Case Of Severe Anaphylaxis Research Articles

Severe hypersensitivity reactions to 2 immunotherapy agents in a patient with cutaneous squamous cell carcinoma.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. There is currently limited data on cross-sensitivity between immunotherapy agents. In this case study, we report a case of severe anaphylaxis to both pembrolizumab and cemiplimab. Pembrolizumab (Keytruda) and cemiplimab (Libtayo) are both approved for the treatment of metastatic cutaneous squamous cell carcinoma. Infusion reactions occur rarely with immunotherapy agents. However, if infusion reactions are severe, the treatment should be discontinued, and there is no guidance as to whether another immunotherapy agent may be used. An 87-year-old-male was diagnosed with metastatic cutaneous squamous cell carcinoma expressing a PD-L1 combined positive score of 81%-90%. He was treated with pembrolizumab and, 15 minutes after completion of the first infusion, developed swelling of the eyelids, ears, and tongue in addition to a whole-body rash without pruritus. Due to the severity of the reaction, pembrolizumab was permanently discontinued and the patient was then started on cemiplimab. The patient received a high-dose corticosteroid as premedication before the first infusion of cemiplimab and tolerated the treatment without any adverse effects. However, when the corticosteroid premedication dose was decreased before the second cycle, the patient had a severe infusion reaction to cemiplimab requiring discontinuation. A patient with metastatic cutaneous squamous cell carcinoma developed a severe hypersensitivity reaction to pembrolizumab and subsequently to cemiplimab, despite premedication.

Severe perioperative anaphylaxis: Incidence in a tertiary hospital in Spain over a 20-year period. A historical cohort study.

To assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments. A historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15min and serum tryptase at 2, 6, and 24h following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later. Over the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8±17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (P<.0001) and 6h (P=.026) and were highest in IgE-mediated reactions (P=.020). All patients required treatment, and 3 events were fatal. In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%). The incidence of severe anaphylaxis in our hospital was 1 in 4.373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.

Anafilaxia perioperatoria severa: Incidencia en un hospital terciario en España durante 20 años. Estudio de cohorte histórico

ObjectiveTo assess the incidence of severe perioperative anaphylaxis, the mechanisms involved, the value of laboratory/skin tests, and the most effective treatments. MethodsA historical cohort study conducted in a tertiary public hospital in Spain. Patients that had undergone anaesthesia during the 20-year period were included. In these patients, 66 cases of severe anaphylaxis were found. In patients with suspicion of severe anaphylaxis, levels of blood histamine at less than 15 minutes and serum tryptase at 2, 6, and 24 hours following the reaction were determined. Skin and specific IgE tests were performed between 4 and 8 weeks later. ResultsOver the 20-year period, 288 594 anaesthetic procedures were performed. We observed cases of 66 severe anaphylaxis reaction (59% men; age, 60.8 ± 17.3 years. Symptoms observed were cardiovascular (86%), respiratory (73%), and mucocutaneous (56%). Elevated serum tryptase levels were associated with degree of severity at 2 (p < 0.0001) and 6 hours (p = 0.026) and were highest in IgE-mediated reactions (p = 0.020). All patients required treatment, and 3 events were fatal.In 84.8% of patients, skin and/or specific IgE tests were positive for antibiotics (35.8%), non-steroidal anti-inflammatory drugs (23.1%), neuromuscular blocking agents (15.4%) and latex (15.4%). ConclusionsThe incidence of severe anaphylaxis in our hospital was 1 in 4 373 anaesthetic procedures, with a death rate of 4.5%. All cases required treatment. Serum tryptase was a good predictor of reaction severity. The most frequent causative agents were antibiotics, non-steroidal anti-inflammatory drugs, neuromuscular blocking agents and latex.

Desensitization to Brentuximab Vedotin after anaphylaxis in refractory Hodgkin's lymphoma.

Brentuximab vedotin (BV) is a monoclonal antibody that targets CD30 antigen. It is indicated for the treatment of CD30 + lymphomas and classical Hodgkin lymphoma (HL), including advanced (stage III-IV) untreated disease, relapsed/refractory disease, and consolidation after autologous hematopoietic stem cell transplantation. In clinical trials the incidence of a hypersensitivity reaction is 1.2%. We present 3 cases of patients with refractory HL and anaphylaxis to the administration of BV ( Table1). Symptoms are analyzed using a grading system described by Brown (2004) and a desensitization protocol was performed with a total dose of 100 mg of BV in 4 solution bags with an initial concentration of 1:1000 of total dose for cases of severe anaphylaxis, and desensitization of 3 solution bags with baseline concentration of 1: 100 for cases of moderate anaphylaxis. Intradermal skin tests were positive. Before desensitization, premedication with methylprednisolone and chlorphenamine was administered, as well as fluid therapy with 0.9% physiological solution at 100 cc/hour at induction stage, 250 cc/hour at maintenance stage, and increased to 500 cc/hour in case of hypersensitivity reaction. Drug desensitization in 12 or 16 steps allows tolerable administration of brentuximab vedotin after moderate to severe anaphylaxis. The favorable response to treatment of these patients may indicate that desensitization is a viable strategy for patients with relapsed or refractory HL.

