2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines

Low-dose oral cow's milk challenge outcome for patients on complete avoidance: A multicenter study in Japan

BACKGROUND

Few studies have reported significant risk factors for allergic symptoms during low-dose (1-3 mL) cow's milk (CM) oral food challenges (OFCs). We investigated patients from multiple centers in Japan to identify high-risk, low-dose CM OFCs and conducted these tests at allergy-specialized facilities.

METHODS

We retrospectively collected the results of the first low-dose CM OFCs performed at 10 hospitals in Japan between January and December 2019. All patients completely eliminated CM and underwent low-dose CM OFCs. The risk factors for positive OFC and anaphylaxis were analyzed using logistic regression analyses.

RESULTS

We included 244 patients (median age: 2.5 years). The median level of CM-specific immunoglobulin E (sIgE) was 13.1 (interquartile range: 3.7-45.6) kUA/L. The rates of positive and anaphylaxis among positive for CM OFCs were 44% and 19%, respectively. Multivariate analyses that separately analyzed each sIgE identified high CM sIgE and casein sIgE levels as significant risk factors for OFC positivity (both p < .001). The optimal cut-off values for CM and casein sIgE levels to predict positive CM OFCs from receiver operating characteristic curves were 5.4 and 7.3 kUA/L, respectively. When CM sIgE or casein sIgE levels were ≥10.9 kUA/L or ≥ 11.5 kUA/L, they corresponded to 5% predicted probabilities of anaphylaxis. Furthermore, when their levels are ≥100 kUA/L, the predicted probabilities increase to 20%.

CONCLUSION

CM and casein sIgE levels should be considered when predicting low-dose CM OFC outcomes.

Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement from the American College of Radiology and the American Academy of Allergy, Asthma & Immunology

Intravenous iodinated contrast media (ICM) is widely used in the United States, and it is imperative to provide guidance on the management of adverse reactions to ICM as well as the preparation, planning, and potential premedication for patients with previous reactions. Currently there is a discordance between the American College of Radiology Contrast Manual, which recommends premedication to prevent repeat hypersensitivity reactions to ICM, and the Anaphylaxis 2020 Practice Parameters Update, which recommends against routine administration of glucocorticoids and/or antihistamines to prevent anaphylaxis with prior ICM hypersensitivity reactions. A task force of experts from radiology who are also members of the American College of Radiology Committee on Drugs and Contrast Media and expert allergists/immunologists including members of the Adverse Reactions to Drugs, Biologics and Latex Committee of American Academy of Allergy, Asthma & Immunology evaluated the scientific evidence to develop consensus recommendations that are endorsed by both organizations. The task force took into account the strength of evidence and balanced the potential risks of recurrent reactions with those of premedication and product avoidance when making these recommendations to improve and standardize the care of patients who experience or have a history of reaction to ICM. © Radiological Society of North America and American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc on behalf of American Academy of Allergy, Asthma & Immunology and by Radiological Society of North America. All rights are reserved, including those for text and data mining, AI training, and similar technologies. This paper was jointly developed by The Journal of Allergy and Clinical Immunology: In Practice, Radiology and jointly published by Elsevier Inc and Radiological Society of North America. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article. Keywords: Contrast allergy, Contrast hypersensitivity, Iodinated contrast allergy, Iodinated contrast hypersensitivity, Anaphylaxis, Contrast skin testing, Contrast switching, Contrast reaction, Delayed contrast reaction, Immediate contrast reaction.

Prevalence of food and inhalant allergies in infants and children from the Nanhai area of Foshan city

BACKGROUND

The aim of our research was to explore the distribution characteristics of the most common food and inhalant allergens in children from Foshan city in Southwest China to provide evidence for the development of prevention and treatment strategies for allergic diseases in children.

METHODS

A total of 635 children who attended the Sixth Affiliated Hospital, South China University of Technology, were included in our retrospective study from February 2013 to October 2019. The sensitivity of immunoglobulin E (IgE) for 20 allergens (10 inhalant allergens and 10 food allergens) was determined. Statistical analysis was performed to analyze differences in the percentage of allergens among individuals according to sex, age and season.

RESULTS

Of the 635 patients, 200 tested positive for allergies. Dust mites were the most common inhalant allergens, followed by dog hair. The highest percentage of positive house dust mite sensitization was in the summer. Among the food allergens, individuals most frequently tested positive for wheat and milk allergies. The percentage of individuals with milk and egg allergies decreased with increasing age.

CONCLUSION

The most common allergens found in children from Foshan were dust mites, dog hair, wheat, tree nuts (hazelnut and pistachio), milk and peanuts. The results obtained could be helpful in determining the etiology of allergic diseases.

Exploring the anti-anaphylaxis potential of natural products: A Review

Allergies are a common health issue affecting many people around the world, especially in developed countries. They occur when the immune system overreacts to substances that are usually harmless. Some common allergic conditions include asthma, sinus infections, skin rashes, food allergies, hay fever, severe allergic reactions, eczema, swelling, and reactions to medications or insect stings. The causes of these allergies are complex and often linked to genetics, which can lead to heightened immune responses known as atopy. Throughout history, plant extracts have been used for various purposes, including medicine and food. In addition, their bioactive compounds show a wide range of beneficial effects, such as reducing allergic reactions, fighting oxidative stress, mast cell stabilizers, and lowering inflammation, highlighting their potential for treating various health conditions. Flavonoids and phenolic compounds are commonly used in anaphylaxis for their potent anti-inflammatory action. This review aims to promote the use of natural products as potential treatments for anaphylaxis. In addition, the discovery of new drugs derived from natural sources holds significant promise for the management of anaphylaxis.

Management and Prevention of Hypersensitivity Reactions to Radiocontrast Media: A Consensus Statement From the American College of Radiology and the AAAAI

Intravenous iodinated contrast media (ICM) is widely used in the United States, and it is imperative to provide guidance on the management of adverse reactions to ICM as well as the preparation, planning, and potential premedication for patients with previous reactions. Currently there is a discordance between the American College of Radiology Contrast Manual, which recommends premedication to prevent repeat hypersensitivity reactions to ICM, and the Anaphylaxis 2020 Practice Parameters Update, which recommends against routine administration of glucocorticoids and/or antihistamines to prevent anaphylaxis with prior ICM hypersensitivity reactions. A task force of experts from radiology who are also members of the American College of Radiology Committee on Drugs and Contrast Media and expert allergists/immunologists including members of the Adverse Reactions to Drugs, Biologics and Latex Committee of American Academy of Allergy, Asthma & Immunology evaluated the scientific evidence to develop consensus recommendations that are endorsed by both organizations. The task force took into account the strength of evidence and balanced the potential risks of recurrent reactions with those of premedication and product avoidance when making these recommendations to improve and standardize the care of patients who experience or have a history of reaction to ICM.

