Signs Of Anaphylaxis Research Articles

A RARE CAUSE OF URTICARIA IN AN NSAID TOLERANT PATIENT

<h3>Introduction</h3> Acetaminophen is one of the most used anti-pyretics to mitigate fever. Few cases have been reported of hypersensitivity reactions to acetaminophen without non-steroidal anti-inflammatory drug (NSAID) intolerance. It is recommended that if there is suspected drug hypersensitivity then the patient should undergo an oral drug challenge. <h3>Case Description</h3> A 49-year-old male presented for evaluation of urticaria that occurred with acetaminophen ingestion. He reported several episodes where he developed diffuse urticaria within 15 minutes of ingestion, but no other symptoms concerning for anaphylaxis. He was unsure of the dose. He also noted urticaria with Excedrin migraine, which contains acetaminophen, aspirin, and caffeine. He tolerated NSAIDs alone. An oral drug challenge was performed. He was administered 250mg of acetaminophen, which he tolerated. After taking his second dose of 250mg, he developed pruritus and 4 urticarial lesions within 30 minutes. He did not have any other signs of anaphylaxis. He was treated with 20mg of loratadine. Upon re-evaluation, he had more diffuse urticarial lesions, but no other symptoms and he remained hemodynamically stable. He was serially monitored every 15 minutes for a total of 90 minutes, with near resolution of his urticaria. <h3>Discussion</h3> Pseudoallergy is an immediate systemic reaction that resembles anaphylaxis but is non IgE-mediated. NSAIDs are a common cause of pseudoallergy. There are cases of acetaminophen hypersensitivity reactions in NSAID intolerant patients due to cross-reactivity. If a patient is NSAID tolerant and develops symptoms with acetaminophen, it is more likely to be IgE-mediated. Acetaminophen challenge should be done with caution and avoided if positive.

DELAYED, PERSISTENT ANAPHYLAXIS AFTER AN ALLERGY INJECTION

<h3>Introduction</h3> Delayed or biphasic anaphylactic reactions are rare. We report a delayed onset, prolonged anaphylactic reaction which occurred twelve hours after the first dose of allergen immunotherapy. <h3>Case Description</h3> 35 year-old male with allergic rhinoconjunctivitis and many positive serum aeroallergen tests initiated allergen immunotherapy for severe persistent symptoms despite treatment with Fluticasone, Cetirizine, and Azelastine. Twelve hours after his first allergy injection, he developed pruritus, took a diphenhydramine and went to sleep. When he awoke the next morning, his spouse noted that his face, back, and chest were erythematous and the pruritus continued. He had scattered urticaria as well. He developed wheezing 24 hours after the injection and then again approximately 72 hours later which he treated with an Albuterol MDI. He did not seek medical attention at any point, but took diphenhydramine which only helped temporarily. He notes that he just "ignored the symptoms." He had an Epi pen in his possession but did not use it. The itching and rash persisted for approximately ten days and the wheezing remitted within five. Allergy injections were not reinitiated. <h3>Discussion</h3> This is an example of late-onset anaphylaxis which lasted greater than a week, likely due to lack of appropriate medical treatment. It is important to educate our immunotherapy patients on the signs of anaphylaxis as well as the possibility that though rare, symptoms can be delayed. In addition, it is important to emphasize the need for prompt medical attention in such situations.

The Timely Administration of Epinephrine and Related Factors in Children with Anaphylaxis.

Anaphylaxis is a severe allergic reaction that requires immediate recognition and intervention. This study investigated the factors related to the timely administration of epinephrine in cases of pediatric anaphylaxis. We performed a retrospective chart review of 107 patients who visited a pediatric emergency center with anaphylaxis between 2015 and 2017. In total, 76 patients received epinephrine injections. We analyzed factors including allergy history, anaphylaxis signs and symptoms, allergen sensitization, anaphylaxis triggers, and time of epinephrine injection. Anaphylactic patients who received epinephrine took a median of 50 min to arrive at the hospital, and patients who did not receive epinephrine took a median of 94 min. Epinephrine administration was significantly delayed by more than 60 min from symptom onset in patients <2 years old. Patients presenting with wheezing symptoms or history of bronchial asthma were significantly more likely to receive epinephrine within 60 min of symptoms onset, while patients with food allergen sensitization were significantly more likely to receive epinephrine within 30 min of hospital arrival. Wheezing, history of asthma, age (≥2 years old), food triggers, and food allergen sensitivity were significant factors for the rapid administration of epinephrine. An immediate diagnosis of anaphylaxis and a rapid administration of epinephrine are essential.

