of patients presenting to the ED with food-induced anaphylaxis, approximately 16% were treated with 2 doses of epinephrine. This study supports the recommendation that patients at risk for food-induced anaphylaxis carry 2 doses of epinephrine. Further study is needed to confirm these results and to expand them to patients who do not present to the ED because that group may have a lower frequency of epinephrine use.     

Anaphylaxis in a tertiary adult allergy clinic: a retrospective review of 516 patients

BackgroundAnaphylaxis is a life-threatening acute allergic reaction that can occur at any age.ObjectiveTo determine the frequency, triggering factors, and clinical features of anaphylaxis among adult patients who were referred to a tertiary health care facility.MethodsA retrospective medical chart review was performed including all patients referred to the outpatient clinic of the adult allergy department in our university hospital between January 1, 2008 and December 30, 2011 to determine cases involving anaphylaxis.ResultsA total of 516 (2.11%) patients among 24,443 admissions were diagnosed with anaphylaxis. Although the second highest frequency of anaphylaxis cases took place in 2008, a gradual rise in the frequency was determined from 2009 to 2011. Drugs (90.7%) were the most frequent cause, followed by Hymenoptera stings (5.4%), foods (1.6%), latex (0.4%), and exercise (0.2%) respectively. The clinical manifestations during anaphylaxis reported by patients were cutaneous (n = 292, 56.6%), respiratory (n = 253, 49%), cardiovascular (n = 212, 41%), neuropsychiatric (n = 60, 11.6%), and gastrointestinal (n = 52, 10.1%), respectively. Approximately one fifth of the patients received epinephrine, whereas 43% of patients did not receive epinephrine during their treatment in the emergency room. An epinephrine auto-injector was prescribed to 42 patients (8.1%).ConclusionIn this study, the second pattern of National Institute of Allergy and Infectious Disease (NIAID) and the Food Allergy and Anaphylaxis Network (FAAN) diagnostic criteria for anaphylaxis predominated among adult patients. Drugs were the leading triggering factor, followed by Hymenoptera stings, foods, latex, and exercise, respectively. Atopy, asthma, and allergic rhinitis were rarely detected.     

Changes in corticosteroid usage by chronic asthma patients during a year of cromoglycate treatment

Fifteen chronic asthmatic, steroid-dependent subjects were treated for one year with disodium cromoglycate (DSCG) while their previous maintenance steroid dosage was gradually reduced or withdrawn. Twelve asthma indices were monitored concurrently so that the observed steroid dose reduction could be related to the degree of control of the chronic asthma. In view of the characteristically varying course of the disease, the observed changes over the whole year were expressed in terms of average and maximum values. The timing and duration of the study were such as to obviate the influence of seasonally determined improvement trends that otherwise may confound drug-related change. A statistically significant reduction in steroid usage was observed in this group of patients and sustained during the year of cromoglycate treatment. The average reduction of the group over the year was 29 per cent, and the median reduction was 33 per cent. Within the group 11 of 15 reduced steroid usage; 3 who had required maintenance prednisone doses above 15 mg. daily were successfully reduced to lower dosage; 4 were converted to alternate-day therapy and stabilized there, whereas conversion attempts had previously failed; in 2 the maintenance steroid regimen was terminated. The possibility that the reduced steroid requirements might be due to the natural course of the disease rather than to the DSCG treatment cannot be entirely excluded.     

A multicenter study on anaphylaxis caused by peanut,tree nuts,and seeds in children and adolescents

Peanut (PN) and tree nuts (TNs) are common causes of anaphylaxis in Western countries, but no information is available in Korea. To feature clinical characteristics of anaphylaxis caused by PN, TNs, and seeds, a retrospective medical record review was performed in 14 university hospitals in Korea (2009–2013). One hundred and twenty‐six cases were identified, with the mean age of 4.9 years. PN, walnut (WN), and pine nut accounted for 32.5%, 41.3%, and 7.1%, respectively. The median values of specific IgE (sIgE) to PN, WN, and pine nut were 10.50, 8.74, and 4.61 kU_A/l, respectively. Among 50 cases managed in the emergency department, 52.0% were treated with epinephrine, 66.0% with steroid, 94.0% with antihistamines, 36.0% with oxygen, and 48.0% with bronchodilator. In conclusion, WN, PN, and pine nut were the three most common triggers of anaphylaxis in Korean children, and anaphylaxis could occur at remarkably low levels of sIgE.     

The economic costs of severe anaphylaxis in France: an inquiry carried out by the Allergy Vigilance Network

Background:  The prevalence of severe anaphylaxis, between 1 and 3 per 10 000, has increased sharply over recent years, with a rate of lethality of 1%. The economic burden is unknown.
Objective:  The aim of this study was to estimate the economic costs of anaphylaxis, including direct costs of treatment, hospitalization, preventive and long-care measures, and the indirect cost: absenteeism.
Methods:  Analysis of 402 patients of anaphylaxis declared by 384 allergists was reported to the Allergy Vigilance Network. The global cost was estimated from the national data of hospital admissions: ICD-10 coding available for 2003, 2004 and 2005.
Results:  Three work/classroom days were lost per patient. Diagnosis required oral challenge with hospitalization in 18% of cases. The estimated mean total cost was 1895€ for food- and drug-related anaphylaxis (5610€ for the most severe), and 4053€ for Hymenoptera anaphylaxis. National statistics recorded 2575 patients in 2005; 22% more than in 2003. The estimated annual cost was 4 789 500 €. The possible reasons for this being an under-estimate include: data coming only from hospitalized patients, poor identification by medical teams unfamiliar with ICD-10 codes, peri-operative anaphylaxis being insufficiently declared, rush-immunotherapy and maintenance treatments for Hymenoptera anaphylaxis. Similarly, the extra cost of cow milk substitutes, as well as insurance costs where deaths are followed by litigation were not taken into account.
Conclusions:  The mean cost of anaphylaxis was 1895–5610€ in nonfatal patients. The prevalence was under-estimated because of many biases, leading to under-estimation of the national cost. Further studies would be necessary to evaluate the value of preventive strategies.     