Omega-5-Gliadin Allergy and Cofactors Leading to Anaphylaxis: A Case Report

Anaphylaxis, a potentially life-threatening systemic reaction, is an increasingly common reason for emergency department (ED) admissions, which often poses diagnostic challenges. We present a case of a 62-year-old man who had recurrent anaphylaxis, initially suspected to be triggered by non-steroidal anti-inflammatory drugs (NSAIDs). By conducting thorough history-taking and comprehensive allergy testing, we identified allergic sensitization to the omega-5-gliadin (O5G) component of gluten, which manifested only when wheat consumption was accompanied by specific factors, notably exercise or NSAID use. He was diagnosed eight years after the first anaphylactic episode with wheat-dependent exercise-induced anaphylaxis (WDEIA). Adherence to a gluten-free diet effectively prevented further episodes. This case underscores the importance of emergency physicians not only in treating anaphylaxis but also in recognizing rare diagnoses, such as cofactor-enhanced food-induced allergic reactions, and understanding their management. This awareness is critical not only for conducting comprehensive assessments in collaboration with allergy specialists but also for facilitating earlier diagnosis, educating patients about the use of epinephrine auto-injectors, and emphasizing essential avoidance measures to prevent the recurrence of anaphylaxis.

Anaphylaxis-Associated Cerebral Infarction: A Case Report

Anaphylaxis is a severe, potentially life-threatening allergic reaction that primarily affects the respiratory and cardiovascular systems. While neurological complications are rare, cerebral infarction may occur due to anaphylaxis-induced hypoperfusion, endothelial dysfunction, and a hypercoagulable state. The mechanisms underlying this association remain poorly understood, and reports of anaphylaxis-related stroke are scarce. A 75-year-old man with a history of diabetes mellitus and hypertension developed respiratory distress and loss of consciousness shortly after a bee sting. He was diagnosed with anaphylactic shock and treated with adrenaline, glucagon, and aggressive fluid therapy. Despite hemodynamic stabilization, he developed persistent left-dominant quadriplegia. Magnetic resonance imaging (MRI) revealed acute ischemic stroke confined to the cortical branches of the middle cerebral artery (MCA) bilaterally, with restricted diffusion on diffusion-weighted imaging (DWI) and decreased apparent diffusion coefficient (ADC) values. Magnetic resonance angiography demonstrated a signal void in the right MCA and stenosis of the left MCA. Perfusion-weighted imaging using time-to-maximum maps indicated prolonged transit time in the infarcted regions, which closely corresponded to the DWI lesions, suggesting that most of the hypoperfused tissue had already progressed to irreversible infarction. Given the extensive infarction and high risk of hemorrhagic transformation, single antiplatelet therapy was selected for secondary stroke prevention. While his neurological symptoms partially improved, he remained functionally dependent at discharge. Cerebral infarction is a rare but serious complication of anaphylaxis, especially in patients with underlying cerebrovascular risk factors. Early recognition of neurological deficits, prompt neuroimaging, and comprehensive hemodynamic stabilization are crucial in preventing irreversible brain ischemia. The underlying pathophysiology is thought to involve multiple mechanisms, including systemic hypotension, mast cell degranulation-induced endothelial dysfunction, transient or persistent cerebral vasoconstriction, and a hypercoagulable state triggered by inflammatory mediators. Considering the etiology of anaphylaxis-associated ischemic stroke is critical for guiding appropriate management strategies. This case highlights the importance of a multidisciplinary approach in managing anaphylaxis-related stroke. Further studies are warranted to clarify the pathophysiological mechanisms and develop tailored therapeutic strategies for this rare but severe condition.

Allergen immunotherapy and dupilumab in atopic dermatitis: Clinical efficacy and disparities in immunological indicators

Objective

Allergen immunotherapy (AIT) and dupilumab have been confirmed to improve symptoms of atopic dermatitis (AD); however, the precise immune mechanisms underlying their efficacy and whether they can elicit synergistic immune effects remain not fully elucidated. We aimed to investigate the clinical efficacy and immunological changes in AD patients undergoing AIT, dupilumab, and a combination of AIT and dupilumab treatment.

Methods

Clinical data, serum samples, and peripheral blood mononuclear cells (PBMC) were collected from house dust mite (HDM)-sensitized AD patients receiving AIT and/or dupilumab at baseline and 6 months. Changes in clinical efficacy, HDM-specific IgE and IgG4, serum cytokines, and lymphocyte subgroups were compared among the treatment groups.

Results

A total of 77 AD patients were included, with 39 in the AIT group, 19 in the dupilumab group, and 19 in the AIT combined dupilumab group. The SCORAD scores significantly improved in all groups after 6 months. Levels of HDM-specific IgE and total IgE remained stable in the AIT group but decreased in the dupilumab and combination groups. Levels of IgG4 against major mite components Der p1 and Der p23 increased in the AIT group and combined treatment group. Serum cytokine levels showed no significant changes, except for a decrease in CCL17 in the dupilumab group. Th1/Th2 and Th17/Th2 ratios increased after dupilumab treatment. There were notable differences in T cell subpopulations when PBMCs were stimulated with HDM extracts after 6-month treatment, tSNE analysis showed the proportion of IL-4+IL-13+CRTH2+T cells increased in the dupilumab group but had no changes in the AIT and combination group.

Conclusions

AIT, dupilumab, and their combination improved clinical symptoms and quality of life in AD patients. AIT promoted allergen-specific IgG4 production, while dupilumab modulated T cell responses and reduced allergen-specific IgE synthesis. The combination of AIT and dupilumab exhibited the immunological parameter changes characteristic of both treatments but did not result in a significantly greater improvement in AD symptoms.

Assessing the safety and adverse effects of paracetamol, ibuprofen, and their combination in paediatric pain and fever management: A prospective observational study

Purpose

Pain and fever are common paediatric complaints that demand meticulous symptom alleviation to ensure the child's holistic well-being. Paracetamol, ibuprofen, and their synergistic coadministration occupy a crucial position, rendering the management of these symptoms efficacious. This study aims to evaluate the safety and adverse effects of paracetamol, ibuprofen, and their combination comprehensively.