IL6-inhibitors in treatment of SARS COVID19

The aim of this study was to evaluate the clinical efficacy and safety of a two-dose approach in the administration of tocilizumab in patients with SARS COVID19&#x0D; Material and methods. The study was carried out on the basis of the Odrex Medical House in 2000-2021. The total sample included 4,112 patients hospitalized in a specialized department with coronavirus pneumonia. Of this sample, 150 patients were prescribed tocilizumab at a dose of 8 mg/kg of patient weight, including 36 (24.0 %) cases when tocilizumab was administered in a two-dose regimen. In the case of a two-dose regimen, the second dose was administered no earlier than 24 hours after the first one.&#x0D; All patients were examined according to the current clinical protocols. The hemogram, the content of CRP, ferritin, interleukin-6 were assessed. All patients received dexamethasone intramuscularly at a dose of at least 6 mg per day.&#x0D; Statistical processing was carried out by methods of analysis of variance using the software Statistica 13.0.&#x0D; Results. After the use of tocilizumab, the patients had a decrease in body temperature and a decrease in the need for oxygen support. At the same time, the normalization of indicators of the activity of the systemic inflammatory response was observed.&#x0D; Mortality after the use of tocilizumab was 29.3 %; in all cases, the deaths had an extremely severe course of coronavirus infection and a significant comorbid background. There were no manifestations of anaphylaxis and cases of secondary infection after the appointment of tocilizumab.&#x0D; Conclusions. The use of tocilizumab could significantly improve the condition of patients with SARS COVID19. There were no signs of anaphylaxis and cases of secondary infection after the administration of tocilizumab. In the absence of a pronounced clinical effect within 24 hours after the first dose of tocilizumab in patients with severe SARS COVID19, it is advisable to re-administer the drug (two-dose regimen)

Anaesthetic Management of Anaphylactic Shock Caused by ruptured Hydatid Cyst of the Liver: A Case Report

Hepatic hydatid disease is very common in developing nations. Although anaphylactic shock is a rare complication during anaesthesia, it can present with severe cardiovascular shock and hypersensitive reactions during surgical removal of hydatid cyst, requiring prompt emergency management. We report a case of 43 year old female posted for elective removal of hydatid cyst in the right lobe of liver under general anaesthesia. An anaesthesist should be aware of the “tell-tale” signs of anaphylaxis and be prepared for early and prompt treatment of anaphylactic shock. Anaphylactic prophylaxis and close monitoring for early diagnosis and prompt treatment of anaphylaxis are essential to avert any complications associated with anaphylactic shock.

Community-Based Adverse Food Reactions and Anaphylaxis in Children With IgE-Mediated Food Allergy at Age 6 Years: A Population-Based Study

