Multiphasic Anaphylaxis: An Uncommon Event in the Emergency Department

Objective : To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. Methods : Retrospective chart review of out-of-hospital, ED, and hospital records over a 4.5-year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with ≥2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths. Results : The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using β-adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria. Conclusion : Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition.     

Abdominal anaphylaxis presenting as trauma: a recipe for delayed diagnosis

Background: Successful shock management requires prompt identification, classification, and treatment; however, the triage of patients with non-hemorrhagic shock to the trauma room can lead to delayed diagnosis with increased morbidity and mortality. Objective: Our goal is to emphasize the importance of shock identification and classification to facilitate the delivery of the appropriate and timely therapy, no matter how the patient is triaged. Case Report: We describe a patient triaged as a trauma patient with suspected hemorrhagic shock yet who was found to have anaphylaxis as the etiology of his condition. Abdominal anaphylaxis, a less recognized presentation of anaphylaxis, is reviewed and discussed. Conclusions: We hope to increase awareness of a less common presentation of anaphylaxis and discuss its management.     

Food-Dependent Exercise-Induced Anaphylaxis: A Review

Food-dependent exercise-induced anaphylaxis (FDEIA), a subtype of exercise-induced anaphylaxis (EIA), is underdiagnosed and unreported. FDEIA is unpredictable and difficult to diagnose because its manifestation relies on the presence of several modifiable factors but can be fatal for the individual if not properly assessed and treated. A proper diagnosis of FDEIA will help prevent unnecessary food and exercise limitations and provide a patient with FDEIA an adaptable lifestyle. The purpose of this article is to review FDEIA characteristics, diagnostic tools, management, and the role of the nurse practitioner in diagnosing and caring for children or adolescents with suspected FDEIA.     

Cold Anaphylaxis: A Case Report

BackgroundCold anaphylaxis is a severe form of hypersensitivity reaction to cold temperatures. Such reactions include a spectrum of presentations that range from localized symptoms to systemic involvement. The condition can be acquired or heritable, although it may also be idiopathic. Treatment consists of second-generation H₁ antihistamines, epinephrine, and supportive care. Prevention involves avoidance of known triggers, most commonly cold immersion due to environment or water exposure.Case ReportWe report the case of a 34-year-old man with cold-induced urticaria/anaphylaxis who presented to our emergency department with hypotension and shortness of breath after exposure to cold air after getting out of a shower. He required two doses of intramuscular epinephrine and was ultimately started on an epinephrine infusion. He was admitted to the intensive care unit for anaphylaxis monitoring and was found to have a positive ice cube test, reinforcing the suspected diagnosis.Why Should An Emergency Physician Be Aware of This?Cold anaphylaxis is a potentially life-threatening phenomenon with specific testing. It is occasionally described in the emergency medicine literature. Providers should be aware of the potential for cold anaphylaxis as it can change patient guidance and alter management. This condition can also contribute to otherwise unclear and sudden decompensation in critically ill patients, as has been reported in cases of cold anaphylaxis induced by cold IV infusions.     

Anaphylaxis Knowledge Among Paramedics: Results of a National Survey

Abstract

Background. Very little is known about prehospital providers’ knowledge regarding anaphylaxis care. Objectives. The purpose of this study was to evaluate how well nationally registered paramedics in the United States recognize classic and atypical presentations of anaphylaxis. We also assessed knowledge regarding treatment with epinephrine, including dosing, route of administration, and perceived contraindications to epinephrine use. Methods. This was a blinded, cross-sectional online survey of a random sample of paramedics registered by the National Registry of Emergency Medical Technicians that was distributed via e-mail. The survey contained two main sections: demographic data/self-assessment of confidence with anaphylaxis care and a cognitive assessment. Results. A total of 3,537 paramedics completed the survey, for a 36.6% response rate. Among the respondents, 98.9% correctly recognized a case of classic anaphylaxis, whereas only 2.9% correctly identified the atypical presentation. Regarding treatment, 46.2% identified epinephrine as the initial drug of choice; 38.9% chose the intramuscular (IM) route of administration, and 60.5% identified the deltoid as the preferred location (11.6% thigh). Of the respondents, 98.0% were confident they could recognize anaphylaxis; 97.1% were confident they could manage anaphylaxis; 39.5% carry epinephrine autoinjectors (EAIs) on response vehicles; 95.4% were confident they could use an EAI; and 36.2% stated that there were contraindications to epinephrine administration in anaphylactic shock. Conclusions. Whereas a large percentage of the paramedics recognized classic anaphylaxis, a very small percentage recognized atypical anaphylaxis. Less than half chose epinephrine as the initial drug of choice, and most respondents were unable to identify the correct route/location of administration. This survey identifies a number of areas for improved education.     

Anaphylaxis to Moringa oleifera in North Africa: A case report and review of the literature

We describe here the third reported case of anaphylaxis after ingestion of some leavers of Moringa oleifera, causing a widespread angioedema, a respiratory distress, and an elevation of serum tryptase. M. oleifera leaves were confirmed as the causative allergen by prick testing with fresh leavers.     