Methods

A prospective observational study was conducted at the Department of Paediatrics, Bombay Hospital Institute of Medical Sciences, Mumbai, India. 108 paediatric patients aged 6 months to 18 years experiencing fever, pain, or both. Patients were assigned to receive one of the three medications and were randomized into one of the three groups: paracetamol, ibuprofen, or a combination. Baseline and 48-hour assessments included vital signs, adverse effects, and biochemical markers including SGOT, SGPT, serum creatinine, platelet count, and occult blood in stool samples.

Results

Paracetamol, ibuprofen, and their combination were found to be equally effective in relieving symptoms associated with fever and pain. The most common adverse effect observed was vomiting, with minimal occurrences of rash, cough, and diarrhoea. Biochemical markers, including SGOT, SGPT, serum creatinine, platelet count, and occult blood in stool samples, remained within normal ranges after 48 h of drug administration.

Conclusion

This study affirms the safety of paracetamol, ibuprofen, and their combination for paediatric pain and fever management. Minimal adverse effects and the absence of significant biochemical derangements support their favourable risk-benefit profiles, emphasizing their importance in paediatric clinical practice.

Clinical characteristics, management, diagnostic findings, and various etiologies of patients with Kounis syndrome. A systematic review

BACKGROUND

Kounis syndrome (KS) is defined by the association of acute coronary syndrome secondary to an anaphylactic reaction. KS is often underdiagnosed, and new etiologies have been proposed.

AIMS

To synthesize the available evidence on clinical profile, management, diagnosis, and etiologies in patients with KS.

METHODS

A search was conducted in the following databases: PubMed, Scopus, EMBASE and Web of Science from inception to March 19th, 2024. Case reports, case series, and observational studies were included. Letters to the editor, editorials, comments, notes, narrative reviews, and systematic reviews were excluded.

RESULTS

A total of 190 studies were included (174 case reports, 13 case series, and 3 observational studies, 214 patients). A predominance of male gender was observed (69.63 %). Mean age was 54.4 ± 16.5 years. The most common comorbidities were hypertension (33.64 %), diabetes (16.82 %), and dyslipidemia (16.35 %). The most frequent clinical manifestations were chest pain (66.35 %) and difficulty breathing (34.11 %). Three variants of KS were identified: type I or allergic coronary vasospasm was the most frequent (43.46 %), and type III, the least common (8.88 %). The most frequent etiology was drug use (38.32 %), primarily antibiotics (42.68 %), followed by animal stings or bites (26.17 %). The calculated KS rate was 11.12 per 1000 people. The mortality rate was 7.47 %, and the majority had a favorable outcome (86.92 %) after management.

CONCLUSIONS

KS is a complex and underdiagnosed disease that should be considered as a differential diagnosis in acute coronary syndrome associated with an allergic reaction.

Anaphylaxis

Anaphylaxis is an acute, potentially fatal systemic hypersensitivity reaction with varied mechanisms and clinical presentations. Although prompt recognition and treatment of anaphylaxis are imperative, both patients and healthcare professionals often fail to recognize and diagnose its early signs. Clinical manifestations vary widely, however, the most common signs are cutaneous symptoms, including urticaria and angioedema. Immediate intramuscular administration of epinephrine into the anterolateral thigh is first-line therapy, and is always safe even if the diagnosis is uncertain. The mainstays of long-term management include specialist assessment, allergen avoidance measures, and the provision of an epinephrine auto-injector with an individualized anaphylaxis emergency plan. This article provides an overview of the causes, clinical features, diagnosis, and acute as well as long-term management of anaphylaxis.

Potential Antiallergic Activity of Two Chemically/Enzymatically-Modified Natural Products Against Active Atopic and Systemic Anaphylaxes in CD1 Mice Models

INTRODUCTION

Anaphylaxis is a globally increasing allergic reaction that is often fatal. Recently, our previous study reported the possibility of using the modified natural products "sodium R-lipoate (NaRLA) and enzymatically modified isoquercitrin (EMIQ)" as potential novel safe agents against the non-immunological-degranulation of mast cells.

METHODS

Here, we extended our previous findings by determining the antianaphylactic activity of 50 and 100 mg/kg body weight of NaRLA and EMIQ (given orally and prior to local or systemic challenge) in mice models of ovalbumin (OVA)-induced IgE-dependent active cutaneous anaphylaxis (ACA) and active systemic anaphylaxis (ASA) in comparison with sulfasalazine (SSZ, amast cell stabilizer).

RESULTS

The pre-treatment of mice with NaRLA or EMIQ completely succeeded, as SSZ, in suppression of the increased vascular permeability associated with IgE-dependent ACA and protected the OVA-sensitized mice from fatal ASA by reducing (p < .001) the skin mast cell degranulation, the elevated peritoneal histamine and interleukin-4 levels, along with decreasing the associated sever gastrointestinal and lung histopathological alterations and inflammation. The high dose of EMIQ prevented death in 70% of mice with anaphylactic shock, better than SSZ.

DISCUSSION

Our data indicated that NaRLA and EMIQ may be potential prophylactic and therapeutic candidates for the alleviation of atopic and systemic anaphylaxis.

Successful management of anaphylactic shock prior to elective cesarean delivery: a case report

BACKGROUND

Anaphylactic cardiovascular collapse is complicated by aortocaval compression during pregnancy, exacerbated by neuraxial anesthesia. Despite recommendations to administer perioperative antibiotics before anesthesia, common practice in Japan involves administering them after anesthesia induction. We report a case of possible antibiotics-induced anaphylaxis just before anesthesia for cesarean delivery.

CASE PRESENTATION

A 24-year-old woman at 37 weeks of gestation presented for a scheduled repeat cesarean under spinal anesthesia. After starting administration of cefazolin prior to anesthesia, she developed anaphylactic symptoms. Hypotension refractory to adrenaline necessitated conversion to an emergency cesarean section under general anesthesia. A neonate was delivered with favorable Apgar scores. Post-delivery, the mother's hemodynamics stabilized significantly. Elevated plasma tryptase confirmed anaphylaxis. Both mother and infant were discharged without further complications.

CONCLUSIONS

This case emphasizes the importance of administering prophylactic antibiotic before anesthesia in mitigating severity of shock induced by anaphylaxis and the crucial role of prompt emergency cesarean in achieving successful outcomes.