To investigate the frequency, characteristics, and risk factors of community-based adverse food reactions, including anaphylaxis, among children with food allergies at 6 years of age in a population-based cohort: the HealthNuts study.The HealthNuts study is a longitudinal population-based study of childhood allergic disease in Melbourne, Australia in which researchers originally enrolled 5276 12-month old infants from community immunization clinics. In this report, 3233 children from this cohort are involved who, at 6 years of age, returned for an assessment. An additional 1222 only completed a questionnaire.All caregivers completed questionnaires, and children underwent skin-prick tests to milk, egg, peanut, soy, wheat, sesame, shellfish, cashew, almond, hazelnut and a panel of aeroallergens. Oral food challenges (OFCs) were performed for eligible children. Children were identified as definite or probable food allergy on the basis of skin tests and/or a history of food reactions or results of OFCs. A total of 413 children were eligible for an OFC.A total of 260 children were confirmed as having a food allergy. A total of 44.6% reported an adverse food reaction in the previous 12 months, nearly one-third having >1, with 73% likely immunoglobulin E–mediated. The most common symptoms were hives and vomiting. The most common foods were nuts and egg. One-half of the reactions occurred at home, with restaurants second (11.6%). A total of 28 children reported anaphylactic reactions; nearly one-half were not recognized as such by parents. Tree nuts (mostly cashew) and peanuts accounted for 65% of the anaphylactic reactions. Epinephrine autoinjectors were used in only 13.8% of all anaphylaxis episodes, only 25% of the parent-recognized anaphylaxis episodes, and none of the unrecognized anaphylaxis episodes. There were no risk factors identified for experiencing an adverse food reaction or anaphylaxis, but children with nut allergies were less likely to report an adverse food reaction compared with those without a nut allergy.A high-frequency of adverse food reactions and anaphylaxis in food-allergic children at the age of 6 years occurred in this population-based cohort study. Only one-half of the episodes of anaphylaxis were identified as such, and only 25% of those were treated with an Epinephrine autoinjector. Improved regular education on the prevention of adverse food reactions and recognition and management of anaphylaxis is needed.Pediatricians and other primary care practitioners need to review avoidance measures, possible symptoms or signs of anaphylaxis, and the importance of epinephrine as first-line therapy for anaphylaxis as part of their well-child care for patients with food allergies.

Acute intraperitoneal rupture of hydatid cysts of the liver: Case series.

Hydatid cyst is a parasitic infection caused mainly by Echinococcus granulosus, which is generally considered benign. However, the hepatic hydatid cyst rupture in the abdominal cavity is a life-threatening incident that requires urgent and multidisciplinary management (emergency physicians, radiologists, anesthetists, and surgeons). This study describes clinical and paraclinical liver hydatid cyst rupture in the peritoneal cavity and details the appropriate treatment.A retrospective review of clinical records of patients hospitalized in Jendouba Hospital for liver hydatid cyst was performed over 8 years, from January 1, 2012 to December 31, 2019. Fifteen cases of liver hydatid cyst complicated with acute rupture into the abdominal cavity were collected out of 625 hydatid liver cysts. All patients underwent emergency laparotomy allowing conservative unroofing procedure associated with peritoneal lavage and external drainage combined with necessary intensive care measures. Clinical features, therapeutic procedures’ details as well as postoperative outcomes are reported. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.There were 9 men and 6 women. Patients’ age ranged from 14 to 59 years, with an average of 38 years. Two patients were admitted with abdominal trauma. Acute abdominal pain was the most common complaint. Only 1 patient had an anaphylactic shock. Abdominal ultrasonography and computed tomography scan showed discontinuous cyst wall associated to intraperitoneal fluid in all cases. Intraoperatively, the intraperitoneal effusion was clear in 13 cases and purulent in 2. All patients underwent unroofing procedures associated with intra-operative peritoneal lavage and external drainage. The mean hospital stay was 6.11 days, and the mean follow-up was 19 months. No case of recurrence was reported among the patients.In endemic areas, rupture of a hepatic hydatid cyst in the abdominal cavity should be considered in every case of acute abdominal pain, especially if associated with anaphylaxis signs. Early management starting in the emergency room is needed to ensure good outcome.

Idiopathic anaphylaxis: Diagnosis and management.

