Presentation Of Anaphylaxis Research Articles

Differences in the Clinical Presentation of Anaphylaxis in Patients with Indolent Systemic Mastocytosis (ISM) versus Idiopathic Anaphylaxis (IA)

Differences in the Clinical Presentation of Anaphylaxis in Patients with Indolent Systemic Mastocytosis (ISM) versus Idiopathic Anaphylaxis (IA)

Pediatric Emergency Department Anaphylaxis: Different Patterns From Adults

Braganza SC, Acworth JP, Mckinnon DR, Peake JE, Brown AF. Arch Dis Child. 2006;91:159–163 PURPOSE OF THE STUDY. Data on acute pediatric anaphylaxis presentations to the emergency department (ED) are limited. STUDY POPULATION. Patients under 16 years of age who presented to a metropolitan, pediatric teaching hospital ED in Australia over a 3-year period with generalized allergic reactions (skin and/or gastrointestinal symptoms) and anaphylaxis (respiratory, cardiovascular, or hypotensive symptoms) that satisfied relevant International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. METHODS. Medical charts were reviewed for incidence, comorbidities, likely etiology, clinical features, management, and disposal. RESULTS. There were 526 children with generalized allergic reactions (9.3 per 1000 ED presentations) and 57 with anaphylaxis (1 per 1000 ED presentations) included. There were no fatalities. For anaphylaxis cases, a cause was recognized in 68% (food: 56% of total; drug: 5%; sting: 5%; other: 2%), cutaneous features were present in 83%, a past history of asthma was reported in 37%, adrenaline was used in 39%, and follow-up was arranged for 81% (only 28% with an allergy clinic). CONCLUSIONS. The incidence of generalized allergic reactions of 9.3 in 1000 was greater than in the adults. REVIEWER COMMENTS. Food, drug, and stinging-insect reactions are the primary causes of anaphylaxis in children (as in adults). Although skin symptoms are present in the majority, the lack of such symptoms should not exclude the diagnosis. All children who suffer an anaphylactic event deserve a consult to an allergist who can confirm the diagnosis, determine or confirm the cause, and instruct the patient on avoidance measures, emergency treatment for subsequent events should they occur, and provide a prognosis regarding possible resolution.

Evidence‐based management of anaphylaxis

For common diseases such as asthma and allergic rhinitis, many efficacious and safe interventions, both pharmacological and nonpharmacological, have been introduced in recent decades. Thousands of prospective, randomized, masked, controlled clinical trials of these interventions have been conducted in large numbers of patients with well-defined symptoms and symptom patterns, and with different levels of disease severity. Newer interventions have been compared with placebo and, increasingly, with more established treatments. The information obtained from these studies has been systematically identified, collated, critically appraised for its validity and usefulness, and summarized (with attention paid to the issue of potential bias) in Cochrane Collaboration reviews and other systematic reviews. Based on relatively abundant evidence, consistent, high-quality recommendations for management of asthma and allergic rhinitis have been promulgated in national and international guidelines (1–3). Most doctors now accept the concept that evidence-based interventions in these diseases are superior to traditionand opinion-based interventions (4). In contrast, the state of the evidence base for the treatment of anaphylaxis has not yet been as thoroughly examined, although recent attempts have been made in this regard (5–7). There are no universally accepted guidelines for pharmacological or nonpharmacological interventions in anaphylaxis; indeed, the definition of the disease continues to evolve (8–11). Anaphylaxis is still considered to be uncommon (12), although the rate of occurrence is increasing (13). Many of the pharmacologic agents available for use in anaphylaxis, for example, adrenaline, first-generation H1-antihistamines such as diphenhydramine, and glucocorticoids, are more than half a century old, and were therefore introduced long before the era of evidence-based medicine. Moreover, when the principles of evidence-based medicine are applied to interventions in anaphylaxis, other concerns become apparent. For a number of reasons, it is difficult to conduct prospective, randomized, double-masked, placebo-controlled trials in this disease. Most cases of anaphylaxis now occur unpredictably in community settings although they also still occur in healthcare settings despite vigilant preventive efforts. The clinical presentation of anaphylaxis is characterized by variability among patients, and variability in the same patient from one episode to another. For example, the time lag between exposure to the trigger and the onset of symptoms can vary from minutes to hours. The severity of symptoms can vary from mild and self-limited to fatal within minutes. The number of symptoms can vary from a few to many symptoms in virtually all body systems (11, 14). For over a decade, the Cochrane Collaboration has led the way in setting high standards for systematic reviews of the evidence base for diagnostic and therapeutic procedures. This approach is widely accepted as the gold standard, and has helped to identify the quality of the F. E. R. Simons, A. Sheikh Department of Pediatrics & Child Health, Department of Immunology, Canadian Institutes of Health Research National Training Program in Allergy & Asthma, Faculty of Medicine, University of Manitoba, Manitoba, Canada; Allergy & Respiratory Research Group, Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK

Case report: Fentanyl-associated intraoperative anaphylaxis with pulmonary edema

To describe an atypical presentation of intraoperative anaphylaxis due to fentanyl.A 40-yr-old otherwise healthy woman was admitted for abdominal hysterectomy. She denied any drug allergies or past adverse anesthetic reactions. Physical examination, vital signs, and laboratory findings were all within normal limits. Twenty minutes after induction of general anesthesia with propofol, lidocaine, fentanyl, and rocuronium, she developed sudden onset of hypotension and bronchospasm. She was treated with fluids and epinephrine, but nonetheless required mechanical ventilation for 48 hr. Chest x-ray revealed pulmonary edema which resolved over two days. She recovered completely and was discharged home. Subsequent skin testing showed reactions to fentanyl and succinylcholine. Because the patient had not received succinylcholine, the cause of her anaphylaxis was attributed to fentanyl. The patient later returned for her hysterectomy and tolerated spinal anesthesia with bupivacaine and morphine.Anaphylaxis is a fulminant, unexpected, IgE-mediated allergic reaction which can be triggered by multiple agents. Common causative agents include neuromuscular blocking drugs, latex, antibiotics, colloids, hypnotics, and opioids. Fentanyl, however, is an extremely unusual cause of anaphylaxis. Pulmonary edema, although uncommon in anaphylaxis, can be a prominent feature, as was the case with this patient.

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

Paediatric emergency department anaphylaxis: different patterns from adults

Background and Aims: Data on acute paediatric anaphylaxis presentations to the emergency department (ED) are limited. All allergic presentations to one Australian paediatric ED were studied to determine epidemiological, clinical,...

Emergency treatment of anaphylaxis

Anaphylaxis is a severe allergic reaction that is potentially fatal. It is the clinical manifestation of a syndrome that represents the most severe allergic reaction affecting the systemic circulation and respiratory function. The clinical presentation of anaphylaxis is a frequent event to all emergency departments (ED) and requires prompt recognition and immediate management. No reliable epidemiological data is available on the incidence of anaphylaxis partly because of the difficulty defining anaphylactic reactions (Resuscitation Council UK, 2005), however, one study found an incidence of 1:2300 attendees at an ED (Stewart and Ewan, 1996). The recent severe rise in childhood allergies and atopic conditions will result in an increasing prevalence of this condition. In addition most anaphylactic reactions are iatrogenic (Pumphrey, 2000), therefore, there is a clear need for practitioners to be able to assess, make a working diagnosis, plan, implement a plan of care with specific outcome identification, and evaluate the care of patients presenting with this condition.

Anaphylaxis presentations to an emergency department in Hong Kong: Incidence and predictors of biphasic reactions

We describe the epidemiology, clinical features and management of anaphylaxis in a population in Hong Kong, including the features associated with progression to biphasic reactions and the nature of these reactions. A retrospective review was undertaken of patients of all age groups, presenting consecutively to the resuscitation room of a large Hong Kong emergency department with the diagnosis of anaphylaxis, from March 1999 to February 2003. There were 282 patients included. Median age was 28 years, with 59% male. A precipitant was identified in 89%, with 19% of patients claiming a known allergy to the precipitant. Seafood was responsible for 71% of all food-related reactions. More patients reacted to nonsteroidal anti-inflammatory drugs rather than antibiotics. Cutaneous features were present in 79%, and 12% presented with hypotension. Ninety-five percent received H1 antagonist, and 67% received epinephrine. Biphasic reactions were reported in 15 (5.3%) cases with 20% of these patients having unstable vital signs. The mean time from treatment to onset of biphasic reaction was 8 h (range 1–23). Patients with respiratory features on initial presentation were less likely to develop biphasic reactions. It is concluded that prolonged observation of patients with anaphylaxis is important, because of the risk of biphasic reactions. Better education could prevent recurrent anaphylaxis.