Profile of cross-reactivity to common pollen allergens in Northwest China based on component resolved diagnosis

The prevalence of allergic diseases such as Allergic Rhinitis and Asthma is steadily increasing globally, with pollen allergy being one of the most significant sensitizing factors. However, the cross-reactivity of different pollen allergies remains unclear, posing challenges in the diagnosis and treatment of individuals with multiple sensitivities. In this study, the Component Resolved Diagnosis technique was performed to simultaneously measure the specific IgE concentrations of 52 patients against Art v and its components (Art v 1), Phl p and its components (Phl p 1, Phl p 4, Phl p 5, Phl p 6, Phl p 7, Phl p 12), Bet v and its components (Bet v 1, Bet v 2), Amb a and its component (Amb a 1), and Amb p. Additionally, sIgE inhibition tests were conducted by Art v, Phl p, and Bet v extracts. Among Art v-positive patients, 64.6% showed positivity for Art v 1. In Phl p-positive patients, Phl p 12 had the highest positivity rate (75.0%). Among Bet v-positive patients, 75.6% exhibited positivity for Bet v 2, whereas for Amb a and Amb p-positive patients, 23.7% and 29.0% respectively showed positivity for Amb a 1. The sIgE inhibition assays results revealed that Art v extract had inhibition rates greater than 73.2% against Phl p and its component Phl p 12, as well as Bet v and its component Bet v 2. Simultaneously, Phl p extract showed inhibition rates of 80.70-89.87% against Phl p 12, Bet v and Bet v 2. Bet v extract showed inhibition rates ranging from 21.9 to 59.8% against Phl p and Bet v 2, with a better inhibition rate (76.80%) against Phl p 12. In conclusion, Art v 1 is identified as the principal component of Art v. The profilin proteins of Phl p and Bet v (Phl p 12 and Bet v 2), are implicated as potential cross-reactive elements contributing to polysensitization in patients with respiratory allergies in the Northwest region of China. This cross-reactivity leads to a shared sensitization mechanism among pollen allergens such as Art v, Phl p, and Bet v.

Perioperative Anaphylaxis in Japanese Secondary Care Institutions: Incidence, Causes, and the Imperative for Improved Diagnostic Practices

Background This research investigates the incidence, suspected causes, and diagnostic procedures for perioperative anaphylaxis (POA), a potentially severe complication, in secondary care hospitals across Japan. Methodology We surveyed Saiseikai hospitals and gathered data on surgical procedures, POA occurrences, potential triggers, and diagnostic methods. Results Among 70,523 surgeries, seven were associated with POA, resulting in an approximate incidence rate of 0.01%. Rocuronium was the most commonly suspected trigger, followed by sugammadex, latex, and angiography contrast agents. Despite the importance of skin tests as the most basic and crucial diagnostic method, they were conducted in only three instances. No in vitro tests for drug identification were conducted, and in four cases, the cause was determined merely based on the timing of drug administration, indicating significant diagnostic limitations. Conclusions The study underscores the critical situation in Japan regarding insufficient diagnostic practices and difficulties in identifying triggering drugs rather than the consistent prevalence of POA in secondary care facilities. The findings emphasize the need for improved diagnostic proficiency and more rigorous drug identification practices to ensure prompt and accurate POA diagnosis. It is essential to conduct further research and interventions to increase patient safety during the perioperative period in secondary care settings.

Food Allergy Reaction Severity and Management in a Diverse Population

BACKGROUND

Definitive treatment for food allergy reactions including anaphylaxis varies widely by reaction severity and socioeconomic status, but little data exist to characterize the relationship between severity, management, and race and ethnicity.

OBJECTIVE

To analyze the differences in reaction severity, epinephrine use, and emergency room (ER) use by race and ethnicity in a large, diverse, food-allergic cohort.

METHODS

We analyzed intake data from participants in the Food Allergy Outcomes Related to White and African-American Racial Differences cohort on the history of food allergy reactions, severity of the reactions, and management associated with each reaction. We used descriptive statistics as well as mixed-effects logistic and Poisson models to describe the differences in reaction severity, ER visits, and total lifetime epinephrine use by race and ethnicity.

RESULTS

A total of 784 children were included in the analysis: 425 (54.2%) were non-Hispanic White, 282 (36.0%) were non-Hispanic Black, and 77 (9.8%) were Hispanic/Latino. Non-Hispanic Black children had increased odds of more severe reactions (odds ratio, 1.7; 95% CI, 1.2-2.3) and higher odds of going to the ER (odds ratio, 2.8; 95% CI, 1.4-5.4). Both non-Hispanic Black (incidence rate ratio, 0.4; 95% CI, 0.3-0.5) and Hispanic/Latino (incidence rate ratio, 0.3; 95% CI, 0.2-0.5) children had lower rates of total lifetime epinephrine use.

CONCLUSIONS

There are significant disparities in the severity and treatment of food allergy reactions by race and ethnicity, resulting in increased ER use and decreased total lifetime epinephrine use. Equipping parents with resources and tools on management of food allergy reactions may result in decreased disparity in access to definitive care.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Factors Associated With Epinephrine Use in the Treatment of Anaphylaxis in Infants and Toddlers

BACKGROUND

Undertreatment of anaphylaxis with epinephrine continues to be an unmet need and is a particular challenge among infants and toddlers.

OBJECTIVE

To address this gap by identifying barriers and solutions to appropriate and timely administration of epinephrine.

METHODS

We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when younger than 36 months. Outcomes of interest included epinephrine use in community and health care settings to treat probable anaphylaxis.

RESULTS

Of 264 probable anaphylaxis cases, 39% of infants (aged <12 months) and 61% of toddlers (aged 12-35 months) received epinephrine at any time during the child's most severe allergic reaction (P = .001). A previous diagnosis of a food allergy was reported in 62% of cases where epinephrine was used compared with 26% of cases where epinephrine was not used (P < .001). In children with a previous diagnosis of a food allergy, epinephrine was used in 89% of those who were prescribed an anaphylaxis action plan compared with 50% of those without a plan (P = .001). The adjusted odds ratio for the association between having an anaphylaxis action plan and epinephrine use in cases of probable anaphylaxis was 5.39 (95% confidence interval, 2.18-13.30).

CONCLUSIONS

Epinephrine use at any time (including in health care settings) during probable anaphylaxis is more likely in infants and toddlers with a previously diagnosed food allergy than those without diagnosis. The provision of an anaphylaxis action plan is also associated with increased epinephrine use during probable anaphylaxis in this population.