Anaphylaxis: pathophysiology, clinical presentations and treatment

Anaphylaxis and anaphylactoid reactions are abrupt, often life-threatening episodes, secondary to the liberation of certain chemical mediators, and their effects on target organs. The number of agents known to trigger such reactions is expanding, with the most common fatal reactions secondary to penicillins, iodinated contrast material (ICM), and hymenoptera stings. Limited studies point to upper airway obstruction and circulatory collapse as the causes of death in man. It is felt that the frequency of cardiovascular involvement is not widely appreciated, and that hypotensive patients can be markedly hypovolemic. The primary goals of treatment should be aimed at preventing or reversing complications, and include immediate attention to the airway, cardiac monitoring, and establishment of intravenous access. The cornerstone of pharmacologic therapy is epinephrine. A comprehensive review of the pathophysiology, symptomatology, and treatment is presented.     

Transient Coagulopathy Due to Wasp Sting: A Case Report

Background

Insect venom anaphylaxis is a potentially life-threatening disorder. Transient coagulopathy in insect venom anaphylaxis is a rare phenomenon.

Anaphylaxis during the first course of high-dose methotrexate: a case report and literature review

What is known and Objective: Methotrexate (MTX) is widely used in the management of paediatric cancer with a generally favourable benefit/risk profile. We report an unusual adverse drug reaction with the first course of high‐dose MTX in a paediatric patient and review the literature for similar cases. Case summary: An 11‐year‐old boy with small‐cell osteoblastic osteosarcoma in the lower limb experienced a case of life‐threatening anaphylaxis during the first course of high‐dose MTX. The adverse event occurred during the first course, likely due to an immune‐mediated mechanism. We postulate that prior antineoplastic treatment might have contributed to the immune response to MTX. What is new and Conclusion: Given that this reaction has rarely been reported, we discuss the present case with a review of other similar cases. Further studies are needed to substantiate this ‘signal alarm’ for serious MTX‐related hypersensitivity reactions.     

1例低分子右旋糖酐氨基酸注射液致过敏性休克的护理

1病例 简介患者，女性，65岁，2007年6月22日因双膝关节间断性疼痛加重伴活动受限半年余来院就诊。入院查体：神志清，精神差，双膝关节肿胀、疼痛、活动受限。入院诊断双膝关节退行性变，曾于2006年6月26日在硬膜外麻醉下行双膝关节清理术，术程顺利，术后给予抗炎、止血，保持患肢功能位等对症处理。于2007年7月2日患者主诉膝关节疼痛，肿胀明显。遵医嘱给予静脉滴注低分子右旋糖酐氨基酸注射液。     

Anaphylaxis to trimethoprim: an under-appreciated risk in acute medical care

Anaphylaxis is a severe, systemic allergic reaction, which is frequently unexpected and carries a high mortality risk as a medical emergency. Anaphylaxis to trimethoprim is not a well recognized event. Since trimethoprim represents the leading antibiotic for the treatment of urinary tract infections, its potential to cause anaphylaxis needs to be recognized, whether alone or as the 'active' ingredient in cotrimoxazole (trimethoprim-sulphamethoxazole combination), by those prescribing it and those providing acute care. A case of probable anaphylaxis following trimethoprim ingestion is presented with discussion supporting its potency including evidence at an immunological level highlighting its under-appreciated risk in acute medical care.     

Histamine poisoning from insect consumption: an outbreak investigation from Thailand

Background: Insect consumption is a common practice in the Asian culture and all over the world. We are reporting an outbreak investigation of histamine poisoning from ingestion of fried insects.

Methods: On 24 July 2014, a group of students at a seminar presented to Angthong Provincial Hospital, Thailand, with pruritic rash after ingesting snacks consisting of fried insects from a vendor. We initiated an outbreak investigation with retrospective cohort design and collected samples of remaining foods for analyses. Attack rates, relative risks and their confidence intervals (CI) were calculated.

Results: Out of 227 students, 28 developed illnesses that were consistent with our case definition which included, flushing, pruritus, urticarial rashes, headache, nausea, vomiting, diarrhea, dyspnea and bronchospasm. Two children were hospitalized for progressive bronchospasm overnight without serious complications. The types of food ingested included a lunch that was provided at the seminar for all students and snacks that 41 students bought from the only vendor in the vicinity. The snacks included fried grasshoppers, silkworm pupae, common green frogs, bamboo borers, crickets and meat balls. The attack rates were highest (82.6 and 85.0%) among students who ingested fried grasshoppers and silkworm pupae and lowest (4.4 and 5.3%) among those who did not ingest them, with relative risk of 18.7 (95% CI 9.6–36.4) for grasshoppers and 16.0 (95% CI 8.8–29.3) for silkworm pupae. Histamine concentrations in the fried grasshoppers and silkworm pupae were 9.73 and 7.66?mg/100g, respectively.

