Death in anaphylaxis in a man with house dust mite allergy

Anaphylactic deaths: A retrospective study of forensic autopsy cases from 2009 to 2019 in Shanghai, China

Anaphylaxis is a rare but well-known cause of sudden unexpected death, although data from forensic autopsies in anaphylactic deaths are limited. Herein, a retrospective study of a series of allergic deaths from 2009 through 2019 in Shanghai, China, was conducted to investigate the demographic, medical, and forensic pathological characteristics of fatal anaphylaxis to improve medicolegal understanding on anaphylactic death. Sixty-two autopsy cases of anaphylactic death were registered in this study. Males dominated the cases (74.2%) against females (25.8%), with an average age of 38.8 years. Medications (98.4%), particularly antibiotics (72.6%), were the most frequent cause of anaphylaxis, and 44 cases (71.0%) occurred in clinics administered illegally by unlicensed clinicians. The anaphylactic symptoms began within a few minutes to less than 1 h in 53 cases, with dyspnea (56.5%) and sudden shock (46.8%) being the most common clinical signs. Thirty cases (48.4%) of anaphylaxis resulted in death within 1 h. Laryngeal edema and multiple tissue eosinophil infiltration (85.5%) were the most prevalent autopsy findings, followed by pulmonary edema and congestion (24.2%), which were considered to be non-specific but suggestive. The comorbidities were mainly cardiovascular disease (33.9%), pneumonia (8.1%) and asthma (8.1%). Serum IgE were measured in 11 of 62 cases, ranging from 43.3 to 591 IU/ml, severed as a helpful marker. Therefore, we suggested a thorough analysis of allergen exposure, clinical history and autopsy findings is required for the diagnosis of anaphylactic death currently.

Fatal anaphylactic shock: A review of postmortem biomarkers and diagnostics

Diagnosing anaphylactic shock postmortem is challenging since differential diagnoses exist and the forensic pathologist often faces subtle findings and lacks relevant information which prevents reaching an opinion of certainty. This review provides an overview of the literature covering research and existing recommendations on the postmortem diagnosis of anaphylactic shock. In order to harmonize the approach and provide guidance for diagnosing deaths from anaphylactic shock in the six forensic centers in Sweden, a guidance protocol aligned with the notion of a holistic view in the approach was devised. Areas in need of further studies include both immunohistological and biochemical investigations to stratify quantitative approaches based on condition and anaphylactic trigger and to lay the ground for and possibly establish alternative matrices.

Oral mite anaphylaxis: who, when, and how?

PURPOSE OF REVIEW

To present an update on the recent advances in the understanding of the mechanisms and practical management of oral mite anaphylaxis (OMA, pancake syndrome).

RECENT FINDINGS

Among novel observations regarding OMA, this review highlights the increased prevalence of aspirin/NSAID hypersensitivity inpatients affected by OMA, the association of OMA with exercise-induced anaphylaxis, the presentation of OMA simulating acute asthma, the occurrence of OMA in childhood, the high severity and lethal potential of OMA, the contamination of other foods, such as oat and corn flour with mites, and the simultaneous induction of OMA symptoms in more than one individual exposed to the same food source.

SUMMARY

OMA is a severe, potentially lethal, acute allergic condition that should be suspected whenever symptoms begin soon after the intake of mite-contaminated foods. Physician awareness on this clinical picture is of paramount importance to establish a correct diagnosis and to implement adequate preventive measures to help patients at risk to avoid its occurrence.

Brazilian experience with atopy patch tests for Dermatophagoides pteronyssinus, Dermatophagoides farinae and Blomia tropicalis

Background

The aim of this study was to evaluate the positivity rates of atopy patch tests for Dermatophagoides pteronyssinus, Dermatophagoides farinae and Blomia tropicalis in patients with respiratory diseases such as asthma and allergic rhinitis with or without atopic dermatitis.

Methods

The patients’ clinical histories were collected, and the patients were subjected to skin prick and patch tests with the three different house dust mites on the same day. The patch tests were examined 48 hours later, and then patients were divided into two groups: I- patients with respiratory diseases, such as asthma and/or rhinitis, and atopic dermatitis and II-patients with only respiratory diseases. A total of 74 patients ranging in age from 2 to 60 years were included in this study; 16 patients were included in group I and 58 were included in group II. This study was approved by the human ethics committee of the Faculty of Medical Science and Health SUPREMA (number 2.007.135), and written informed consent was collected from each patient or their parents prior to enrollment.

