Kounis syndrome: ST elevations in the setting of anaphylaxis

Acute coronary syndrome in the presence of an allergic reaction is known as Kounis syndrome, which is an underdiagnosed disorder and has nuances regarding management. We present a patient brought to the hospital as an ST segment elevation myocardial infarction (STEMI) alert in the setting of an allergic reaction triggered by food.

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.

Adrenaline-resistant anaphylactic shock caused by contrast medium in a patient after risperidone overdose: a case report

BACKGROUND

In Japan, the use of risperidone in combination with adrenaline is contraindicated, except in cases of anaphylaxis. Therefore, there is limited clinical evidence regarding the interaction of these two drugs. Here, we report the clinical course of a case of adrenaline-resistant anaphylactic shock induced by a contrast medium injection after a risperidone overdose.

CASE PRESENTATION

A man in his 30s was transported to our hospital after attempting suicide by taking 10 mg of risperidone and jumping from a height of 10 m. To determine the location and severity of his injuries, he was injected with an iodinated contrast medium, after which he developed generalized erythema and hypotension and was diagnosed with anaphylactic shock. A 0.5 mg dose of adrenaline was administered with no improvement, followed by another 0.5 mg dose that did not change his blood pressure. After infusion of a sodium bicarbonate solution (8.4%), administration of fresh frozen plasma, and additional administration of adrenaline (0.6-1.2 µg/min), his blood pressure improved, and he recovered from the anaphylactic shock.

CONCLUSIONS

This was a rare case of a risperidone overdose followed by adrenaline-resistant anaphylactic shock. The resistance is likely associated with the high blood concentration of risperidone. Our findings indicate that the potential for decreased adrenergic responsiveness should be considered in patients undergoing risperidone treatment in the event of anaphylactic shock.

Direct Versus Indirect Query Performance of ICD-9/-10 Coding to Identify Anaphylaxis

BACKGROUND

Anaphylaxis is an often under =diagnosed, severe allergic event for which epidemiological data are sporadic. Researchers have leveraged administrative and claims data algorithms to study large databases of anaphylactic events; however, little longitudinal data analysis is available after transition to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).

OBJECTIVE

Study longitudinal trends in anaphylaxis incidence using direct and indirect query methods.

METHODS

Emergency department (ED) and inpatient data were analyzed from a large state health care administration database from 2011 to 2020. Incidence was calculated using direct queries of anaphylaxis ICD-9-CM and ICD-10-CM codes and indirect queries using a symptom-based ICD-9-CM algorithm and forward mapped ICD-10-CM version to identify undiagnosed anaphylaxis episodes and to assess algorithm performance at the population level.

RESULTS

An average of 2.4 million inpatient and 7.5 million ED observations/y were analyzed. Using the direct query method, annual ED anaphylaxis cases increased steadily from 1,454 (2011) to 4,029 (2019) then declined to 3,341 in 2020 during the coronavirus disease 2019 (COVID-19) pandemic. In contrast, inpatient cases remained relatively steady, with a slight decline after 2015 during the ICD version transition, until a significant drop occurred in 2020. Using the indirect queries, anaphylaxis cases increased markedly after the ICD transition year, especially involving drug-related anaphylaxis.

CONCLUSIONS

Nontypical drug associations with anaphylaxis episodes using the ICD-10-CM version of the algorithm suggest poor performance with drug-related codes. Further, the increased granularity of ICD-10-CM identified potential limitations of a previously validated symptom-based ICD-9-CM algorithm used to detect undiagnosed cases.

Clinical Characteristics of Anaphylaxis in Children Aged 0-16 Years in Xi'an, China

INTRODUCTION

Anaphylaxis is a serious systemic hypersensitivity reaction that usually has a rapid onset and may cause death. The aim of this study was to clarify the clinical characteristics of anaphylaxis in children of all ages in Xi'an, China.

METHODS

A retrospective study was conducted on anaphylaxis cases in the emergency department of the Affiliated Children's Hospital of Xi'an Jiaotong University between January 1, 2016, and July 1, 2021. The statistical methods used were the χ2 test, Fisher's exact test, and Z-test.