Relation of Streptococcus Pyogenes tonsillitis isolate to antimicrobial agents and its infection treatment

We reported the case of tonsillitis treatment in a 17-years-old boy with use of chemical non-antibiotic preparations, plant derived products and antibiotic benzathine phenoxymethylpenicillin. The antimicrobial agents for treatment were selected on the basis of their activity against a disease agent, the group A β-hemolytic strain Streptococcus pyogenes BS1 isolated from a patient. The bacterium was susceptible in vitro to β-lactams, with largest zones conditioned by penicillin G and benzathine phenoxymethylpenicillin discs, to fluoroquinolones and to cephems, with exception of cefazolin. Lincosamide clindamycin, macrolide spiramycin, aminoglycoside gentamicin, erythromycin, tetracycline and combination of sulfamethoxazole and trimethoprim were inactive against this bacterium. The Streptococcus pyogenes BS1 demonstrated intermediate susceptibility to the cephalosporin cephalexin, fluoroquinolone lomefloxacin and glycopeptide vancomycin. Non-antibiotic preparations were evaluated against Streptococcus pyogenes BS1 also. Among them "Stomatidin", "Chlorophyllipt", and phages of "Pyofag" were more effective than "Decatylen", "Decasan" and "Furadonin" in vitro. The antimicrobial applications of "Stomatidin", "Chlorophyllipt" and phages of "Pyofag" in the patient were less effective compared to the result of antibiotic benzathine phenoxymethylpenicillin treatment. Complete recovery of the patient was achieved with use of this antibiotic and Calendula flower extract as an local anti-inflammatory agent.

Retrospective evaluation of hypersensitivity reactions and anaphylaxis in dogs (2003-2014): 86 cases

OBJECTIVE

To characterize anaphylactic reactions in dogs, including clinical signs, severity, treatments, prognosis, and estimated incidence. To determine whether glucocorticoids influence clinical recovery and survival.

DESIGN

Retrospective study between January 1, 2003 and April 28, 2014.

SETTING

University teaching hospital.

ANIMALS

Eighty-six dogs treated for a type I hypersensitivity reaction. Nineteen dogs fulfilled the criteria for anaphylaxis, and 67 dogs had mild cutaneous reactions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The estimated incidence was 0.04% for anaphylaxis and 0.15% for mild hypersensitivity reactions. The female:male ratio (2.3:1) was significantly higher (P = 0.032) compared to our source population (ratio of 1:1.158). Vaccines were the most frequent trigger for anaphylaxis (57.9%) and mild hypersensitivity reactions (28.4%). Seventy-four (86%) dogs had cutaneous signs, and 11 (57.9%) dogs with anaphylaxis had no cutaneous signs reported. Forty-two (48.8%) dogs received both an H1 antagonist and a glucocorticoid, 34 (39.5%) dogs received an H1 antagonist only, and 6 (6.9%) dogs received a glucocorticoid only. The majority of the dogs survived, and 1 was euthanized due to complications. Clinical signs associated with nonsurvival included respiratory signs (P = 0.006), particularly respiratory distress (P < 0.00001) and cyanosis (P < 0.00001), and circulatory shock (P = 0.005). The analysis of the interaction between etiology, clinical signs, treatment, and outcome did not show any association between pairs of variables.

CONCLUSIONS

In the current study, anaphylaxis had a relatively good prognosis, and cutaneous signs were not always present. Based on the present data, the use of glucocorticoids to treat mild type I hypersensitivity reactions and anaphylaxis in dogs was not associated with clinical improvement or survival.

Anaphylaxis: Emergency Department Treatment

Anaphylaxis is a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise. Intramuscular epinephrine is the immediate treatment of all patients. Intravenous epinephrine should be used in patients in shock, either as a bolus or infusion, along with fluid resuscitation. Airway obstruction must be recognized, and early intubation may be necessary. For shock that is refractory to epinephrine, additional vasopressors may be needed. Disposition depends on patient presentation and response to treatment. Mandatory observation periods are not necessary, because biphasic reactions are difficult to predict and may occur outside of typical observation periods.

Anaphylaxis:: After the Emergency Department

After treating the acute anaphylactic reaction, the clinician's next task is to prevent a recurrence. The patient should be observed in the ED. How long this observation period should last depends on their clinical course, risk factors, and social support. All patients should be discharged with a prescription for 2 epinephrine autoinjectors and counseled on appropriate use. The patient should also receive education on the signs and symptoms of anaphylaxis and avoiding triggers. The patient should follow-up with an allergy specialist who can confirm triggers and provide immunotherapy as indicated.

Innovations in the treatment of anaphylaxis: A review of recent data

PURPOSE OF REVIEW

The current standard of first-line emergency treatment of anaphylaxis is intramuscular (IM) epinephrine, mostly administered through epinephrine autoinjector (EAI) in the outpatient setting. However, undercarriage and underuse of EAIs are common, and delayed epinephrine use is associated with increased morbidity and mortality. Patients, caregivers, and healthcare professionals have expressed a strong desire for small, needle-free devices and products that would offer improved carriage, ease of use, and more convenient, less invasive routes of epinephrine administration. Novel mechanisms of epinephrine administration are under investigation to help address several recognized EAI limitations. This review explores innovative nasal and oral products under investigation for the outpatient emergency treatment of anaphylaxis.

FINDINGS

Human studies of epinephrine administered through nasal epinephrine spray, a nasal powder spray, and a sublingual film have been conducted. Data from these studies indicate promising pharmacokinetic results comparable to those of the standard of outpatient emergency care (0.3-mg EAI) and syringe and needle IM epinephrine administration. Several products have shown maximum plasma concentration values higher than those of the 0.3-mg EAI and manual IM injection, although it remains unclear whether this has clinical relevancy in patient outcomes. Generally, these modalities show comparable time to maximum concentrations. Pharmacodynamic changes observed with these products are comparable to or more robust than those seen with EAI and manual IM injection.

SUMMARY

Given comparable or superior pharmacokinetic and pharmacodynamic results and safety of innovative epinephrine therapies to those of current standards of care, US Food and Drug Administration approval of these products may help address numerous barriers that EAIs present. The ease of use and carriage and favorable safety profiles of needle-free treatments may make them an attractive alternative to patients and caregivers, potentially addressing injection fears, needle-based safety risks, and other reasons for lack of or delayed use.

Overview of Allergy and Anaphylaxis

Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.

[Characterization of patients with anaphylaxis in a tertiary hospital in Medellin, Colombia (2009-2019)]

OBJECTIVE

To characterize demographically and clinically the patients with anaphylaxis treated in a third level health institution in Medellin, Colombia.

METHODS

A cross-sectional descriptive observational study was carried out, which includedpatients were diagnosed with anaphylaxis between 2009 and 2019. Information was retrieved from medical records through a collection instrument. Subsequently, a descriptive statistical analysis of proportions and measures of central tendency of the variables of interest was performed.

