Vomiting and syncope in a 14-year-old female

Abstract

HISTORY OF PRESENT ILLNESS A 14-year-old female presented with hives, vomiting, and syncope after eating a barbecue pork sandwich from a take out store. The sandwich contained pork, black pepper, garlic powder, tomato juice, corn syrup, vinegar, and onion powder served on white bread. She ate half of the sandwich and had a can of Coke to drink. Within minutes, she developed itching on her neck and urticaria starting at the neck and spreading throughout her body. She also developed facial and lip swelling without wheezing or other respiratory symptoms. On arrival to the emergency room, she vomited and had syncope. She was unconscious for two minutes and upon awakening continued vomiting. No blood pressure was recorded and her physical exam was remarkable for diffuse urticaria with angioedema of her lower lip. She was treated with epinephrine, diphenhydramine, solumedrol, and intravenous fluids. The hives resolved in 2 hours. She was observed for 6 hours and discharged on prednisone, hydroxyzine, and cimetidine. Four months later she had another episode after eating a turkey sandwich on plain white bread while on a car trip. Five hours after eating, she chewed a piece of Juicy Fruit gum. She felt slightly nauseous and drank a bit of peach and papaya fruit drink. Immediately thereafter, she began to feel warm. She then had a few bites of cucumber and green pepper and Mountain Dew to drink. She then developed vomiting, diarrhea, and abdominal pain. She then had syncope and the paramedics were called. Upon arrival of the paramedics, her initial blood pressure was 70/30, her pulse was 72, and her respiratory rate was 20. She was given 2 Ls of normal saline intravenously and her blood pressure improved to 80 systolic by Doppler. Upon arrival to the emergency room her blood pressure was 102/23 and her pulse was 105. Intravenous fluids were continued and repeat blood pressure was 97/24 and pulse 95. After another 1.5 L of intravenous normal saline her blood pressure was 95/51 and her pulse was 84. She then received another liter of intravenous normal saline for a total of 4.5 L of replacement fluid. In addition, she was treated with epinephrine, diphenhydramine, and prednisone. Her skin then developed a generalized reddish hue without urticaria, pruritis, or rash. Over the next few hours her blood pressure normalized at 122/58 with a pulse of 77. She was monitored for 12 hours and then discharged home on diphenhydramine and prednisolone with a prescription for an Epi Pen. Neither episode was associated with aspirin or pain medications. There were no associated oral symptoms or seizure activity. None of the episodes were associated with exercise or extremes in temperature. She had no history of food allergies aside for minimal eye swelling around freshly washed shrimp.