Introduction: Idiopathic anaphylaxis (IA) is a diagnosis of exclusion and is based on the inability to identify a causal relationship between a trigger and an anaphylactic event, despite a detailed patient history and careful diagnostic assessment. The prevalence of IA among the subset of people who experienced anaphylaxis is challenging to estimate and varies widely, from 10 to 60%; most commonly noted is ∼20% in the adult anaphylactic population. Comorbid atopic conditions, such as food allergy, allergic rhinitis, and asthma, are present in up to 48% of patients with IA. Improved diagnostic technologies and an increased understanding of conditions that manifest with symptoms associated with anaphylaxis have improved the ability to determine a more accurate diagnosis for patients who may have been initially diagnosed with IA. Methods: Literature search was conducted on PubMed, Google Scholar and Embase. Results: Galactose-α-1,3-galactose (α-gal) allergy, mast cell disorders, and hereditary a-tryptasemia are a few differential diagnoses that should be considered in patients with IA. Unlike food allergy, when anaphylaxis occurs within minutes to 2 hours after allergen consumption, α-gal allergy is a 3-6-hour delayed immunoglobulin E-mediated anaphylactic reaction to a carbohydrate epitope found in red meat (e.g., beef, lamb, pork). The more recently described hereditary α-tryptasemia is an inherited autosomal dominant genetic trait caused by increased germline copies of tryptase human gene alpha-beta 1 (TPSAB1), which encodes α tryptase and is associated with elevated baseline serum tryptase. Acute management of IA consists of carrying an epinephrine autoinjector to be administered immediately at the first signs of anaphylaxis. Long-term management for IA with antihistamines and other agents aims to potentially reduce the frequency and severity of the anaphylactic reactions, although the evidence is limited. Biologics are potentially steroid-sparing for patients with IA; however, more research on IA therapies is needed. Conclusion: The lack of diagnostic criteria, finite treatment options, and intricacies of making a differential diagnosis make IA challenging for patients and clinicians to manage.

Caregiver-Reported Presentation of Severe Food-Induced Allergic Reactions in Infants and Toddlers

Recognizing anaphylaxis in infants and toddlers can be challenging for health care providers and caregivers, and current diagnostic criteria and anaphylaxis action plans do not specifically address this younger population. To describe symptoms and signs observed by primary caregivers of infants and toddlers during severe food-induced allergic reactions. We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when less than 36 months of age. Respondents who were present during the child's most severe reaction were asked to report symptoms and signs observed. The survey asked about infant- and toddler-specific symptoms and signs in lay language for caregivers. Data were compared with patient-reported data from past studies to identify distinct patterns among the younger population. The survey was completed for 374 children (193 infants, 181 toddlers). The most common symptoms and signs reported were skin reactions (90%), facial and extremity swelling (59%), gastrointestinal issues (51%), and coughing/wheezing (45%). Infants (aged <12 months) more frequently experienced skin reactions, skin mottling, and ear pulling/scratching or putting fingers in ears, as compared with toddlers (aged 12-35 months). Toddlers experienced throat itching and coughing/wheezing more frequently than infants. Anaphylaxis presentation demonstrates similarities and differences in infants and toddlers. Modifying the terminology used in the current criteria allowed for reporting of symptoms and signs of anaphylaxis that are more common in infants and toddlers. Diagnostic criteria, clinical guidelines, and anaphylaxis action plans may be enhanced to address this young, often nonverbal, population.

Urticaire de l’enfant

The cumulative incidence of urticaria in children is close to 10%. Two forms are described: the superficial form and the deep form, or angioedema. In young children aged under 3 years, urticaria is commonly annular and ecchymotic, and is mistaken for erythema multiforme or acute hemorrhagic edema. Serum sickness-like reaction is a particular form of urticaria characterized by angioedema of the extremities, fever and arthralgia, and it is chiefly drug-induced (cephalosporins). With children, questioning and clinical examination are essential and, in most cases, reveal an etiology. The main causes of acute or recurrent urticaria are viral infections and/or drugs (non-specific histamine release), whereas chronic urticaria is mostly due to physical causes. In developed countries, parasitic infections are rarely the cause. Arguments in favor of a food allergy are as follows: a setting of atopy, onset within one hour of taking the suspect food, absence of fever or infection, a duration of less than 24hours, possible association with other signs of anaphylaxis, and further recurrence with each new intake of the suspect food. First-line treatment of urticaria without signs of severity consists solely of non-sedating antihistamine (associated with removal of the cause where the latter has been determined). Nearly one-third of cases of urticaria in children progress over a prolonged period of more than 6 weeks, thus constituting chronic urticaria (most often a form of mild recurrent urticaria during episodes of infection and/or medication). Chronic urticaria is very rarely due to an underlying inflammatory disease or a genetic disease such as cryopyrinopathy, and first-line etiological assessment is usually limited to the following tests: CBC, sedimentation speed and/or CRP, and transaminases.