RESULTS

A total of 1820 records were reviewed and data from 253 patients were included. Among the reported comorbidities, drug allergy was the most prevalent (28%). The most frequent manifestations of anaphylaxis were cutaneous and respiratory. Most of the cases presented basal tryptase values ≤ 11.4 ng/mL (94.7%). Different etiological agents (food, drugs, insects and latex) were reported, and their frequency varied according to age. Adrenaline, steroids, and antihistamines were the treatments of choice in 39.9, 34.3, and 39.9% of cases, respectively.

CONCLUSIONS

The characteristics of anaphylaxis in a medical center in Colombia coincide with those reported in Latin American. The treatment of anaphylaxis is not standardized, which makes it necessary to educate the health personnel and develop national guidelines.

[Drug allergy: Fundamental aspects in diagnosis and treatment.]

BACKGROUND

Any substance used as a treatment for any disease can produce harmful or unpleasant events called adverse drug reactions (ADRs). They are due to inherent biological effects of the drug and are caused by immunological and non-immunological mechanisms.

OBJECTIVES

To describe the immunological mechanisms of hypersensitivity reactions (HSR) to drugs, their epidemiology, risk factors, classification, clinical manifestations, diagnosis, treatment, and prognosis.

METHODS

A review of the most current literature in English and Spanish was carried out, in the main databases, related to the HSR of various drug groups.

RESULTS

This study describes the terms used to define ADRs and HSRs, their classification and clinical manifestations, current diagnostic tools, treatment algorithms and prognosis of the most frequently used medications and with the highest prevalence of reported adverse events.

CONCLUSION

ADRs are a challenging entity, with a complex pathophysiology that has not been fully understood. Its approach requires a careful consideration since not all drugs have validated tests for their diagnosis nor a specific treatment. When indicating the use of any drug, the severity of the disease, the availability of other treatments and the potential risks of developing future adverse events should always be taken into consideration.

Idiopathic Anaphylaxis? Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland

The most common causes of anaphylaxis, according to various authors and depending on the age of the studied groups, are: Hymenoptera venom, food, and medications. Unfortunately, we are not always able to indicate the cause of anaphylaxis. There are data in the literature where as many as 41% of all cases are idiopathic anaphylaxis. Since the introduction of new diagnostic methods such as molecular diagnostics (MD) in our centre, the percentage of idiopathic anaphylaxis in the Anaphylaxis Register has significantly decreased. The purpose of this study was to identify possible causes of idiopathic anaphylaxis in patients with a history of moderate to severe anaphylactic reactions. After using MD, the causative agent was found in another 29 people. The proportion of people with idiopathic anaphylaxis in the Registry decreased from 9.2% to 3.5%. There were no significant differences in the incidence, although men appear to be slightly more common in primary idiopathic anaphylaxis. The mean age of primary idiopathic anaphylaxis was 40 years, but this was as high as 51 for anaphylaxis with alpha-gal allergy. Exercise may or may not be present as a cofactor despite its established role, e.g., in wheat-dependent exercise-induced anaphylaxis (WDEIA). In most of the analyzed cases, i.e., 70%, the reaction took place within an hour. The longest time interval from exposure to the development of symptoms is in the case of alpha-gal allergy; in this analysis, it was at least 5 h after ingestion of the so-called "red meat". Patients are not aware of the disease, or further attacks cannot be prevented. As many as 80% had idiopathic anaphylaxis prior to visiting the centre, and 80% developed anaphylaxis after visiting the centre, which emphasizes the need to not stop the medical team in their search for the causes. As many as 93% of cases required medical intervention, of which adrenaline was used only in 34.5%, antihistamines in 86%, systemic glucocorticosteroids (sCS) in 75%, and fluids in 62% of cases. A total of 83% of patients received an emergency kit for self-administration. Idiopathic anaphylaxis can be resolved as known-cause anaphylaxis after a thorough medical history and, if possible, without exposing the patient after using appropriate, modern in vitro diagnostic methods, including molecular diagnostics. The diagnosis of idiopathic anaphylaxis should extend the diagnosis to include alpha-gal syndrome, LTP syndrome and WDEIA.

Anaphylaxis in elderly people

PURPOSE OF REVIEW

Anaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management.

RECENT FINDINGS

Data from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data.

SUMMARY

The most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.

Assessment of Selected Intestinal Permeability Markers in Children with Food Allergy Depending on the Type and Severity of Clinical Symptoms

Background: Food allergy (FA) has a broad range of symptoms, and clinical manifestations may concern several reactions from one system or organ. Aim: The aim of the study was to assess intestinal permeability (IP) based on the analysis of serum zonulin and bacterial lipopolysaccharides (LPS) levels in children with FA, taking into account the pathomechanism of immune reaction, clinical symptoms of FA and their severity. Material and methods: The study comprised 103 patients aged 7–60 months (median 34); 49 children with IgE-mediated allergy and 25 children with non-IgE-mediated allergy; the reference group comprised 29 children with functional gastrointestinal disorders. IP markers were determined using ELISA. Results: There was no correlation between the severity of clinical symptoms and the level of IP markers in children with FA. Zonulin and LPS levels were significantly higher in children with FA and gastrointestinal symptoms. Zonulin levels in the subgroup of children with non-IgE-mediated FA and gastrointestinal symptoms were significantly higher than in the subgroup of children with IgE-mediated FA and these symptoms. The level of LPS was significantly higher in the subgroup with IgE-mediated FA and atopic dermatitis. Conclusions: Zonulin and LPS levels were significantly higher in children with FA compared to children from the reference group. Zonulin levels were significantly higher in children with non-IgE-mediated FA than in children with IgE-mediated FA.

Modern Approaches to the Management of Children with Mucopolysaccharidosis Type I

This article presents modern data on epidemiology, etiology, and clinical manifestations of mucopolysaccharidosis (MPS) type I in children. MPS develops due to deficiency of particular lysosomal enzyme which determines the disease type. The article considers in details disease's pathogenesis and classification. Evidence-based approaches to diagnosis (differential diagnosis included) are covered, moreover, special attention is paid to pathogenetic, symptomatic, and surgical treatment of MPS.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present nonspecific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms, and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

Emergency treatment of anaphylaxis: concise clinical guidance

Anaphylaxis is a serious systemic hypersensitivity reaction that is usually rapid in onset and may cause death. It is characterised by the rapid development of airway and/or breathing and/or circulation problems. Intramuscular adrenaline is the most important treatment, although, even in healthcare settings, many patients do not receive this intervention contrary to guidelines. The Resuscitation Council UK published an updated guideline in 2021 with some significant changes in recognition, management, observation and follow-up of patients with anaphylaxis. This is a concise version of the updated guideline.