Discussion and conclusion: Through epidemiological analysis and laboratory confirmation, we have illustrated that histamine poisoning can occur from ingestion of fried insects. We postulate that histidine, which is present in high concentration in grasshoppers and silkworm pupae, is decarboxylated by bacteria to histamine, a heat stable toxin. The ingestion of histamine is responsible for the clinical pictures being reported.     

类胰蛋白酶在过敏性疾病诊断中的应用

目的评价类胰蛋白酶(tryptase)测定在过敏性疾病诊断中的应用。方法应用Unicap100测定变态反应科门诊不同疾病组35例患者血清类胰蛋白酶水平,以30名健康志愿者作为对照,并与血清总IgE进行相关性分析。结果35例患者中,18例慢性荨麻疹缓解期患者,平均类胰蛋白酶水平(4.74±2.54)μg/L;10例既往有明确过敏性休克病史者(4.86±2.55)μg/L;7例严重全身过敏反应急性发作期(17.4±7.87)μg/L;30名健康志愿者(4.36±1.67)μg/L;严重全身过敏反应急性发作期组明显高于其他各组(P<0.01),余各组之间差异无统计学意义;血清类胰蛋白酶水平与总IgE之间没有明确的相关性。结论血清类胰蛋白酶水平在严重全身过敏反应急性期升高,有辅助诊断的意义,但并非适用于所有过敏性疾病的诊断。     

Familial Anaphylaxis after Silkworm Ingestion

Herein, we present a case of anaphylaxis in multiple family members after ingesting silkworms, an Asian delicacy. While food allergies, including anaphylaxis are unfortunately common, there are no previous reports of multiple family members suffering an anaphylactic reaction after eating silkworms. In addition, both family members required multiple doses of epinephrine and eventually an epinephrine infusion to improve their blood pressures. All interventions, including the epinephrine infusions, were started by emergency medical services (EMS) with on-line medical direction. Both the reaction and the required treatment are not extensively documented in the medical literature.     

多种胰岛素过敏3例报道并文献复习

目的 总结胰岛素制剂过敏的临床表现和处理措施.方法 对我院3例多种胰岛素制剂过敏患者的临床资料进行回顾性分析,并结合文献复习,分析总结胰岛素制剂过敏的原因、机制、临床表现、诊断与处理方法.结果 胰岛素过敏原因有药物制剂本身、注射途径和患者体质等;绝大多数胰岛素过敏反应属Ⅰ型超敏反应,Ⅲ、Ⅳ型变态反应也有出现;若胰岛素过敏,可选择更换胰岛素、改用口服药物或脱敏治疗.结论 如考虑胰岛素过敏,若患者状况允许首选口服降糖药物治疗,但当患者不得不使用胰岛素时,则须考虑胰岛素脱敏治疗.     

Anaphylaxis: clinical concepts and research priorities

Anaphylaxis is a severe immediate-type hypersensitivity reaction characterized by life-threatening upper airway obstruction bronchospasm and hypotension. Although many episodes are easy to diagnose by the combination of characteristic skin features with other organ effects, this is not always the case and a workable clinical definition of anaphylaxis and useful biomarkers of the condition have been elusive. A recently proposed consensus definition is ready for prospective validation. The cornerstones of management are the supine position, adrenaline and volume resuscitation. An intramuscular dose of adrenaline is generally recommended to initiate treatment. If additional adrenaline is required, then a controlled intravenous infusion might be more efficacious and safer than intravenous bolus administration. Additional bronchodilator treatment with continuous salbutamol and corticosteroids are used for severe and/or refractory bronchospasm. Aggressive volume resuscitation, selective vasopressors, atropine (for bradycardia), inotropes that bypass the beta-adrenoreceptor and bedside echocardiographic assessment should be considered for hypotension that is refractory to treatment. Management guidelines continue to be opinion- and consensus-based, with retrospective studies accounting for the vast majority of clinical research papers on the topic. The clinical spectrum of anaphylaxis including major disease subgroups requires clarification, and validated scoring systems and outcome measures are needed to enable good-quality prospective observational studies and randomized controlled trials. A systematic approach with multicentre collaboration is required to improve our understanding and management of this disease.     

Emergency medical recognition and management of idiopathic anaphylaxis

Idiopathic anaphylaxis (IA) is a diagnosis of exclusion that is made when no identifiable causative factors can be found for an episode of anaphylaxis. IA is a potentially life-threatening disease that is the result of a nonimmunologic mast cell activation syndrome. Acute presentation and treatment of these patients is most often in the emergency department and is clinically the same as anaphylaxis from allergens. Since these episodes are unpredictable and often recurrent, these patients are at risk of death if not identified on acute presentation and managed appropriately. As an increasing number of patients are being diagnosed with IA, they will be presenting to emergency departments with initial and recurrent episodes of IA. Therefore, increased awareness of IA and coordinated care is needed so that the morbidity and mortality of this potentially fatal disease can be kept at a minimum.