Le Réseau d’Allergo-Vigilance® fête ses 20 ans

The purpose of this article is to recall the circumstances of the creation of the Allergo-Vigilance® network (RAV), its legal framework and its missions: keeping a register of severe anaphylaxis cases whatever the etiology (food, drugs, hymenoptera or others), participation in multicentric studies, continuing medical education, publications, health watch role (emerging allergens..), epidemiological tool..In addition, the methods of collecting and analyzing declarations, access to the computer site (https://www.allergyvigilance.org), the main work of the RAV, the links with the European network NORA are recalled as well as the various projects to come.

Anaphylaxie alimentaire au pitaya ou « fruit du dragon » croisée avec pignon de pin et noix de cajou, allergènes en cause

We report a case of severe anaphylaxis to pitaya (Dragon fruit) in a 10-year-old child, with a history of anaphylaxis to pine nut and cashew nut. Performing immunoblot and immunoblot inhibition test, we showed IgE reactivity of the patient's serum towards pitaya proteins of 50, 23 and 11kDa molecular weight. The high homology between the proteins of 50 and 23kDa and the cashew nut legumin Ana o 2, and between the 11kDa protein and the LTP Pru p 3, confirms cross-reactivity of these three food allergens, though they belong to different botanical families. Allergenic risk of pitaya is now to consider in patients allergic to pine nut, an emergent allergen, and in the more and more frequent allergic patients to cashew nut and other anacardiaceous species.

ARIA-EAACI statement on severe allergic reactions to COVID-19 vaccines - An EAACI-ARIA Position Paper.

Further to the approval of the Coronavirus disease 2019 (COVID-19) vaccine BNT162b2, several severe anaphylaxis cases occured within the first few days of public vaccination. An investigation is taking place to understand the cases and their triggers. The vaccine will be administered to a large number of individuals worldwide and there are raising concerns that severe adverse events might occur. With the current information, the European Academy of Allergy and Clinical Immunology (EAACI) states its position for the following preliminary recommendations that are to be revised as soon as more data emerge. To minimize the risk of severe allergic reactions in vaccinated individuals, it is urgently required to understand the specific nature of the reported severe allergic reactions, including the background medical history of the individuals affected and the mechanisms involved. To achieve this goal, all clinical and laboratory information should be collected and reported. Mild and moderate allergic patients should not be excluded from the vaccine as this could have a significant impact on reaching the goal of population immunity. Healthcare practitioners vaccinating against COVID-19 are required to be sufficiently prepared to recognize and treat anaphylaxis properly with the ability to administer adrenaline. Further to vaccine administration, a mandatory observation period of at least 15 minutes should be followed for all individuals. The current data have not shown any higher risk for patients suffering from allergic rhinitis or asthma, and this message should be clearly stated by physicians to enable our patients to trust the vaccine. More than 30% of the population suffers from allergic diseases and the benefit of the vaccination clearly outweighs the risk of severe COVID-19 development.

Peanut or hazelnut? About two cases of severe anaphylaxis to hazelnut involving PR-10

Peanut or hazelnut? About two cases of severe anaphylaxis to hazelnut involving PR-10

Refractory Anaphylaxis: Data From the European Anaphylaxis Registry.

Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 μg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances—requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.

Adrenaline in anaphylaxis treatment. Balancing benefits and harms

ABSTRACTIntroduction: Although anaphylaxis is a relatively common disorder, clinicians and scientists have debated on how to best define and manage this condition. The current recommendations are focused on the central role of adrenaline, but evidence in support of this therapeutic approach is modest, mainly for the lack of well-designed trials. Conversely, serious adverse effects are commonly reported following adrenaline use, especially when given intravenously. These include hypertension, ventricular arrhythmias, myocardial infarction, pulmonary edema.Areas covered: Anaphylaxis treatment, with special focus on adrenaline utilization, both in pre-hospital and in-hospital settings. Aim is to examine in depth the balance between benefits and harms of this important drug.Expert opinion: Due to the lack of solid evidence supporting the use of adrenaline in patients with anaphylaxis, except in severe cases, the strength of recommendations should be readdressed, limiting administration to selected categories of patients. Caregivers should promptly act in pre-hospital setting, given the shortness of time and lack of technology. In the hospital setting, and more specifically in the ED, clinicians should consider the prompt use of adrenaline in severe anaphylaxis cases, but they should also be able to judiciously wait in the vast majority of milder anaphylactic reactions, which may resolve spontaneously.

