Anaphylaxis

Anaphylaxis is an acute, rapidly progressive, potentially life-threatening systemic allergic reaction. Anaphylactic reactions were caused by an immunoglobulin E– (IgE-) mediated mechanism and anaphylactoid reactions were caused by non-IgE mediated mechanisms. More recently, definitions have changed. Anaphylactic reactions are caused by any immune-mediated mechanism (IgE, IgG, or immune complex), and nonallergic anaphylaxis refers to nonimmune-mediated reactions. Regardless of the mechanism, the reactions are indistinguishable. Clinically, patients typically present with varying degrees of dermatologic (e.g., hives), respiratory (e.g., wheezing), gastrointestinal (e.g., vomiting), and circulatory (e.g., hypotension) manifestations. Reactions can range from mild to severe and may be fatal. The most common causes of anaphylaxis in the pediatric population include foods, drugs, venom, and latex.

ETIOLOGY AND PATHOGENESIS

IgE-mediated anaphylaxis, a type I hypersensitivity reaction, is the most understood form of anaphylaxis . A person is exposed to an antigen, and upon reexposure, crosslinkage of IgE occurs followed by an immediate release of potent mediators from tissue mast cells and peripheral basophils. These mediators include histamine, leukotrienes, nitric oxide, and neutral proteases, which all lead to vasodilatation, increased vascular permeability, bronchoconstriction, and additional inflammation. At times, the reaction occurs with the first known exposure. Other mechanisms include direct stimulation of mast cells and basophils, as is observed with morphine and exercise- and cold-induced anaphylaxis. Blood products and radiocontrast media may lead to activation of complement and subsequent reactions. Anaphylaxis to aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) may result from the interference of the arachidonic acid pathway. Other agents may act through one or more of the above mechanisms. The most common IgE-mediated reactions occur with food, drugs, venom, and latex. The leading cause of anaphylaxis in children is food. In the United States, the most common foods implicated in anaphylactic reactions include milk, eggs, soy, wheat, peanuts, tree nuts, and fish (although almost any food can cause a reaction). Children often develop tolerance and outgrow reactions to milk, egg, soy, and wheat; this is less likely to occur with peanuts, tree nuts, and fish. Drug allergy is another common cause of IgE-mediated anaphylaxis, with penicillin and other β-lactam antibiotics being the most commonly implicated agents. Other medications, such as aspirin and NSAIDs, may also lead to reactions. Fire ants and hymenoptera (e.g., honey bees, yellow jackets, hornets, and wasps) are common causes of anaphylaxis in both children and adults. Children with spina bifida and health care workers are at higher risk for latex allergy. Although latex allergy had been on the rise, current use of latex precautions, latex-free gloves, and health care provider awareness have stabilized the incidence of latex reactions. There is also an entity known as exercise-induced anaphylaxis. Three groups of patients present with anaphylaxis after exercising: some of whom have known specific food triggers, others in whom any food ingestion may lead to symptoms, and a third group in which there is no known food trigger. Those with a food trigger have symptoms when they exercise within 4 hours of a meal. Other causes of anaphylaxis include immunizations, radio contrast material, blood products, allergy immunotherapy, and those that remain unknown (idiopathic).

Type 1 hypersensitivity reaction

CLINICAL PRESENTATION

Patients with anaphylaxis may have different clinical manifestations . Anaphylaxis is often underdiagnosed or misdiagnosed because of clinicians’ failure to recognize symptoms. There has been a recent attempt to standardize the diagnostic criteria to help clinicians to better recognize anaphylaxis . Approximately 90% of children with allergic reactions have skin manifestations, which include hives, angioedema, pruritus, or flushing. Although the remainder may not have skin involvement, they are still having a reaction, and that reaction may be more severe than those that occur with skin findings present. Tongue and throat swelling, dysphagia, and choking are manifestations of upper airway edema. Lower respiratory tract symptoms, such as coughing and wheezing, are the next most common symptoms. Vomiting, diarrhea, and abdominal pain are often seen, especially in food-induced anaphylaxis. Cardiovascular manifestations include tachycardia, hypotension, shock, and (rarely) bradycardia. Children may also be lethargic, and some have described a “feeling of impending doom.” Symptoms can develop within minutes of exposure, although most occur within 30 minutes to 1 hour. Most anaphylactic reactions are uniphasic in which the patient has a reaction, is treated, and improves. A biphasic response may also occur in which a patient becomes asymptomatic after the initial reaction and then develops a second reaction that may be the same or more severe than the initial reaction. Protracted anaphylaxis has also been described in which patients have symptoms that persist for days. Both biphasic and protracted reactions seem to occur less frequently in the pediatric population.

Differential Diagnosis Given the involvement of multiple organ systems in anaphylaxis, many other life-threatening diagnoses can present similarly . Vocal cord dysfunction presents with inspiratory stridor and coughing. Wheezing and stridor are also signs of an airway foreign body, croup, bronchiolitis, or an asthma exacerbation. Patients complaining of oral pruritus after food ingestion may have an oral allergy. This is typically self-limited and does not progress to anaphylaxis. Circulatory failure in the form of hypotension, tachycardia, and poor peripheral perfusion may be indicative of a systemic inflammatory response or shock . Vasovagal reactions usually present with history of syncope (see Chapter 48). Although urticaria can be an early sign of anaphylaxis, it also is an isolated local cutaneous reaction or may be associated with underlying infection . Flushing may occur after ingestion of particular food products, including additives such as monosodium glutamate (MSG) and sulfites, which are found in smoked foods and preservatives. “Red man syndrome” occurs with the use of vancomycin, presents with f lushing, and typically resolves with termination of the infusion. Other diagnoses that present with multisystemic involvement include panic attacks, capillary leak syndrome, hereditary angioedema, and systemic mastocytosis. A good history will help distinguish these diagnoses from anaphylactic reactions.

Sign and symptoms of anaphylactic reactions

EVALUATION

The diagnosis and treatment of anaphylaxis are based on history of event, clinical manifestations, and examination. No diagnostic tests are available that will help to guide management in the immediate setting. However, some diagnostic tests such as serum histamine, urinary histamine, and serum tryptase can be helpful after the acute event (Table 18-3). If performed judiciously and expeditiously, these values can prove useful in supporting the clinical diagnosis of anaphylaxis. Serum histamine levels can be drawn if a patient presents within 1 hour of reaction. β-Tryptase levels are often recommended because they peak 60 to 90 minutes after an anaphylactic reaction and may remain elevated for 6 hours. Positive results are helpful, but a patient may still have had an anaphylactic reaction if results are negative. After someone has a reaction, the cause is then pursued. Often, referral to a specialist is recommended. Knowledge of positive and negative predictive values and sensitivity and specificity of various tests is important. False-positive and false-negative testing can occur; therefore, specific skin prick testing and cap radioallergosorbent testing (RAST) is often useful to confirm one’s suspicion . Of note, intradermal testing should never be used for food allergy testing. Intradermal tests are performed for allergies to pollens. The authors do not recommend broad panels of testing; however, if there is a suspicion for a specific food, then the clinician should test accordingly.

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