Life-threatening Allergic Reactions Increasing Among Children

Abstract Anaphylaxis, a sudden and potentially life-threatening allergic reaction, is increasing among children according to a new report. As the rate rises, there is an increased need for awareness and education for parents and caregivers to help them recognize and treat anaphylaxis. For children who do are at-risk of an anaphylactic reaction, parents and teachers need to be vigilant about the signs of anaphylaxis and to begin treatment quickly. The chances of a positive outcome are increased if necessary medications are on hand during a life-threatening situation. As more children suffer from potentially life-threatening anaphylactic reactions, access to these medications and to emergency room care is essential to safeguarding the health of children.

Improved Efficacy of Oral Immunotherapy Using Non-Digestible Oligosaccharides in a Murine Cow's Milk Allergy Model: A Potential Role for Foxp3+ Regulatory T Cells.

Oral immunotherapy (OIT) is a promising therapeutic approach to treat food allergic patients. However, there are some concerns regarding its safety and long-term efficacy. The use of non-digestible oligosaccharides might improve OIT efficacy since they are known to directly modulate intestinal epithelial and immune cells in addition to acting as prebiotics. To investigate whether a diet supplemented with plant-derived fructo-oligosaccharides (FOS) supports the efficacy of OIT in a murine cow's milk allergy model and to elucidate the potential mechanisms involved. After oral sensitization to the cow's milk protein whey, female C3H/HeOuJ mice were fed either a control diet or a diet supplemented with FOS (1% w/w) and received OIT (10 mg whey) 5 days a week for 3 weeks by gavage. Intradermal (i.d.) and intragastric (i.g.) challenges were performed to measure acute allergic symptoms and mast cell degranulation. Blood and organs were collected to measure antibody levels and T cell and dendritic cell populations. Spleen-derived T cell fractions (whole spleen- and CD25-depleted) were transferred to naïve recipient mice to confirm the involvement of regulatory T cells (Tregs) in allergy protection induced by OIT + FOS. OIT + FOS decreased acute allergic symptoms and mast cell degranulation upon challenge and prevented the challenge-induced increase in whey-specific IgE as observed in sensitized mice. Early induction of Tregs in the mesenteric lymph nodes (MLN) of OIT + FOS mice coincided with reduced T cell responsiveness in splenocyte cultures. CD25 depletion in OIT + FOS-derived splenocyte suspensions prior to transfer abolished protection against signs of anaphylaxis in recipients. OIT + FOS increased serum galectin-9 levels. No differences in short-chain fatty acid (SCFA) levels in the cecum were observed between the treatment groups. Concisely, FOS supplementation significantly improved OIT in the acute allergic skin response, %Foxp3+ Tregs and %LAP+ Th3 cells in MLN, and serum galectin-9 levels. FOS supplementation improved the efficacy of OIT in cow's milk allergic mice. Increased levels of Tregs in the MLN and abolished protection against signs of anaphylaxis upon transfer of CD25-depleted cell fractions, suggest a role for Foxp3+ Tregs in the protective effect of OIT + FOS.