[Allergy risk assessment and surveillance]

The assessment of a patient's allergic risk can be based on the ABCDE methodology to be standardized. Hospital monitoring should be routine in case of signs of anaphylaxis.

Characteristics of anaphylaxis patients who visited emergency departments in Korea: Results from a national emergency department information system

Background

Anaphylaxis is an allergic disease with fatal respiratory or cardiovascular symptoms that require immediate emergency treatment. We aimed to understand the characteristics and frequency of emergency department (ED) visits of patients with anaphylaxis in Korea.

Methods

Between 2007 and 2013, using data from 147 ED from the National Emergency Department Information System in Korea, we retrospectively evaluated patients with a primary diagnosis of anaphylaxis.

Results

During the study, a total 23,313 patients visited the ED due to anaphylaxis. The number of patients with anaphylaxis who visited the ED increased from 3.0 per 100,000 population in 2007 to 11.6 per 100,000 population in 2013 (P<0.001). Overall, the frequency of anaphylaxis emergency department visits increased by 1.24 times each year (95% CI 1.23–1.25). The risk of visiting ED due to anaphylaxis by population-based age-specific group was highest in the 60–69 years old (OR 2.30, 95% CI 1.96–2.70). Deaths from anaphylaxis increased by 1.35 times per year (95% CI 1.13–1.62). The causes of anaphylaxis were unknown (80.8%; 95% CI 80.35–81.38), drugs (8.9%; 95% CI 8.47–9.24), food (4.1%; 95% CI 3.87–4.39), bees (3.2%; 95% CI 3.02–3.48) and arthropods (2.3%; 95% CI 2.11–2.48). In 2009, drugs were the most common cause of anaphylaxis in November (35.5%), followed by food in May (15.5%) (P<0.001). Between July and September, stings from insects were the most common causes (P<0.001). By age, food was the most common cause in children aged <6 years (7.6%, <12 months; 9.0%, 1–6 years) and drugs in those aged ≥7 years. The 7-year overall mortality rate was 0.104 case per 1,000,000 population; men accounted for 77.8% of the deaths. By region, the number of cases was the highest in metropolitan areas, Gyeonggi and Seoul; however, the number of anaphylaxis cases per 100,000 population was the highest in Jeju and Gangwon.

Conclusion

Based on ICD-10 codes, the number of ED visits due to anaphylaxis is increasing in Korea, and the incidence of anaphylaxis varies by region, season, and age.

A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020)

Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.

Pathophysiological, Cellular, and Molecular Events of the Vascular System in Anaphylaxis

Anaphylaxis is a systemic hypersensitivity reaction that can be life threatening. Mechanistically, it results from the immune activation and release of a variety of mediators that give rise to the signs and symptoms of this pathological event. For years, most of the research in anaphylaxis has focused on the contribution of the immune component. However, approaches that shed light on the participation of other cellular and molecular agents are necessary. Among them, the vascular niche receives the various signals (e.g., histamine) that elicit the range of anaphylactic events. Cardiovascular manifestations such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and cardiac alterations are crucial in the pathophysiology of anaphylaxis and are highly involved to the development of the most severe cases. Specifically, the endothelium, vascular smooth muscle cells, and their molecular signaling outcomes play an essential role downstream of the immune reaction. Therefore, in this review, we synthesized the vascular changes observed during anaphylaxis as well as its cellular and molecular components. As the risk of anaphylaxis exists both in clinical procedures and in routine life, increasing our knowledge of the vascular physiology and their molecular mechanism will enable us to improve the clinical management and how to treat or prevent anaphylaxis.

Key Message

Anaphylaxis, the most severe allergic reaction, involves a variety of immune and non-immune molecular signals that give rise to its pathophysiological manifestations. Importantly, the vascular system is engaged in processes relevant to anaphylactic events such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and decreased cardiac output. The novelty of this review focuses on the fact that new studies will greatly improve the understanding of anaphylaxis when viewed from a vascular molecular angle and specifically from the endothelium. This knowledge will improve therapeutic options to treat or prevent anaphylaxis.

COVID-19 Vaccination Safety and Tolerability in Patients Allegedly at High Risk for Immediate Hypersensitivity Reactions

The reported incidence of immediate hypersensitivity reactions (IHR) including anaphylaxis after COVID-19 vaccination is 10-fold higher than for other vaccines. Several patient groups are theorized to be at particular risk. Since specific vaccination guidelines for these patients are based on expert opinion, we performed a retrospective monocentric analysis of the tolerability of adenoviral vector and mRNA-based COVID-19 vaccines in a cohort of patients allegedly at high risk of IHR. Reactions were assessed immediately on-site by allergists during a monitored vaccination protocol and after 3–7 days through telephone interviews. The cohort included 196 patients (aged 12–84 years) with primary mast cell disease (pMCD, 50.5%), idiopathic anaphylaxis (IA, 19.9%), hereditary angioedema (HAE, 5.1%) or miscellaneous indications (24.5%). Twenty-five immediate reactions were observed in 221 vaccine doses (11.3%). Most occurred in IA or miscellaneous patients. None fulfilled anaphylaxis criteria and most were mild and self-limiting. Reaction occurrence was significantly associated with female sex. In total, 13.5% of pMCD patients reported mast cell activation-like symptoms within 72 h post-vaccination. All pediatric pMCD patients (n = 9, 12–18 years) tolerated both mRNA-based vaccine doses. In summary, adenoviral vector and mRNA-based COVID-19 vaccines were safe and well-tolerated in patients with pMCD, HAE, and IA. No anaphylaxis was observed. The mild and subjective nature of most reactions suggests a nocebo effect associated with vaccination in a medicalized setting. Patients with pMCD could experience mild flare-ups of mast cell activation-like symptoms, supporting antihistamine premedication.

Safely Reducing Hospitalizations for Anaphylaxis in Children Through an Evidence-Based Guideline

BACKGROUND

Emergency department visits for anaphylaxis have increased considerably over the past few decades, especially among children. Despite this, anaphylaxis management remains highly variable and contributes to significant health care spending. On the basis of emerging evidence, in this quality improvement project we aimed to safely decrease hospitalization rates, increase the use of cetirizine, and decrease use of corticosteroids for children with anaphylaxis by December 31, 2019.