Anaphylaxis and Adverse Drug Reactions

INTRODUCTION Any substance that patients are exposed to in the perioperative period including drugs, blood products, or environmental antigens such as latex can produce anaphylaxis. Pharmacologic agents also have the potential to produce predictable and unpredictable adverse reactions. The most life-threatening form of an adverse reaction is anaphylaxis, however, the clinical presentation of anaphylaxis may represent different immune and nonimmune responses.(1) There is confusion in the literature about the term anaphylaxis, and multiple terms have been reported to describe the spectrum of reactions. Based on current ideas, anaphylaxis is best defined as a clinical syndrome characterized by acute cardiopulmonary collapse following antigen (also called allergen) exposure. This presentation will define the spectrum of anaphylactic and adverse drug reactions an anesthesiologist may encounter.

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 (≥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. (J Allergy Clin Immunol 2001;108:861-6.)

The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department.

We retrospectively studied anaphylaxis in an A&E department from computerized records. In 1993 (Study A), of 55,000 patients seen in casualty, nine had severe anaphylaxis (ANA) with loss of consciousness (LOC) or fainting (about 1: 6000). Fifteen had generalized allergic reactions (GR) without LOC or fainting, but including dyspnoea due to laryngeal oedema or asthma, angioedema and/or urticaria. Thus there were 24 (about 1:2300) generalized reactions involving hypotension and/or respiratory difficulty. A further case diagnosed as hyperventilation syndrome was probably a wasp sting GR. Six cases of urticaria and/or angioedema were also identified. Of the nine with ANA, a possible cause was identified in eight (3 stings; 2 drugs; 3 foods). There was delay in arrival in A&E: hypotension was noted in three and had resolved spontaneously in six. Only 3/9 were related with adrenaline: i.v. hydrocortisone and chlorpheniramine was the mainstay of treatment. No investigation was recommended nor advice given on future management. Four patients were later referred to our allergy clinic by their GPs. In study B (aug-Oct 1994), nine cases of ANA were identified (1:1500), eight due to bee or wasp stings. The increased incidence was probably related to more detailed history-taking. Only three were treated with adrenaline. The use of adrenaline for future anaphylaxis was discussed with six patients, and five were referred to our allergy clinic. A reaction to the same allergen had occurred previously in 24%. Improved awareness of anaphylaxis and its management is necessary.

Characteristics of Anaphylaxis

Relatively little is known about the etiology and presentation of anaphylaxis in the outpatient setting. This large case series describes the

Latex Hypersensitivity

Latex hypersensitivity is a growing concern for patients and healthcare workers. This report reviews available literature concerning the incidence, etiology, treatment, and prevention of this serious reaction. Although most allergic reactions to natural rubber are type IV hypersensitivity reaction or contact dermatitis, some people have type I or anaphylactic reactions. The risk of latex allergy increases with exposure to latex. At greatest risk are patients who undergo multiple surgeries and prolonged catheterization with latex catheters. Despite the typical presentation of anaphylaxis, symptoms of latex allergy may progress from mild to severe in seconds. Strict avoidance of latex is a must. Some patients may require premedication with corticosteroids, H1-antagonists, and H2-antagonists. Anyone with an allergy to latex should wear a Medic Alert bracelet or pendant alerting healthcare workers to their sensitivity. Healthcare workers who are sensitive should use non-latex gloves and equipment.This paper was originally published in Adverse Drug Reaction News, a publication of the Drug Information Service, Department of Pharmacy Services. University Hospital, University of Utah. It is reprinted with permission.

Anaphylactic shock secondary to rattlesnake bite

Anaphylactic reactions to Crotalidae envenomation are extremely rare. The presentation of anaphylaxis after envenomation can be a confusing variable in the timely diagnosis of both problems. The therapy of this dual disorder involves combining treatment of the obvious shock from the allergic reaction with a standard approach to Crotalidae envenomation. We present the case of a 22-year-old man who presented to the emergency department with urticaria, hypotension, and bronchospasm that developed immediately after his second envenomation from a rattlesnake. His symptoms resolved after administration of 0.8 mg SQ epinephrine, 100 mg IV diphenhydramine, 2,000 mL normal saline IV, and 250 mg IV methylprednisolone. Only one previous case report of anaphylactic shock from a rattlesnake bite could be found in the medical literature.