Anaphylaxis: Emergency Department Treatment

Epinephrine, Pregabalin, and Crizotinib as Three Medicines with Polish Implications over Three Last Centuries and in View of Three Different Drug Discovery Approaches

The discovery of epinephrine (adrenaline) and its subsequent implications in medicine owes significant contributions to Cybulski across different centuries, who, in 1894, was pivotal in identifying the adrenal medulla's role in blood pressure regulation and naming the active substance "nadnerczyna", known today as adrenaline. His work demonstrated the adrenal glands' critical function in the body's regulatory mechanisms beyond the nervous system. Cybulski's groundbreaking research laid foundational knowledge for future endocrinological studies and pharmaceutical advancements. In the late 20th century, Andruszkiewicz collaborated with Silverman at Northwestern University to develop pregabalin, the active ingredient in Lyrica. Their innovative synthesis of gamma-aminobutyric acid derivatives led to a significant advancement in treating epilepsy, neuropathic pain, and fibromyalgia. Andruszkiewicz's expertise in organic chemistry and enzymology was crucial in this collaborative effort, resulting in the successful development and commercialization of Lyrica. Additionally, Mroczkowski's leadership at Pfizer contributed to the development of crizotinib, a notable anaplastic lymphoma kinase and proto-oncogene 1 tyrosine-protein kinase inhibitor used to treat specific types of non-small cell lung cancer. Her work exemplifies the continuing influence of Polish researchers in pioneering drug discovery and advancing therapeutic treatments over the past three centuries. These contributions highlight Poland's significant role in global pharmaceutical innovations and medical research.

Anaphylaxis as an Unusual Cause of Shock in the Trauma Setting: A Case Report

Anaphylactic shock is the most severe form of an acute systemic allergic reaction and can be potentially lethal if left untreated. Here, we present the case of a 51-year-old male with no significant medical history, who arrived at our hospital's emergency trauma bay following a motor vehicle accident caused by a sudden onset of malaise while driving. Upon arrival, the patient's airway was patent, but he reported a sensation of a foreign body in his larynx. He also had an oxygen saturation of 88%, although no abnormal breath sounds were auscultated. The patient was also hypotensive and tachycardic, with no favorable response after crystalloid administration. He had no neurological alterations but was diaphoretic, with hives spreading across his trunk and all four extremities. Upon further interrogation, we identified that he had consumed diclofenac, a non-steroidal anti-inflammatory drug (NSAID), 45 minutes before the driving incident. Prompt recognition and management of the anaphylactic shock were initiated alongside the assessment and treatment of the traumatic injuries. This case highlights the importance of considering unusual causes of shock in trauma patients. It underscores the need for a comprehensive approach to patient care in trauma settings, where multiple etiologies of shock should be considered and managed simultaneously.

A Guide to the Use of Vasopressors and Inotropes for Patients in Shock

Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.

Alpha-Gal Syndrome: A Novel and Increasingly Common Cause of Anaphylaxis

The alpha-gal syndrome is a recently described cause of anaphylaxis to red meat that has been increasing in frequency over time. It is related to Lone Star tick bites in the United States and occurs in many other parts of the world. It is especially common in the southeastern United States. In addition to the usual symptoms of anaphylaxis, gastrointestinal symptoms are prominent. Another unusual feature is the delay of several hours between eating meat and the development of symptoms. Diagnosis can be made by a blood test for the immunoglobulin E antibodies to a specific oligosaccharide. As many as 10% of patients diagnosed with idiopathic anaphylaxis have alpha-gal syndrome in some parts of the United States. The only current treatment is a meat-free diet. Clinician awareness of alpha-gal syndrome is low, and because severe recurrent life-threatening episodes can occur, it is an important condition for emergency clinicians to be aware of.