Results

In the skin prick tests, the most prevalent mite that evoked a reaction was Dermatophagoides pteronyssinus, followed by Dermatophagoides farinae and Blomia tropicalis. Regarding the atopy patch tests, the mite that most frequently induced a positive reaction was Dermatophagoides farinae (78.4%), followed by Dermatophagoides pteronyssinus (77%) and Blomia tropicalis (52.7%). A comparison of the skin prick and atopy patch tests revealed that 53 patients (71.6%) were positive on both tests, and 30 (56.6%) patients were positivite for the same mite. We found six patients (8%) who had a positive clinical history of allergy and only exhibited positivity on the atopy patch test.

Discussion

Most studies have been performed with atopic dermatitis patients, but in this study, most of the patients had respiratory conditions. Blomia tropicalis is a mite that is prevalent in tropical areas, such as Brazil, and only two publications include these three mites, wich are present in Brazil. The APT may produce positive results in concordance with the SPT resuts, but may also be the only positive test ( 8%) as we observed in our study. These results suggest that the mite atopy patch test is relevant and should be considered as an additional test for patients with clinical histories of allergic respiratory disease who have negative prick test results.

Conclusion

The APT should be considered as an additional test when the SPT and specific serum IgE tests are negative in patients with clinical histories of allergies.

Health Hazards Associated with Arthropod Infestation of Stored Products

Insects and mites are common inhabitants and accidental invaders of food, including durable commodities, and their presence can have both direct and indirect effects on human health. The most common direct effect is contamination of food with arthropod fragments and related contaminants, which may be allergenic or even carcinogenic. The most important indirect effect is that their presence can change the storage microenvironment, making durable products suitable for the rapid development of fungi and other microorganisms. Some of these fungi can produce toxins (e.g., aflatoxins) that endanger human health. Insects may actively or passively contribute to the spread of microorganisms, increasing product contamination, and they may host bacteria that have developed antibiotic resistance, contributing to their spread in food. Several species also may host, attract, or transmit tapeworms, predators, or parasitoids that may affect health. This review synthesizes research on these topics and suggests directions for future research.

International consensus (ICON) on: clinical consequences of mite hypersensitivity, a global problem

Since mite allergens are the most relevant inducers of allergic diseases worldwide, resulting in significant morbidity and increased burden on health services, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), formed by the American Academy of Allergy, Asthma and Immunology (AAAAI), the American College of Allergy, Asthma and Immunology (ACAAI), the European Academy of Allergy and Clinical Immunology (EAACI), and the World Allergy Organization (WAO), has proposed to issue an International Consensus (ICON) on the clinical consequences of mite hypersensitivity. The objectives of this document are to highlight aspects of mite biology that are clinically relevant, to update the current knowledge on mite allergens, routes of sensitization, the genetics of IgE responses to mites, the epidemiologic aspects of mite hypersensitivity, the clinical pictures induced by mites, the diagnosis, specific immunotherapeutic approaches, and prevention.

Hidden allergens and oral mite anaphylaxis: the pancake syndrome revisited

PURPOSE OF REVIEW

To present currently available information on oral mite anaphylaxis.

RECENT FINDINGS

Oral mite anaphylaxis (pancake syndrome) is a new syndrome characterized by severe symptoms triggered by the intake of foods containing mites and their allergens. Breathlessness, face and/or laryngeal angioedema, wheezing, rhinorrhea, cough, dysphagia, and wheals are the most frequent clinical manifestations.

SUMMARY

Pancake syndrome can occur in individuals at any age and in any geographical location. Foods made with wheat and corn flour, especially pancakes, are the most common inducers of the clinical picture. Both, domestic and storage mites have been incriminated. Increased physician awareness is required for early diagnosis and treatment, and for the prevention of future episodes in predisposed individuals.

Fatal visit to the dentist

A 23-year-old woman was mortally afraid of dental interventions and decided to have her four wisdom teeth removed by outpatient surgery under endotracheal anaesthesia. According to the files, the patient was categorized as ASA I and Mallampati II, and surgery was considered an elective routine intervention. Soon after initiation of anaesthesia, O2 saturation and blood pressure dropped, and the young woman died shortly afterwards in spite of immediate resuscitation measures. At first, an allergic reaction to succinylcholine, which had been administered as a muscle relaxant, was suspected. Autopsy and histological examination showed haemorrhagic pulmonary oedema and a defined lesion in the midportion of the oesophageal mucosa in spite of correct placement of the endotracheal breathing tube. Ultimately, misintubation into the oesophagus, which had not been noticed at first, was determined as cause of death.