A CASE OF NEUROTOXIC SNAKE BITE IN A METROPOLITAN CITY (NEW DELHI): PAIN ABDOMEN WITH ANAPHYLAXIS AS A PRESENTATION

Snake bites present as life threatening emergencies and are seen more commonly in rural tropical countries. Snake bites have neurotoxic, hemotoxic, myotoxic or mixed presentation. We present a case of neurotoxic snake bite in an urban setting of New Delhi, a metropolitan city, where snake bites aren’t common. The patient presented as an acute emergency in casualty, without any previous forthcoming history of snake bite, with a history of pain abdomen, vomiting and signs of anaphylaxis. Rapidly progressive neurological deficit started with ptosis followed by stridor, dyspnoea, respiratory arrest and shock. The patient was given standard management of anaphylaxis and snakebite (polyvalent anti-snake venom and neostigmine) based on WHO guidelines of snake bite. Patient recovered without any neurological deficit within a week. Although snakebites are rare in urban setting, they are reported. Neurotoxic snakebites can occur in sleep by kraits and can present as catastrophic life threatening emergency in early morning hours, as in our case.

Knowledge and experience regarding perioperative anaphylaxis among anesthesiologists in Istanbul

Anesthesiologists are among the physicians with the highest probability of encountering cases with anaphylaxis. Therefore, they should be familiar with recent developments in anaphylaxis diagnosis and treatment. This study assessed the personal experiences and knowledge of the current diagnostic criteria and management of anaphylaxis among anesthesiologists. Anesthesiologists working in Istanbul were randomly selected and requested to complete a 16-item questionnaire related to their experiences with perioperative anaphylaxis and knowledge about current anaphylaxis guidelines. The study group consisted of 203 physicians; 10.8% of them reported having experienced any case with perioperative anaphylaxis during their own practice. The leading responsible agents were penicillins and other antibiotics (36.3%), followed by neuromuscular blocking agents (32%). Most of the physicians reported hypotension as the most important sign of anaphylaxis under general anesthesia and preferred epinephrine as the first-line medication during anaphylaxis. Antibiotics and neuromuscular blocking agents were the most common causative agents identified in the cases of perioperative anaphylaxis experienced by our study group. Like other health care providers, anesthesiologists should be aware of recent advances in anaphylaxis diagnosis and treatment.

Managing anaphylaxis in the office setting.

Although the definition of anaphylaxis for clinical use may vary by professional health care organizations and individuals, the definition consistently includes the concepts of a serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or even fatal. In this review, we presented the important topics in the treatment of anaphylaxis in the office setting. This review will discuss triggers and risk factors, clinical diagnosis, and management of anaphylaxis in the office setting. Anaphylaxis in the office setting is a medical emergency. It, therefore, is important to prepare for it, to have a posted, written anaphylaxis emergency protocol, and to rehearse the plan regularly. In this review, we presented the important steps in managing anaphylaxis in the office. Treatment of anaphylaxis should start with epinephrine administered intramuscularly at the first sign of anaphylaxis. Oxygen and intravenous fluids may be needed for moderate-to-severe anaphylaxis or anaphylaxis that is quickly developing or if the patient is unresponsive to the first injection of epinephrine. Antihistamine therapy is considered adjunctive to epinephrine, which mainly relieves itching and urticaria. Corticosteroids, with an onset of action of 4-6 hours, have no immediate effect on anaphylaxis. To prevent near-fatal and fatal reactions from anaphylaxis, the patient, the family, and the physician must remember to follow the necessary steps when treating anaphylaxis. In anaphylaxis, there is no absolute contraindication for epinephrine.

Reversion of Asthmatic Complications and Mast Cell Signalling Pathways in BALB/c Mice Model Using Quercetin Nanocrystals.

The tranquillizing effects of quercetin on allergic asthma are promising, but its poor water solubility and bioavailability is still a bottleneck. In this study, an ovalbumin (OVA) sensitized BALB/c mice asthma model was used to investigate the potential of quercetin nanocrystals (nQ) on relieving asthma aggravation. The water soluble nQ was prepared by the homogenization using the high energy sonication method. X-ray diffraction data showed the formation of nQ (10-30 nm) which was in agreement with transmission electron microscopy. The nQ was found to be more stable and soluble in PBS, and sera of BALB/c mice compared to bulk quercetin. Dose dependent experiments with nQ on OVA sensitized asthma mice exhibited significant anti-asthmatic potential of nQ at much lower dose (1 mg/kg body weight) compared to bulk quercetin. The treatment of nQ remarkably resulted in reduced OVA specific immunoglobulin E (sIgE) production, anaphylaxis signs and type 1 skin test. The nQ also significantly modulated the expression of Th2 cytokines like IL-4 and IL-5, which are responsible for IgE class switching and suppressed the degranulation/secretion of different chemical mediators (PGD2, mMCPT-1 Cys-L and TSLP) from activated mast cells. The levels of FcεR1, Syk, c-Yes, PI-3, p-PI-3, PLC-γ2, and p-PLC-γ2 were found to be reduced in the OVA sensitized BALB/c mice treated with nQ compared to those treated with OVA only. The results indicate that nQ alleviate pulmonary inflammation and airway hyporesponsiveness in allergic asthma at much lower dose compared to bulk quercetin and may be considered as a potential drug for the treatment of asthmatic patients.