Spirulina (Arthrospira platensis): Antiallergic Agent or Hidden Allergen? A Literature Review

Presently, there has been an increase in the consumption of the blue-green microalga-spirulina (Arthrospira species), which dominates 99.5% of the total world production of microalgae. Primarily sold as a dietary supplement, it is also incorporated into snacks, pasta, cookies, and bread. Owing to its nutrient abundance, spirulina has a variety of potential applications. Extensive studies have been conducted on the health benefits of spirulina, but its safety in terms of allergy has received limited attention. Therefore, to bridge this knowledge deficit, this review aimed to evaluate the allergenic and antiallergic potential of spirulina. In the PubMed and Scopus databases using words related to allergy, we attempted to detect papers on hypersensitivity to spirulina. A total of 128 records were identified, of which 49 were screened. Ultimately, in this review, we analyzed four case studies, encompassing a total of five patients with allergies to spirulina. We assessed the severity of allergic reactions following World Allergy Organization (WAO) Anaphylaxis Guidance 2020, which varied from mild (grade 2) to severe (grade 4) based on the patient's symptoms. Additionally, our findings indicate that allergy to spirulina is not commonly reported or diagnosed. However, most of the described cases (four of five) regarding allergy to spirulina according to WAO Anaphylaxis Guidance 2020 were classified as anaphylaxis. Furthermore, it is noteworthy that spirulina also possesses antiallergic properties, as evidenced by research studies. Our article delves into both the allergic and antiallergic potential of spirulina.

Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self

We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.

Mechanisms for hypothermia during anaphylactic hypotension in awake rats

Hypothermia develops during systemic anaphylaxis in rodents. The aim of this study was to elucidate the mechanism for the hypothermia by assessing the roles of locomotor activity, tail heat dissipation, heat production in the brown adipose tissue (BAT) activity, and chemical mediators during ovalbumin-induced anaphylactic hypotension in awake rats. We measured the core body temperature (Tcore) and mean blood pressure (MBP), along with the surface temperature of the interscapular region (TiScap), an indirect measure of BAT activity, and the tail (Ttail). During anaphylaxis, MBP decreased to the nadir of 53 ± 2 mmHg at 8 min with recovery toward baseline. Tcore began to decrease at 7.5 min with the nadir of 36.1 ± 0.2°C at 30 min from the baseline of 38.0 ± 0.1°C. TiScap also significantly decreased, but its onset was preceded by that of Tcore. Ttail decreased after antigen, suggesting the absence of increased heat dissipation from the tail. The physical activity, as evaluated by moved distances, did not decrease until 20 min after antigen, followed by a progressive decrease. Reduced movement using a restraint maneuver not only reduced Tcore in nonsensitized rats but also augmented the anaphylactic hypothermia in the early phase (1.5-18 min) in sensitized rats. Combined antagonism against platelet-activating factor (PAF) and histamine H1 receptors abolished antigen-induced hypotension but only attenuated hypothermia. In conclusion, decreased locomotor activity, but not tail heat dissipation or decreased BAT activity, may at least in part contribute to this hypothermia. PAF and histamine are involved mainly in hypotension but only partly in hypothermia during rat anaphylaxis.NEW & NOTEWORTHY Anaphylactic shock is a life-threatening systemic hypotension. Hypothermia is observed during systemic anaphylaxis of rats. We determined the mechanism as follows: decreased locomotor activity, but not tail heat dissipation or decreased BAT activity, may at least in part contribute to this hypothermia. PAF and histamine are involved mainly in hypotension, but only partly in hypothermia during rat anaphylaxis.

Mast Cells and Basophils in IgE-Independent Anaphylaxis

Anaphylaxis is a life-threatening or even fatal systemic hypersensitivity reaction. The incidence of anaphylaxis has risen at an alarming rate in the past decades in the majority of countries. Generally, the most common causes of severe or fatal anaphylaxis are medication, foods and Hymenoptera venoms. Anaphylactic reactions are characterized by the activation of mast cells and basophils and the release of mediators. These cells express a variety of receptors that enable them to respond to a wide range of stimulants. Most studies of anaphylaxis focus on IgE-dependent reactions. The mast cell has long been regarded as the main effector cell involved in IgE-mediated anaphylaxis. This paper reviews IgE-independent anaphylaxis, with special emphasis on mast cells, basophils, anaphylactic mediators, risk factors, triggers, and management.

Circulatory shock in adults in emergency department

Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.