METHODS

A multipronged intervention strategy including a revised evidence-based guideline was implemented at a tertiary children's teaching hospital by using the Model for Improvement. Statistical process control was used to evaluate for changes in key measures. Length of stay and unplanned return visits within 72 hours were monitored as process and balancing measures, respectively. As a national comparison, hospitalization rates were compared with other hospitals' data from the Pediatric Health Information System.

RESULTS

Hospitalizations decreased significantly from 28.5% to 11.2% from preimplementation to implementation, and the balancing measure of 72-hour revisits was stable. The proportion of patients receiving cetirizine increased significantly from 4.2% to 59.7% and use of corticosteroids decreased significantly from 72.6% to 32.4% in patients without asthma. The proportion of patients meeting length of stay criteria increased from 53.3% to 59.9%. Hospitalization rates decreased nationally over time.

CONCLUSIONS

We reduced hospitalizations for anaphylaxis by 17.3% without concomitant increases in revisits, demonstrating that unnecessary hospitalizations can be safely avoided. The use of a local evidence-based guideline paired with close outcome monitoring and sustained messaging and feedback to clinicians can effectively improve anaphylaxis management.

Secondary Antibiotic Prophylaxis for Latent Rheumatic Heart Disease

BACKGROUND

Rheumatic heart disease affects more than 40.5 million people worldwide and results in 306,000 deaths annually. Echocardiographic screening detects rheumatic heart disease at an early, latent stage. Whether secondary antibiotic prophylaxis is effective in preventing progression of latent rheumatic heart disease is unknown.

METHODS

We conducted a randomized, controlled trial of secondary antibiotic prophylaxis in Ugandan children and adolescents 5 to 17 years of age with latent rheumatic heart disease. Participants were randomly assigned to receive either injections of penicillin G benzathine (also known as benzathine benzylpenicillin) every 4 weeks for 2 years or no prophylaxis. All the participants underwent echocardiography at baseline and at 2 years after randomization. Changes from baseline were adjudicated by a panel whose members were unaware of the trial-group assignments. The primary outcome was echocardiographic progression of latent rheumatic heart disease at 2 years.

RESULTS

Among 102,200 children and adolescents who had screening echocardiograms, 3327 were initially assessed as having latent rheumatic heart disease, and 926 of the 3327 subsequently received a definitive diagnosis on the basis of confirmatory echocardiography and were determined to be eligible for the trial. Consent or assent for participation was provided for 916 persons, and all underwent randomization; 818 participants were included in the modified intention-to-treat analysis, and 799 (97.7%) completed the trial. A total of 3 participants (0.8%) in the prophylaxis group had echocardiographic progression at 2 years, as compared with 33 (8.2%) in the control group (risk difference, -7.5 percentage points; 95% confidence interval, -10.2 to -4.7; P<0.001). Two participants in the prophylaxis group had serious adverse events that were attributable to receipt of prophylaxis, including one episode of a mild anaphylactic reaction (representing <0.1% of all administered doses of prophylaxis).

CONCLUSIONS

Among children and adolescents 5 to 17 years of age with latent rheumatic heart disease, secondary antibiotic prophylaxis reduced the risk of disease progression at 2 years. Further research is needed before the implementation of population-level screening can be recommended. (Funded by the Thrasher Research Fund and others; GOAL ClinicalTrials.gov number, NCT03346525.).

Physicians' knowledge and practice concerning diagnosis and management of anaphylaxis: The situation in Egypt

Introduction

Early recognition of an anaphylaxis event is crucial for instituting lifesaving management. We sought to explore knowledge and practice towards anaphylaxis in a sample of physicians from ten Egyptian governorates.

Methods

An eighteen question-based questionnaire was developed by expert allergists to evaluate the knowledge and practice towards anaphylaxis, based on the World Allergy Organization guidelines for the assessment and management of anaphylaxis. The questionnaires were distributed, and the answered forms collected via emails, and data were tabulated, and analysed.

Results

In this cross-sectional study, a total of 242 physicians completed the survey (183 (75.6%) paediatricians, 32 (13.2%) internists, 22 (9.1%) intensivists and five (2.1%) anaesthetists). Only 91 participants (37.6%) identified all the four proposed anaphylaxis clinical scenarios while 70, 45 and 36 identified three, two and one scenario, respectively. Loss of consciousness and abdominal symptoms were not recognised as possible presentations of anaphylaxis by 64.5% and 80.2% of the participants, respectively. Epinephrine was considered the first line treatment by 98 (40.5%), corticosteroids by 77 (31.8%) and antihistamines by 25 (10.3%). 75 (31%) responders identified the right dose of epinephrine while 119 (49.2%) identified the proper route. Concerning practice, 83 physicians (39.2%) used epinephrine for all cases of anaphylaxis, 88 (41.5%) used it for refractory cases only whereas 41 (19.3%) did not use epinephrine at all.

Discussion

Our survey shows that the knowledge of Egyptian physicians and their practice towards anaphylaxis are still inadequate. The current situation reinforces the need to disseminate and encourage the adoption of the international guidelines for anaphylaxis diagnosis and treatment.

Management of Anaphylaxis

The key to managing anaphylaxis is early epinephrine administration. This can improve outcomes and prevent progression to severe and fatal anaphylaxis. Delayed or lack of administration of epinephrine is associated with fatal reactions. Positioning in a recumbent supine position, airway management, and intravenous fluids are essential in its management. Antihistamines and glucocorticosteroids should not be prescribed in place of epinephrine. β-adrenergic agonists by inhalation are indicated for bronchospasm associated with anaphylaxis despite optimal epinephrine treatment. Long-term management of anaphylaxis includes the identification and avoidance of triggers; identification of cofactors, such as mast cell disorders; patient, parent, and caregiver education, and interventions to reduce allergen sensitivity, such as the use of venom immunotherapy for Hymenoptera hypersensitivity. Long-term management is covered in other articles. Consultation with an allergist/immunologist is recommended when necessary.

Management of Anaphylaxis in Infants and Toddlers

Anaphylaxis is a systemic allergic reaction that can be caused by food, drugs, insect bites, or unknown triggers in infants and toddlers. Anaphylaxis rates are increasing. Infants and toddlers may have increased exposure to known and unknown allergens, decreased ability to describe their symptoms, and an expanded differential diagnosis for consideration on presentation. The most common symptoms in these age groups are cutaneous and gastrointestinal. Age-specific language may be helpful for caregivers to identify and describe the symptoms of anaphylaxis in infants and toddlers. Long-term management of anaphylaxis includes allergy evaluation to guide avoidance and assess prognosis and education on allergic reaction management; this incorporates the prescription of epinephrine autoinjector and provision of an allergy emergency plan.