Prevalence of Self-Reported Food Allergy in Lebanon: A Middle-Eastern Taste.

Background. Food allergy (FA) is an important health problem in Western countries but there is limited data on the prevalence of food allergy in the Middle East. The main objective of our study is to assess the prevalence of self-reported food allergy in Lebanon. Methods. The survey was conducted by Telephone Calls questionnaire through random selection of landline phone numbers from the white pages all over Lebanon. A study questionnaire addressing the main objectives of the study was filled during the telephone call conversation. Results. Food allergy prevalence is estimated to be 4.1% in infants and children and 3.2% in adults. 65% of patients suffering from food allergy are females and 35% are males. Skin reactions are the most common symptoms among food allergy sufferers, reported in 86% of the cases. Signs of anaphylaxis appeared in 10.8% of cases. Fruits were the most common allergens at 35%, followed by eggs (19%) and nuts (16%). Cow's milk and spices ranked fourth (14%). Only half of food allergy sufferers sought medical advice. Allergists, dermatologists, gastroenterologists, or GPs (general practitioners) were consulted. Blood testing for specific IgE was the main diagnostic tool used by physicians. Conclusion. This is a pilot study of self-reported food allergy prevalence in Lebanon based on telephone survey. General prevalence is estimated to be 4.1% in infants and children and 3.2% in adults. Our study may improve awareness for proper diagnosis, food elimination, and acquisition of epinephrine autoinjectors in this part of the world.

A Case of Anaphylaxis with Unusual Clinical Presentation that Obscured Early Diagnosis

Anaphylaxis is a severe systemic allergic reaction, which progresses rapidly and may cause death. However, the diagnosis of anaphylaxis is difficult because initial symptoms and signs of anaphylaxis have various patterns. We reported a case of anaphylaxis with unusual clinical presentation that made diagnosis difficult. A 14-year-old male presented emergency department with dizziness and temporary hypotonia. While observing his symptom, the patient’ s blood pressure decreased rapidly. After thorough history taking, we found out that he had been suffered from pruritus and nausea for two days. The patient received a large volume of crystalloid and intramuscular epinephrine. And the blood pressure recovered soon. When physicians evaluate patients with respiratory or circulatory compromise, we should consider the possibility of anaphylaxis through careful history taking and administer epinephrine immediately if necessary. Key Words: Muscle Hypotonia; Anaphylaxis; Hypotension; Epinephrine

The awareness of anaphylaxis reaction to local anesthesia in Dentistry

Background: Anaphylaxis is one of the rare clinical events specifically related to anesthesia leading to morbidity and mortality. In this manner, the aim of our study was to determine knowledge of Iranian dentists about symptom, sign and management of anaphylaxis to local anesthesia. Methods: The study was designed with a questionnaire (16 questions) related to anaphylaxis to local anesthesia in Iran. The dentists working in their private office and clinic of medical dentist randomly selected and asked to complete questionnaire. Results: 72% of dentists accepted to take part in the study. Although all attendants knew one or more symptoms and signs of anaphylaxis but none of them marked all options related to anaphylaxis. In relation to, about 72.9% of dentists knew epinephrine as the first choice in the treatment of anaphylaxis shock, but only 20% of them had kept emergency equipments and facilities such as drugs in their offices to treat shock. This study showed that less than 10% of the dentists were aware of the recommended dose of epinephrine to use in adults or children. Conclusion: Our study concludes that some of dentists are not aware of this emergency vital clinical condition. Therefore, dentists should be developed their knowledge on the subject of the causes and treatment of anaphylaxis shock alternatively with attendance in related courses which holding by academic centers.