The Utilization of Activated Charcoal in the Management of Anaphylaxis: A Case Series

Anaphylaxis is a sudden onset of systemic hypersensitivity caused by mast cell and basophil degranulation. Food, Hymenoptera venom, and drug allergy are among the leading causes of anaphylaxis, particularly in adults. We can consider anaphylaxis caused by swallowing food or medication as a form of poisoning. Because in anaphylaxis, just like in poisoning, an allergen entering the body poses a life-threatening risk. Therefore, the allergen should be removed from the digestive system immediately. However, the decontamination of the gastrointestinal tract is not routinely used to prevent further absorption of allergens from the intestine into the systemic circulation. Among the gastrointestinal decontamination methods is the use of activated charcoal. In this article, we present four patients who developed anaphylaxis due to drug and food intake and were administered oral activated charcoal after their primary treatment (on average, 15-45 minutes after the first presentation) was completed. The youngest of the patients was 22 years old, and the oldest was 40. No side effects, prolonged anaphylactic state, and biphasic reactions were observed in the follow-up of the patients. All patients were discharged after 48-72 hours of hospitalization. The routine approach to poisoning treatment includes patient stabilization, toxidrome recognition, antidote administration, and supportive care, as well as measures to enhance toxin elimination. In anaphylaxis caused by oral allergens, the substance that initiates the reaction can be compared to a kind of toxin. Eliminating the allergen and reducing its absorption could be achieved by administering activated charcoal. Activated charcoal should be considered adjunctive therapy in treating food and oral drug-induced anaphylaxis. This treatment, when administered in a timely manner, might prevent the development of biphasic reactions and the prolongation of the allergic process in anaphylaxis.

Current and Future Strategies for the Diagnosis and Treatment of the Alpha-Gal Syndrome (AGS)

The α-Gal syndrome (AGS) is a pathognomonic immunoglobulin E (IgE)-mediated delayed anaphylaxis in foods containing the oligosaccharide galactose-α-1,3-galactose (α-Gal) such as mammalian meat or dairy products. Clinical presentation of AGS can also comprise immediate hypersensitivity due to anticancer therapy, gelatin-containing vaccines or mammalian serum-based antivenom. The IgE initial sensitization is caused by hard-bodied tick bites and symptomatic individuals typically develop delayed pruritus, urticaria, angioedema, anaphylaxis, malaise or gut-related symptoms. Due to inapparent presentation, delayed reactions and a wide variety of patients´ clinical history, the AGS diagnosis and treatment remain challenging. This review covers not only current diagnostic methods used for AGS such as the skin prick test (SPT), the oral food challenge (OFC), anti-α-Gal IgE levels measurement and the basophil activation test (BAT), but also potentially relevant next-generation diagnostic tools like the mast cell activation test (MAT), the histamine-release (HR) assay, omics technologies and model-based reasoning (MBR). Moreover, it focuses on the therapeutical medical and non-medical methods available and current research methods that are being applied in order to elucidate the molecular, physiological and immune mechanisms underlying this allergic disorder. Lastly, future treatment and preventive tools are also discussed, being of utmost importance for the identification of tick salivary molecules, with or without α-Gal modifications, that trigger IgE sensitivity as they could be the key for further vaccine development. Bearing in mind climate change, the tick-host paradigm will shift towards an increasing number of AGS cases in new regions worldwide, which will pose new challenges for clinicians in the future.

Drug-Induced Mast Cell Eradication: A Novel Approach to Treat Mast Cell Activation Disorders?

Mast cell activation is a key event in allergic reactions, other inflammatory states, and mast cell activation syndromes. Mast cell-stabilizing agents, mediator-targeting drugs and drugs interfering with mediator effects are often prescribed in these patients. However, the clinical efficacy of these drugs varies, depending on the numbers of involved mast cells and the underlying pathology. One straightforward approach would be to eradicate the primary target cell. However, to date, no mast cell-eradicating treatment approach has been developed for patients suffering from mast cell activation disorders. Nevertheless, recent data suggest that long-term treatment with agents that effectively inhibit KIT-function results in the virtual eradication of tissue mast cells and a sustained decrease in serum tryptase levels. In many of these patients, mast cell depletion is associated with a substantial improvement in mediator-induced symptoms. In patients with an underlying KIT D816V+ mastocytosis, such mast cell eradication requires an effective inhibitor of KIT D816V, such as avapritinib. However, the use of KIT inhibitors must be balanced against potential side effects. We here discuss mast cell-eradicating strategies in various disease models, the feasibility of this approach, available clinical data, and future prospects for the use of KIT-targeting drugs in mast cell activation disorders.