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.     

Management of anaphylaxis: a systematic review

To establish the effectiveness of interventions for the acute and long‐term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi‐randomized controlled trials, controlled clinical trials, controlled before–after studies and interrupted time series and – only in relation to adrenaline – case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty‐five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1‐antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long‐term management interventions studied were anaphylaxis management plans and allergen‐specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom‐triggered anaphylaxis.     

Incidence of anaphylaxis in the emergency department of a general hospital in Milan.

OBJECTIVE: To evaluate incidence and causes of anaphylactic reactions in the emergency room (E.R.) of a general hospital in Milan during a 2-year period. Methods: We retrospectively studied the computerized records of patients discharged from an E.R. with a diagnosis of anaphylactic reaction. Anaphylaxis was established on the presence of at least two cutaneous, respiratory, gastrointestinal or cardiovascular system symptoms. Results: During 1997 and 1998, out of 38 685 patients referred to the E.R., 13 had severe anaphylaxis with loss of consciousness (LOC) and 127 had anaphylactic symptoms, without LOC. Of the 13 patients with LOC, a possible cause was identified in 12 (five foods, six drugs, one hair dye). In the other 127 patients anaphylaxis was related to foods in 49 cases (38.5%), drugs in 44 (34.6%), unknown causes in 29 (22.8%), hymenoptera stings in two (1.5%), and other causes in three (2.3%). Conclusion: The incidence of anaphylactic reactions was 0.4% and mainly affected females and atopic subjects. Foods, particularly fruits and vegetables, appeared to be the most important cause; other important causes were non steroidal antiinflammatory drugs and beta-lactam antibiotics.     

Incidence of anaphylaxis in the emergency department: a 1-year study in a university hospital

The aim of this study was to estimate the incidence of anaphylaxis in an emergency department, identify rate and risk factors of recurrent anaphylaxis, and describe its clinical features and management. A retrospective study of patients who attended the emergency department at Thammasat University Hospital was conducted during 2003-2004 with anaphylactically related ICD-9 and ICD-10 terms. There were 64 patients who experienced 65 anaphylactic episodes during the 1-year period. The anaphylaxis occurrence rate was 223 per 100,000 patients per year. The most common manifestations were cutaneous symptoms and signs, followed by respiratory expression. Food allergy was the most common cause of anaphylaxis. Eighty-five percent of admitted cases had monophasic anaphylaxis. Patients with and without biphasic reactions did not differ significantly in terms of epinephrine and steroid usage. In conclusion, anaphylaxis is not rare. Epinephrine and steroid usage did not prevent biphasic reactions.     

Brain tumor in the first year of life: a single institute study.

Brain tumors in infants present special diagnostic and therapeutic challenges. To figure out the clinical features, pathological classification of the tumors and the treatment outcome of infantile brain tumors, 458 children (age<16) with brain tumors were reviewed retrospectively. Among them 21 cases (4.6%) were diagnosed during the first 12 months of life. Two tumors were definitely of congenital origin. The majority of infants with brain tumors presented with increased intracranial pressure. Fourteen tumors were located at the supratentorial area. Sixteen cases had neuroepithelial tumors; astrocytoma (optic pathway), supratentorial primitive neuroectodermal tumor (PNET) and medulloblastoma were found in three cases each. There were two treatment-related mortalities. Compared with the outcomes in older children, the treatment outcome was poorer in medulloblastoma and the optic pathway glioma which showed a higher growth potential. Because of the limited application of postoperative adjuvant therapy, radical surgical removal played a more important role in this age group. The prognosis of patients in whom the tumors could not be totally removed, largely depended on the pathological malignancy of the tumors. Though the treatment outcome was not always dismal, immaturity of the brain, higher growth potential, perioperative risks, limitations in adjuvant therapy, and pessimistic attitude on the part of parents made management more challenging.     

Buckwheat-induced anaphylaxis: a case report.

Buckwheat (Fagopyrum schulentum) is not taxonomically related to wheat and other cereal grains. Buckwheat flour is used as a wheat substitute in breads, biscuits, pancakes, and crepes. Occupational exposure to buckwheat flour has been associated with rhinitis, conjunctivitis, contact urticaria, and occupational asthma. We present a patient who developed urticaria and hypotension after ingestion of buckwheat crepes. Skin testing by the prick technique revealed 3+ positive reaction to buckwheat with negative reactions to other foods including wheat, egg white, and milk. RAST for anti-buckwheat IgE was strongly positive. Buckwheat ingestion is a potential cause of food-related anaphylaxis. There does not appear to be cross-reactivity between buckwheat and wheat allergy.     