A case of severe anaphylaxis following coronary angiography

Anaphylaxis reactions are not uncommon in routine practice and involve multiple systems usually. Cardiovascular collapse is the severest form of reaction. We present a case of severe anaphylactic reaction with cardiovascular collapse without other systems involvement which had to treat with intravenous adrenaline for a prolonged duration (successfully). The case is presented because of the rarity of presentation (single system involvement) and requirement of prolonged use of adrenaline for more than 24 h.

A case of severe anaphylaxis after Ropalidia marginata (a paper wasp) sting in Sri Lanka

Introduction: Ants, bees and wasps are insects in Order Hymenoptera. Victims of Hymenoptera sting can present with nuisance pain to more severe form of anaphylaxis [1]. Ropalidia marginata (Kaladuruwa) is the most common social wasp of Peninsula of India [2]. Traditional medication is a common practice in rural Sri Lanka for insect sting. Nest of the Ropalidia marginata is crushed and mixed with water to make a paste which is applied on the painful area over the stinging site of paper wasp as a common traditional treatment.Although there are many cases of allergic reactions after wasp sting, the individual species of Ropalidia marginata causing severe anaphylaxis is not reported. We report a school boy presented with severe anaphylaxis after this paper wasp sting in Deniyaya, Sri Lanka.

Risk Factors in Fatal Cases of Anaphylaxis due to Contrast Media: A Forensic Evaluation

Background: Fatalities following contrast medium exposure are extremely rare in clinical routine, though they may occur as an exception. Some may fall under the purview of the inquiring authorities and forensic pathologists due to their in-hospital occurrence. The purpose of this study was to assess the risk factors for anaphylaxis due to contrast medium administration that can be identified in fatal cases. Methods: Fatalities occurred during the course of clinical investigations with contrast media described in the literature and fatal reactions to contrast agents that had undergone forensic investigations in our medicolegal center were reviewed with respect to patient characteristics, administered contrast medium, performed biochemical investigations and potential risk factors identified based on clinical history and medical records. Results: Biochemical investigations into the fatal cases examined in our facility revealed increased mast cell tryptase, total IgE and activated mast cells in all subjects. Data obtained from the literature and our own investigations indicated that in only a minority of the fatal cases had there been previous exposure to contrast compounds, while most cases of severe anaphylaxis involved patients who apparently reacted on initial exposure. Conclusions: Most fatal cases failed to present any identifiable predisposing conditions out of those traditionally considered as risk factors for an anaphylactic reaction to contrast compounds in the medical histories of the patients. Comprehensive clinical histories and thorough reviews of medical data, along with exhaustive forensic investigations, provide information that is relevant in order to better appreciate the interwoven relationships linking all factors potentially involved in the pathogenesis of fatal anaphylaxis to contrast media.

Severe anaphylaxis during sentinel lymph node biopsy (SLNB)

The aim of this study was to present two cases of severe anaphylaxis during sentinel lymph node biopsy (SLNB). Case 1: A 64-year-old-woman had two months earlier been diagnosed with breast ductal invasive carcinoma by first local excision. She was taken for further surgery with SLNB. At induction she received midazolam, fentanyl, propofol, atracurium, cefazolin and paracetamol. She was given a subcutaneous injection of the dye Patent Blue V (PBV) and shortly afterward she developed a blue rash over her abdomen and her blood pressure dropped precipitously. She was treated successfully with intravenous adrenaline and fluids. Six weeks later, a skin prick test (SPT) and intradermal test (ID) to all used drugs, latex and B-lactamics were performed. SPT and ID to PBV were positive with 3mm and 6.5m in weal diameter. ID test to cefazolin was also positive (6.5mm). All others were negative. Case 2: A 49-year-old woman required local excision of a breast lump with SLNB. She received midazolam, fentanyl, cefazolin and atracurium. PBV was then injected and 15 min later, she developed generalized erythema and severe hypotension and bradycardia. She required, intravenous adrenaline and amines infusion postanaesthetic. SPT and ID to all used drugs, latex and B-lactamics were performed. SPT to PBV diluition 1:100 and 1:10 were positive with 3mm and 8mm in weal diameter. The ID testing of atracurio in major concentration of 1:1000 revealed a 7 mm increase in the weal. All others were negative.

Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

Near fatal anaphylaxis at general anesthesia in an 11 year old boy

Methods During general anaesthesia exposure to a number of different agents is common. In addition, anti-inflammatory drugs, antiemetics, antacids, antibiotics and analgesics may be used, and all may elicit reactions. Follow up is recommended to include serum tryptase, specific IgE, skin prick test (SPT), intradermal tests (IDT), basophil activation test (BAT) and provocations. We present a case of severe anaphylaxis in an 11-year-old boy during hand surgery with rhinitis at exposure to pollen and pets only.

A Case of Codeine Induced Anaphylaxis via Oral Route

Codeine is widely prescribed in clinical settings for the relief of pain and non-productive coughs. Common adverse drug reactions to codeine include constipation, euphoria, nausea, and drowsiness. However, there have been few reports of serious adverse reactions after codeine ingestion in adults. Here, we present a case of severe anaphylaxis after oral ingestion of a therapeutic dose of codeine. A 30-year-old Korean woman complained of the sudden onset of dyspnea, urticaria, chest tightness, and dizziness 10 minutes after taking a 10-mg dose of codeine to treat a chronic cough following a viral infection. She had previously experienced episodes of asthma exacerbation following upper respiratory infections, and had non-atopic rhinitis and a food allergy to seafood. A skin prick test showed a positive response to 1-10 mg/mL of codeine extract, with a mean wheal size of 3.5 mm, while negative results were obtained in 3 healthy adult controls. A basophil histamine release test showed a notable dose-dependent increase in histamine following serial incubations with codeine phosphate, while there were minimal changes in the healthy controls. Following a CYP2D6 genotype analysis, the patient was found to have the CYP2D6*1/*10 allele, indicating she was an intermediate metabolizer. An open label oral challenge test was positive. To the best of our knowledge, this is the first report of a patient presenting with severe anaphylaxis after the ingestion of a therapeutic dose of codeine, which may be mediated by the direct release of histamine by basophils following exposure to codeine.

Implementation of Anaphylaxis Management Guidelines: A Register-Based Study

BackgroundAnaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines.MethodsWithin the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data.Results2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time.ConclusionThere is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted.

A case of severe anaphylaxis to kidney bean: phaseolin (vicilin) and PHA (lectin) identified as putative allergens

A case of severe anaphylaxis to kidney bean: phaseolin (vicilin) and PHA (lectin) identified as putative allergens

Médicaments facteurs de risque de sévérité de l’anaphylaxie alimentaire de l’adulte. Étude cas-contrôle

Between 1995 and 2008, a case-control study was conducted to determine the role of drugs as risk factors for severe food anaphylaxis in adults. Data including exercise, alcohol intake, and use of aspirin, non steroidal anti-inflammatory drugs, beta-blockers, and angiotensin-converting-enzyme inhibitors (ACEI) were prospectively recorded. Multivariate analysis was used to compare 76 cases of severe anaphylaxis (SA) with 235 cases of mild to moderate food allergy (mmFA). The M/F sex ratio was 54.6% in SA and 36% in mmFA (p < .003). SA represented 17.3% of all food allergies below 45 years and 54.6% over this age. Drug intake did not differ between the two age categories. Drug use was noted in 40.8% of SA and 14.9% of mmFA (p < .0005). Aspirin, NSAIDs, betablockers and ACEI were associated with respectively 15.8%, 6.6%, 10.5% and 5.3% of SA, and with 1.7%, 0.9%, 1.7% and 0.4% of mmFA (p < .003). The respective odds ratios were 10.8, 8.2, 6.8 and 13.0. No other drugs were associated with FA. Exercise and alcohol intake were associated to drugs with respectively 10.5% and 27.6% of SA and 0.4% and 8.1% of mmFA (p < .0005). Exercise drastically increased the risk of drugs. We conclude that aspirin, NSAIDs, betablockers and ACEI are significant risk factors for severe IgE-dependent food allergy. The underlying mechanisms are discussed. Adults with food allergy or sensitization should avoid taking aspirin and NSAIDs before meals and should receive drug families other than ACEI and betablockers for hypertension. In case of pre-existing heart disease, the benefit-risk ratio of ACEI and beta-blockers has to be carefully considered.