RESULTS

A total of 110 cases of anaphylaxis were collected: 70% were male, 13 were <1 year old, 17 were 1-2 years old, 42 were 3-6 years old, 38 were 7-16 years old, 10 (9.1%) had ≥2 anaphylaxis, and 75 (68.1%) had a previous history of allergy. The triggers of anaphylaxis were analyzed: 50 cases (45.5%) were induced by food, 37 cases (33.6%) by drugs, 6 cases (5.5%) by insect bites, 4 cases (3.6%) by exercise, and 12 cases (11.8%) by unknown causes. Common food allergens were milk (20%, 10/50), buckwheat (16%, 8/50), eggs (14%, 7/50), and fruits (14%, 7/50). The most common drug triggers were antibiotics (59.4%, 22/37), non-steroidal anti-inflammatory drugs (NSAIDs) (10.8%, 4/37), vaccines (10.8%, 4/37), and herbal medicines (10.8%, 4/37). Common food allergens vary by age: milk and eggs for infants, fruit for children aged 1-2 years, and buckwheat for children older than 3 years. Ninety-eight cases (89.1%) had skin mucosal involvement, 78 (70.9%) had respiratory compromise, 45 (40.9%) had cardiovascular compromise, and 31 (28.2%) had gastrointestinal symptoms. Cardiovascular compromise and reduced level of consciousness were statistically different between the age groups (p < 0.05). Twenty cases (18.2%) had resolved spontaneously when they reached the hospital, 53 cases (48.1%) received epinephrine, 18 (16.4%) were hospitalized, and 2 (1.8%) experienced a biphasic reaction.

CONCLUSIONS

Males are overrepresented in children with anaphylaxis, and food and drugs are common triggers in children. However, the types of common food triggers differ across age groups, and infants are more likely to have cardiovascular compromise and a reduced level of consciousness. However, the use of epinephrine remains inadequate. The training of clinical staff in recognizing anaphylaxis needs to be strengthened.

Effects of a standardized patient-based simulation in anaphylactic shock management for new graduate nurses

Background

Patients may be endangered if new graduate nurses cannot recognize and manage anaphylactic shock. Consequently, enhancing the new graduate nurses’ understanding of their roles and responsibilities during the rescue of a patient with anaphylactic shock is important. However, due to its inherent limitations, traditional classroom-based teaching makes it difficult to explore the potential of the students. Although popular simulation teaching has several notable advantages, it has not been proven to be effective in training inexperienced nurses on anaphylactic shock. We investigated the effect of a standardized patient-based simulation on the behaviors of new graduate nurses’ during anaphylactic shock rescue to identify an effective and safe method for contemporary nursing education.

Methods

Except for the ill or pregnant, all the new graduate nurses were included in the study as students to undergo a standardized patient-based simulation conducted in the clinical skills center of a general hospital. The simulation training was designed to teach students to recognize the signs and symptoms of anaphylactic shock, place the patient in the correct position, stop the ongoing intravenous infusion of the antibiotic which triggers the anaphylactic shock, restart an intravenous infusion on a new infusion apparatus, give 100% oxygen via a nasal cannula or mask, preserve airway patency, call the rapid response team, and correctly administer the medications prescribed by the clinicians. Before and after the training, the instructors evaluated each student’s skills and behaviors using a clinical competency evaluation list. After the training, all students completed the Chinese version of the Simulation Design Scale (SDS) to demonstrate their satisfaction with the program and then participated in semi-structured interviews with their instructors.

Results

All 104 graduate nurses had a significant improvement on the 6 competencies of the clinical competency evaluation list after the simulation training (P < 0.001). The SDS scores revealed that the students were highly satisfied with all the aspects of the simulation training (the 20 satisfaction rates were all above 90.00%). During the semi-structured interviews, most of the new graduate nurses reported that simulation training in the management of anaphylactic shock was critical and would guide them in clinical practice.

Conclusion

Simulation training in anaphylactic shock is a potentially viable and effective method for teaching new graduate nurses to manage clinical incidents.

Camrelizumab-induced anaphylactic shock in an esophageal squamous cell carcinoma patient: A case report and review of literature

BACKGROUND

Camrelizumab (SHR-1210), an immune checkpoint inhibitor, is clinically used as a therapeutic option for various types of tumors. However, reports of adverse reactions associated with camrelizumab are gradually increasing. Anaphylactic shock due to camrelizumab has not been reported previously, until now. We report here, for the first time, a case of anaphylactic shock associated with camrelizumab in a patient with esophageal squamous cell carcinoma.