Anaphylaxis and epinephrine auto-injector training: who will teach the teachers?

BACKGROUND: Anaphylaxis is the most urgent clinical immunologic event. Effective treatment is best achieved by administration of epinephrine. Accidental exposure to the responsible allergen is the most common cause of anaphylaxis, and because it could be fatal within minutes, epinephrine in preloaded syringes and auto-injectors has been introduced. In our experience patients and medical personnel are not familiar with the use of this device. OBJECTIVE: We sought to assess community-based professionals' knowledge of epinephrine auto-injector use and their ability to educate patients. METHODS: Study participants consisted of a medical convention's delegates and emergency department personnel in metropolitan Toronto, as well as pharmacists of the target hospitals and retail pharmacists. Research assistants approached eligible professionals to fill out a questionnaire and demonstrate their ability to use a standard placebo auto-injector trainer. RESULTS: A total of 122 professionals (composed of emergency physicians, family practitioners, and pediatricians) consented to participate in this study. The majority of participants (81%) did not have a placebo trainer to educate their patients; 76% did not know the 2 available dose strengths. To provide instructions and reinforcement, physicians clearly must have the necessary skills and knowledge, yet only 25% of the study participants were able to demonstrate the 3 steps of injection correctly. CONCLUSION: Our study highlights a specific and important deficiency in medical professionals' care of patients at risk for anaphylaxis. The results challenge the current methods of educating professionals, as well as patients, when prescribing or using epinephrine auto-injectors. Clearly a new approach to educating and maintaining such skills is required.     

Incidence of anaphylaxis with circulatory symptoms: a study over a 3-year period comprising 940 000 inhabitants of the Swiss Canton Bern

BACKGROUND: Diagnosis of anaphylaxis is clinically based and usually straightforward. However, data on the epidemiology of anaphylaxis, particularly the most profound and life-threatening form such as anaphylactic shock are limited and thought to be under-reported. OBJECTIVE: The primary aim of this study was to investigate the incidence and the causes of severe anaphylaxis with circulatory signs in the Canton Bern, which comprises about 940 000 inhabitants or approximately one-seventh of the population of Switzerland. METHODS: During a 3-year period, 1 January 1996 to 31 December 1998, all medical records (7739 documents) from the two allergy clinics of the Canton Bern have been reviewed. In addition, all seven board-certified specialists of the Foederatio Medicorum Helveticorum (FMH) in Allergology and Clinical Immunology of this Canton as well as all 17 hospitals with emergency units of this area have been contacted for cases with an anaphylactic event not referred to the allergy clinics. RESULTS: Overall, 226 individuals, 106 females (47%) with a mean age of 41 years (range, 5-74 years) and 120 males (53%) with a mean age of 38 years (8 months-83 years) were diagnosed as having presented generalized, life-threatening anaphylaxis with circulatory symptoms. Altogether, these patients experienced 246 episodes of severe systemic reactions. In addition, death due to anaphylaxis occurred in three subjects. The annual incidence of anaphylaxis per 100 000 inhabitants per year ranged between 7.9 and 9.6 cases. Hymenoptera stings (58.8%), drugs (18.1%), and foods (10.1%) were the most commonly identified culprits for anaphylaxis. In 5.3% of all anaphylactic events, the cause could not be identified. CONCLUSION: The incidence rate of severe life-threatening anaphylaxis with circulatory signs in the Canton Bern, Switzerland, with 7.9-9.6 per 100 000 inhabitants per year is comparable to the findings of other epidemiological investigations. In most events, a causal agent or allergen could be identified by a careful allergological examination.     

Rhinovirus frequently detected in elderly adults attending an emergency department

The general aim was to investigate the burden of respiratory virus illness in a hospital emergency department, during two different epidemic seasons. Consecutive patients attending an emergency department during two study periods (February/March 2009 and 2010) were enrolled using broad inclusion criteria (fever/preceding fever and one of a set of ICD-9 codes suggestive of respiratory illness); nasopharyngeal washes were tested for the most common respiratory viruses using PCR-based methods. Influenza A virus was detected in 24% of samples collected in February/March 2009, whereas no samples tested positive for influenza during February/March 2010 (pandemic H1N1 Influenza A having circulated earlier in October-December 2009). Rhinovirus (HRV) was detected in 16% and 8% of patients recruited over the two study periods, respectively. Other respiratory viruses were detected rarely. Patient data were then analyzed with specific PCR results, comparing the HRV-positive group with virus-positive and no virus-detected groups. Individuals over 65 years old with HRV presented with signs, symptoms and underlying conditions and were admitted to hospital as often as the other enrolled patients, mainly for dyspnoea and chronic obstructive pulmonary disease acute exacerbation. Conversely, younger individuals with HRV, although presenting with respiratory signs and symptoms, were generally diagnosed with non-respiratory conditions. HRV was detected frequently in elderly patients attending the emergency department for respiratory distress without distinguishing clinical features. Molecular diagnosis of lower respiratory tract infections and surveillance of infectious diseases should include tests for HRV, as this virus is associated frequently with hospitalization of the elderly.