Pancake syndrome (oral mite anaphylaxis)

Oral mite anaphylaxis is a new syndrome characterized by severe allergic manifestations occurring in atopic patients shortly after the intake of foods made with mite-contaminated wheat flour. This clinical entity, observed more frequently in tropical/subtropical environments, is more often triggered by pancakes and for that reason it has been designated "pancake syndrome". Because cooked foods are able to induce the symptoms, it has been proposed that thermoresistant allergens are involved in its production. A novel variety of this syndrome occurs during physical exercise and therefore has been named dust mite ingestion-associated exercise-induced anaphylaxis. To prevent mite proliferation and the production of anaphylaxis, it has been recommended that wheat flour be stored at low temperatures in the refrigerator.

Anaphylaxis from ingestion of mites: pancake anaphylaxis

Oral mite anaphylaxis is a new syndrome characterized by severe allergic symptoms occurring immediately after eating foods made with mite-contaminated wheat flour. This syndrome, which is more prevalent in tropical environments, is triggered more often by pancakes, and for that reason, it has been designated "the pancake syndrome." Because cooked foods are able to induce the symptoms, it has been suggested that thermoresistant allergens are involved in its pathogenesis. A variety of this syndrome can occur during physical exercise (dust mite ingestion-associated exercise-induced anaphylaxis).

House dust mite-related allergic diseases: role of skin prick test, atopy patch test, and RAST in the diagnosis of different manifestations of allergy

The atopy patch test (APT) was recently defined as an important tool in diagnosis of atopic dermatitis (AD) and also of rhinitis and asthma caused by hypersensitivity to the house dust mites. We evaluated 465 children (279 males and 186 females) aged 0.4-17.6 years (mean 6.6 +/- 3.8 years), by dividing them into four groups: group A, current AD (40 patients); group B, current AD with respiratory symptoms (156 patients); group C, past AD with respiratory symptoms (203 patients); and the control group, respiratory symptoms with no history of AD (66 patients). The APT was significantly more frequently positive in groups with current AD (groups A and B) or past AD (group C) than in the control group, while skin prick test (SPT) and radioallergosorbent test (RAST) were significantly more frequently positive in the control group. With multivariate analysis, for APT, significant differences were found in the comparison between group A vs group B (odds ratio (OR) 1.55) and between group A vs group C (OR 1.81). The mean age was significantly lower in group A than in groups B, C, and the control group and with less significance in groups C vs D. Children sensitized to mites with current or past AD, with or without respiratory symptoms, have a different response to diagnostic tests, which is characterized by a highly significantly more frequent positive APT in comparison with subjects who have respiratory symptoms but a negative history for AD, who show the common response to SPT and RAST.

Astigmatid mites (Acari: Sarcoptiformes) of forensic interest

This paper reviews the occurrence of mites of the infraorder Astigmata in situations involving the legal system, particularly in the area of medicocriminal entomology. Species in the families Acaridae, Lardoglyphidae and Histiostomatidae are encountered in stored food products and in vertebrate carrion, including human remains. Some of these species are incidentals, whereas others are obligate necrophages. Phoretic associations between these mites and insects allows for rapid dispersal and colonization of such patchy resources.

The importance of starch and sucrose digestion in nutritive biology of synanthropic acaridid mites: alpha-amylases and alpha-glucosidases are suitable targets for inhibitor-based strategies of mite control

The adaptation of nine species of mites that infest stored products for starch utilization was tested by (1) enzymatic analysis using feces and whole mite extracts, (2) biotests, and (3) inhibition experiments. Acarus siro, Aleuroglyphus ovatus, and Tyroborus lini were associated with the starch-type substrates and maltose, with higher enzymatic activities observed in whole mite extracts. Lepidoglyphus destructor was associated with the same substrates but had higher activities in feces. Dermatophagoides farinae, Chortoglyphus arcuatus, and Caloglyphus redickorzevi were associated with sucrose. Tyrophagus putrescentiae and Carpoglyphus lactis had low or intermediate enzymatic activity on the tested substrates. Biotests on starch additive diets showed accelerated growth of species associated with the starch-type substrates. The inhibitor acarbose suppressed starch hydrolysis and growth of the mites. We suggest that the species with higher starch hydrolytic activity in feces were more tolerant to acarbose, and alpha-amylase and alpha-glucosidase of synanthropic mites are suitable targets for inhibitor-based strategies of mite control.

Mast cell tryptase in a case of anaphylaxis due to repeat antibiotic exposure

Mast cell tryptase can be an indicator of type I hypersensitivity reaction and thus may serve as a surrogate marker of anaphylaxis. A 34-year-old white male patient presented with a history of systemic lupus erythematosus. Shortly after administration of cefazolin for dialysis, he developed pruritus and shortness of breath. He expired an hour later. Autopsy excluded anatomic causes of death. There was an elevated postmortem mast cell tryptase level, 29.2 ng/mL. For mast cell tryptase level to be useful, the patient must survive long enough after exposure to an allergen for mast cells to release this enzyme. A credible allergen must be identified. In this case such, mast cell tryptase could establish anaphylaxis as the cause of death. The case suggests that in a patient with autoimmune disease, it may be prudent to test for immune reaction to a drug before administering it a second time via pinprick or other method.