CASE SUMMARY

An 84-year-old male esophageal cancer patient received radiotherapy and chemotherapy 11 years ago. He was diagnosed with advanced esophageal squamous cell carcinoma with liver metastasis (TxN1M1) and received the first immunotherapy (camrelizumab 200 mg/each time, once every 3 wk) dose in December 2020, with no adverse reactions. Three weeks later, a generalized rash was noted on the chest and upper limbs; palpitations and breathing difficulties with a sense of dying occurred 10 min after the patient had been administered with the second camrelizumab therapy. Electrocardiograph monitoring revealed a 70 beats/min pulse rate, 69/24 mmHg (1 mmHg = 0.133 kPa) blood pressure, 28 breaths/min respiratory rate, and 86% pulse oximetry in room air. The patient was diagnosed with anaphylactic shock and was managed with intravenous fluid, adrenaline, dexamethasone sodium phosphate, calcium glucosate, and noradrenaline. Approximately 2 h after treatment, the patient’s anaphylactic shock symptoms had been completely relieved.

CONCLUSION

Due to the widespread use of camrelizumab, attention should be paid to anti-programmed cell death 1 antibody therapy-associated hypersensitivity or anaphylactic shock.

Successful prolonged cardiopulmonary resuscitation after intraoperative cardiac arrest due to povidone-iodine allergy: A case report

BACKGROUND

Iodophor (povidone-iodine) is widely used clinically because of its broad-spectrum antibacterial effects. Although extremely rare, it may cause anaphylactic shock, which itself carries the life-threatening risk of cardiac arrest.

CASE SUMMARY

We present a case in which a patient with postoperative infection went into anaphylactic shock and cardiac arrest caused by povidone-iodine during secondary surgery. The patient was successfully resuscitated by 2 h of cardiopulmonary resuscitation.

CONCLUSION

This is the first known case of cardiac arrest caused by povidone-iodine allergy.

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.

Anaphylactic shock in a small cell lung cancer patient receiving atezolizumab therapy: a rare but potentially fatal complication

Immunotherapy has been a revolutionary innovation in cancer therapy in recent years, but it is accompanied by various unique immune-related adverse events (irAEs). Among these irAEs, anaphylactic shock is very rare. Here, we report a case of a patient who developed anaphylactic shock after receiving one dose of atezolizumab. A 74-year-old male patient with small cell lung cancer experienced recurrence 10 years after surgery. After one cycle of treatment, the patient developed a grade 2 rash and recovered after receiving oral methylprednisolone tablets. In the second cycle, atezolizumab was discontinued. Then, the patient was scheduled to receive atezolizumab plus carboplatin and etoposide again after three weeks, but approximately three minutes after an intravenous infusion of atezolizumab, the patient developed signs and symptoms of anaphylactic shock, such as dyspnea, cold limbs, and loss of consciousness. At this point, the infusion was immediately stopped, and a normal saline infusion was administered. Meanwhile, ECG monitoring, supplemental humidified high-flow supplemental 100% oxygen, epinephrine, dopamine, hormone treatment with methylprednisolone, and other anti-shock treatments were carried out. For better recuperation, this patient was transferred to the intensive care unit for further treatment and was discharged two days later. Anaphylactic shock develops rapidly and is also a very severe complication. Prompt detection, diagnosis, and therapeutic intervention are the basics for survival.

Anaphylactic shock due to ruptured pulmonary hydatid cyst in a young patient from Iran

Introduction

and importance: Hydatidosis is a zoonotic condition caused by contact with the tapeworm Echinococcus granulosus metacestode. The liver and lungs are the most prominent locations for cysts. This is a rare case of pulmonary hydatid cyst (PHC) rupture in a young woman following a severe cough.

Case presentation

On July 9, 2018, a 20-year-old woman presented to our hospital in northern Iran with a complaint of cough with excessive sputum, dyspnea, drooling, symptoms of nausea and vomiting, itching and urticarial. Imaging findings showed evidence of a large, space-occupying mass in the right lung. She underwent a thoracoscopic wedge resection (TWR) as a minimally invasive technique, to remove the wall and contents of the cyst. Also, anaphylactic shock occurred in the patient. Due to hemodynamic disorders and heart and respiratory failure, unfortunately, the patient expired.