Buckwheat-induced anaphylaxis: a case report.

Buckwheat (Fagopyrum schulentum) is not taxonomically related to wheat and other cereal grains. Buckwheat flour is used as a wheat substitute in breads, biscuits, pancakes, and crepes. Occupational exposure to buckwheat flour has been associated with rhinitis, conjunctivitis, contact urticaria, and occupational asthma. We present a patient who developed urticaria and hypotension after ingestion of buckwheat crepes. Skin testing by the prick technique revealed 3+ positive reaction to buckwheat with negative reactions to other foods including wheat, egg white, and milk. RAST for anti-buckwheat IgE was strongly positive. Buckwheat ingestion is a potential cause of food-related anaphylaxis. There does not appear to be cross-reactivity between buckwheat and wheat allergy.     

Hepatic granulomas: a 10 year single centre experience

BACKGROUND: Epithelioid granulomas have been reported in 2-15% of unselected liver biopsies, with numerous underlying aetiologies described. However, all UK series were reported before identification of hepatitis C virus (HCV). AIM: To evaluate the current aetiologies of hepatic granulomas and to assess the prognosis for the "idiopathic" group, in which all investigations for a recognised cause were negative or normal. METHODS: A retrospective review of patient case notes between 1991 and 2001; all patients who had a liver biopsy at Glasgow Royal Infirmary revealing epithelioid granulomas had their case notes and liver biopsies reviewed and a standard proforma completed. RESULTS: Over the study period, 1662 liver biopsies were performed. Hepatic granulomas were found in 63. Of those identified, 47 were female, with a mean age of 42 years (range, 17-81). Underlying aetiologies were as follows: primary biliary cirrhosis (PBC; 23.8%), sarcoidosis (11.1%), idiopathic (11.1%), drug induced (9.5%), HCV (9.5%), PBC/autoimmune hepatitis (AIH) overlap (6.3%), Hodgkin lymphoma (6.3%), AIH (4.8%), tuberculosis (4.8%), resolving biliary obstruction (3.2%), and other single miscellaneous causes (9.5%). Of the seven patients with idiopathic hepatic granulomas, one was lost to follow up, one died of stroke, and the remaining five were well with no liver related morbidity at a mean follow up of 6.2 years. CONCLUSIONS: The aetiology of hepatic granulomas is broad ranging, with HCV an important cause in this population. Despite extensive investigations, a 10-15% of patients still had "idiopathic" hepatic granulomas. However, the prognosis for this last group appears to be excellent.     

Features of patients with anaphylaxis admitted to a university hospital.

BACKGROUND: Anaphylaxis in hospitalized patients has been infrequently reviewed. There are few studies of anaphylaxis from Asian countries. OBJECTIVE: To describe the clinical characteristics of patients with anaphylaxis admitted to Siriraj Hospital. METHODS: The medical records of 101 patients admitted with clinical anaphylaxis between January 1, 1999, and December 31, 2004, were reviewed. Data were analyzed using the chi2 test. RESULTS: The annual occurrence of anaphylaxis increased from 9.16 per 100,000 admitted persons in 1999 to 55.45 per 100,000 admitted persons in 2004. The case fatality rate was 0.19 per 100,000 admitted persons. The mean +/- SD age was 23.73 +/- 21.84 years. Males experienced more anaphylaxis than females in pediatric patients and vice versa in adult patients. Biphasic anaphylaxis was found in 7% of pediatric and 2% of adult patients. Anaphylaxis occurred in the hospital in 37% of patients. Involved systems were cutaneous (86%), respiratory (80%), cardiovascular (52%), and oral and gastrointestinal (36%). Identifiable causes were drugs (50%), foods (24%), idiopathic (15%), and insect stings/bites (11%). Epinephrine was given to 77% of the patients. CONCLUSIONS: We report the clinical characteristics of patients with anaphylaxis admitted to a university hospital. Knowing the clinical features will raise physician awareness of this condition.