Pancake syndrome (oral mite anaphylaxis)

Oral mite anaphylaxis is a new syndrome characterized by severe allergic manifestations occurring in atopic patients shortly after the intake of foods made with mite-contaminated wheat flour. This clinical entity, observed more frequently in tropical/subtropical environments, is more often triggered by pancakes and for that reason it has been designated "pancake syndrome". Because cooked foods are able to induce the symptoms, it has been proposed that thermoresistant allergens are involved in its production. A novel variety of this syndrome occurs during physical exercise and therefore has been named dust mite ingestion-associated exercise-induced anaphylaxis. To prevent mite proliferation and the production of anaphylaxis, it has been recommended that wheat flour be stored at low temperatures in the refrigerator.

An update on oral anaphylaxis from mite ingestion

OBJECTIVE

To review systemic reactions due to the oral ingestion of mites.

DATA SOURCES

We performed a MEDLINE search of peer-reviewed research articles published between 1993 and 2004 relevant to the subject of anaphylactic reactions to mite-contaminated foods.

STUDY SELECTION

Recent studies that emphasized the potentially life-threatening nature of anaphylactic reactions, responsible foodstuffs and mites, populations at risk, and pathogenesis were selected for inclusion in this review.

RESULTS

Although relatively few new cases of oral mite anaphylaxis are reported in the literature, we speculate that this clinical condition is occurring more frequently than realized in many geographic locations, and only the suspicion of an informed physician can contribute to its diagnosis and prevention. Oral anaphylaxis from mite-contaminated foods may be lethal if not promptly recognized and treated, and some preventive measures may be helpful for individuals at risk. Frequent cross-reactions among domestic, storage, and phytophagous mites explain the increased risk of oral mite anaphylaxis in sensitive patients living in both urban and rural areas. The enzymatic activity of some mite allergens contributes to the pathogenesis of this syndrome by means of mucosal damage and enhanced allergen absorption through the oral route.

CONCLUSIONS

Oral mite anaphylaxis is a severe, potentially lethal allergic condition that occurs in many countries and is frequently undiagnosed. Early recognition may lead to the implementation of simple prophylactic measures in at-risk populations of allergic patients.

Usefulness of serum mast cell-specific chymase levels for postmortem diagnosis of anaphylaxis

Chymase, a serine protease, is stored mainly in secretory granules of human mast cells. Serum chymase concentration was examined in 8 autopsy cases with anaphylaxis as well as in 104 control cases without anaphylaxis. It was detected in all 8 cases with anaphylaxis (range 3-380 ng/ml, mean 89.8 ng/ml), while it was detected in only 2 of the 104 controls and was below a detectable level (<3 ng/ml) in the other 102. Serum tryptase levels are known to be a diagnostic indicator of anaphylaxis, therefore the relationship between serum chymase and tryptase levels was investigated in the 8 cases of anaphylactic death; a significant positive correlation was found (r=0.826, p=0.011). Furthermore, chymase was shown to be quite stable in serum. These results showed that measurement of serum chymase levels might be an additional tool for postmortem diagnosis of anaphylaxis.

Black oesophagus: a rare disorder with potentially fatal outcome. A forensic pathological approach based on five autopsy cases

Black oesophagus is a rare pathological condition of unknown aetiology characterised by a full length, circumferential black discolouration of the entire oesophageal mucosa. The disease is sporadically encountered during upper gastrointestinal endoscopy. We used conventional histology, enzyme histochemistry and immunohistology to examine five autopsy cases (four males, one female; age range 43-86 years) of black oesophagus. On microscopical examination, the esophageal mucosa was entirely necrotic with demarcation by a leukocytic infiltrate in the upper submucosa. This infiltrate was dominated by neutrophilic granulocytes and scattered macrophages lacking haemosiderin deposits, placing the noxious mucosal injury in a time frame of approximately 24-72 h prior to death. Black oesophagus was established as the immediate cause of death in one case due to desanguination from the oesophagus and significantly contributed to the fatal outcome in a second case. Apart from a history of chronic alcohol consumption in four cases, no other pre-existing pathological or debilitating conditions could be established. The remarkably consistent pathomorphological picture of the disease seems to be the result of impaired microcirculation of the oesophageal mucosa due to prolonged hypotension of variable aetiology. The diagnosis of black oesophagus requires exclusion of other causes such as ingestion of caustic materials and should be based on histological examination.