Clinical discussion

The rupture of a hydatid cyst may result in irreversible damage. PHC rupture is a serious complication that causes excessive coughing and chest pain. A rupture into the pleural or pericardial cavity is a serious and potentially fatal disease.

Conclusion

Anaphylactic shock should be considered as one of the serious complications of PHC, particularly in young ones. Therefore, early diagnosis and appropriate treatment are essential to prevent severe complications such as anaphylactic shock.

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Anaphylactic shock due to ruptured pulmonary hydatid cyst in a young patient from Iran.

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Radiography and CT scan showed evidence of a large, space-occupying mass in the right lung.

•

Early diagnosis and appropriate treatment are essential to prevent severe complications such as anaphylactic shock.

Naturally occurring hypothermia promotes survival in severe anaphylaxis

Although hypothermia has received substantial attention as an indicator of severity in anaphylaxis, it has been neglected from the perspective of whether it could act as a disease-modifying factor in this condition. Here, the impact of naturally occurring (spontaneous) hypothermia on anaphylaxis was evaluated in a murine model of ovalbumin (OVA)-induced allergy. Nonextreme changes in the ambient temperature (T_a) were used to modulate the magnitude of spontaneous hypothermia. At a T_a of 24°C, challenge with OVA intraperitoneally or intravenously resulted in a rapid, transient fall in body core temperature, which reached its nadir 4-6°C below baseline in 30 min. This hypothermic response was largely attenuated when the mice were kept at a T_a of 34°C. The T_a-dependent attenuation of hypothermia resulted in a survival rate of only 30%, as opposed to survival of 100% in the condition that favored the development of hypothermia. The protective effect of hypothermia did not involve changes in the rate of mast cell degranulation, as assessed by the concentration of mast cell protease-1 in bodily fluids. On the other hand, hypothermia improved oxygenation of the brain and kidneys, as indicated by higher NAD⁺/NADH ratios. Therefore, it is plausible to propose that naturally occurring hypothermia makes organs more resistant to the anaphylactic insult.

Atezolizumab-induced anaphylactic shock in a patient with hepatocellular carcinoma undergoing immunotherapy: A case report

BACKGROUND

Atezolizumab is a programmed death ligand 1 (PD-L1) inhibitor, and its combination with bevacizumab has been proven an effective immunotherapy for unresectable hepatocellular carcinoma (HCC). Treatment with immune checkpoint inhibitors (ICIs) can lead to hypersensitivity reactions; however, anaphylactic shock is rare. We present a case of life-threatening anaphylactic shock during atezolizumab infusion and performed a relevant literature review.

CASE SUMMARY

A 75-year-old man was diagnosed with HCC recurrence after hepatectomy. He was administered immunotherapy with atezolizumab plus bevacizumab after an allergy to a programmed death-1 (PD-1) inhibitor. The patient showed a sudden onset of dizziness, numbness, and lack of consciousness with severe hypotension during atezolizumab infusion. The treatment was stopped immediately. The patient’s symptoms resolved after 5 mg dexamethasone was administered. Because of repeated hypersensitivity reactions to ICIs, treatment was changed to oral targeted regorafenib therapy.

CONCLUSION

Further research is necessary for elucidating the hypersensitivity mechanisms and establishing standardized skin test and desensitization protocols associated with PD-1 and PD-L1 to ensure effective treatment with ICIs.

Remimazolam anaphylaxis during anesthesia induction

Anaphylactic shock is a potentially lethal complication during anesthesia and requires appropriate management to save the patient's life. We report a 32-year-old man who developed anaphylaxis during induction of general anesthesia with remimazolam for hand surgery. He received general anesthesia with midazolam 4 weeks before. This time facial flushing followed by a decrease of peripheral oxygen saturation (SpO₂) and blood pressure occurred 2 min after starting continuous remimazolam infusion at 6 mg/kg/h. Hypotension and SpO₂ were recovered by repeated administration of adrenaline. Despite no increase of serum tryptase levels, intradermal allergy tests 4 weeks postoperatively revealed that remimazolam and midazolam were positive, suggesting remimazolam as a causative agent for anaphylaxis. In the previous surgery, midazolam, which has a similar structure to remimazolam, may have caused sensitization. This is probably the first case report of anaphylaxis caused by remimazolam.