Successful rapid intravenous desensitization for radioiodine contrast allergy in a patient requiring urgent coronary angiography

An 81-year-old white woman presented to our hospital with chest pain on a background history of recurrent left main coronary artery in-stent restenosis and severe allergic reaction to iodixanol (Visipaque; GE Healthcare, Mississauga, Ontario, Canada) radiocontrast media (RCM). The patient’s cardiovascular risk factors included only dyslipidemia. The patient’s cardiac history was significant for prior coronary artery bypass graft surgery, severe aortic stenosis that necessitated transapical aortic valve replacement, and dual-chamber pacemaker insertion for symptomatic sinus pauses. Despite these surgical interventions, ongoing angina necessitated multiple previous percutaneous coronary intervention (PCI) procedures to the left main coronary artery. In-stent restenosis of the left main coronary artery led to multiple presentations to the hospital, where the patient’s left main coronary artery was treated with a drug-eluting stent implantation and subsequent interventions that used cutting balloons and drug-eluting balloons. Other comorbidities included a childhood history of asthma, obstructive sleep apnea, gastroesophageal reflux disease, and neuropathy secondary to prior surgeries. With each successive angiography and PCI, the patient developed an anaphylactoid reaction to Visipaque RCM, which progressed in severity. In 2008, after coronary angiography, our patient developed flushing, hypotension, and a rash consistent with hives. Subsequently, she was pretreated according to hospital protocol with diphenhydramine 50 mg orally 1 hour before and prednisone 100 mg orally 13 hours, 7 hours, and 1 hour before future angiography. In August 2012, the patient presented to the hospital with persistent chest pain and underwent coronary angiography. She was pretreated for contrast allergy as previously described. Upon initial injection of RCM while attempting to intubate the left main coronary artery, our patient’s blood pressure dropped to 65/30 mm Hg, and she required intravenous fluids, hydrocortisone, epinephrine, emergent intubation, and intra-aortic balloon pump insertion. Balloon angioplasty to the left main coronary artery was successful for critical left main coronary artery in-stent restenosis. After several days in the coronary intensive care unit, the patient was successfully extubated and ultimately discharged home. In December 2012, recurrent chest pain prompted another attempt at coronary angiography. Pretreatment with prednisone 50 mg orally for 3 days as well as our routine hospital protocol for contrast allergy had no effect. The injection of 2 mL Visipaque RCM caused immediate hypotension and flushing, and the procedure was aborted. After the procedure, our patient was transferred to the coronary care unit for fluid resuscitation. Our patient was identified as high risk for receiving RCM, with risk factors of a previous reaction, asthma, and cardiovascular disease. Upon consultation with allergy and immunology department personnel, a rapid intravenous desensitization protocol to Visipaque RCM was devised due to the urgency of the procedure. Before angiography, the b-blocker was stopped to prevent hypotension and an angiotensin-converting-enzyme inhibitor was stopped so to reduce the risk of angioedema. The pretreatment regiment was augmented for desensitization, which included the following: prednisone 100 mg (1 mg/kg) at 13 hours, 7 hours, and 1 hour before; diphenhydramine 50 mg intramuscular 1 hour before; and ranitidine 300 mg orally 1 hour before the initiation of intravenous desensitization. The desensitization protocol was initiated 2 hours before angiography, as previously described, with Visipaque RCM (Table I). Upon completion of desensitization, there were no symptoms or signs of an anaphylactic and/or anaphylactoid response. Coronary angiography was completed with 300 mL Visipaque RCM, with complete hemodynamic stability throughout the procedure. After angiography, our patient was stable, without signs of anaphylaxis, and was discharged home in good condition.