Risk Factors in Severe Anaphylaxis: Which Matters The Most, Food or Cofactors?

BACKGROUND AND OBJECTIVE

The prevalence of anaphylactic shock, the most severe manifestation of anaphylaxis, remains unknown. Risk factors and biomarkers have not been fully identified. Objective: To identify risk factors in anaphylactic shock patients.

METHODS

Using lipid transfer protein (LTP)allergy as a model, the characteristics of patients who developed anaphylaxis and anaphylactic shock were compared. Demographics, pollen sensitization, foods ingested up to 2 hours before the reaction onset, and the presence of a cofactor were recorded. Culprit foods were identified by compatible clinical history and positive allergological work-up (skin prick test and/or sIgE).

RESULTS

150 reactions were evaluated, suffered by 55 patients with An (134 reactions) and 12 with AnS (16 reactions). Patients in the anaphylaxis group experienced twice as many reactions (mean [SD] 2.4[2.5] in An vs 1.3[1.5) in AnS, p<0.02). No relationship between any food group and reaction severity was found. The most frequent food involved in both groups of patients was the combination of several plant-derived foods ("plant food mix"), followed by peach and nuts. Indeed, in the "plant food mix" reactions the presence of a cofactor was more often observed than in other food groups. On the other hand, cofactors were not present in peach- and nuts-related reactions. Exercise was the most frequent cofactor in all groups.

CONCLUSION

In our series, the severity of the reactions was not determined by the kind of food or presence of a cofactor. Anaphylactic shock seems an infrequent presentation that may be related with other individual-related factors that need further evaluation.

Anaphylactic shock due to traumatic rupture of pulmonary hydatid cyst: Case report

INTRODUCTION

Hydatid cyst is an infectious disease caused by « ECHINOCOCCUS GRANULOSIS », it can be asymptomatic or manifests depending on size, location, and relation with other organs, or by complication like rupture. This latter might occur spontaneously or post-traumatic, and it might manifest with an anaphylactic shock, a life-threatening situation.

IMPORTANCE

Anaphylactic shock is a rare cause of traumatic shock state.

CASE PRESENTATION

A 30 years old man with no medical history was admitted to the emergency room after a car accident, on his admission, his Glasgow coma scale was 10/15 with a blood pressure of 80/30 mmHg, he was intubated and stabilized hemodynamically. The full-body CT scan showed no abnormalities except on the thoracic level where it showed a well-limited rounded formation with regular contours containing hydro-aeric level related to ruptured hydatid cyst. After ruling out the diagnosis of hemorrhagic, hypovolemic shock, the diagnosis of anaphylactic shock due to a post-traumatic rupture of the hydatid cyst was maintained.

CONCLUSION

Post-traumatic rupture of the hydatid cyst is a rare emergency that requires early diagnosis and management. Surgery remains the principal treatment of ruptured hydatid cyst. Anaphylactic shock is a life-threatening situation with various symptoms; epinephrine is the cornerstone for management of this type of shock.

Mining of mortality-related findings in rare bleeding disorders: a retrospective study from two centers

BACKGROUND

Rare bleeding disorders include inherited coagulation disorders except for von Willebrand disease and hemophilia A and B. These disorders affect both men and women worldwide and mainly have an autosomal recessive pattern of inheritance. Given the paucity of cases of rare bleeding disorders, there are limited data regarding some topics among bleeding disorders.

METHODS

This retrospective study from 2005-2019 collected demographic data and the causes of death among cases with rare bleeding disorders from 2 provinces of Iran.

RESULTS

Overall, 5 deaths were reported, including 3 cases with factor V deficiency, a case with factor XIII deficiency, and a case with combined factor V and factor VIII deficiencies. The main causes of death were bleeding in the central nervous system (2 cases; 1 with factor V deficiency and 1 with combined factor XIII deficiency). Post-partum hemorrhage was the cause of death in a woman with factor V deficiency while anaphylaxis shock was the cause of death in the case with combined factor V and factor VIII deficiencies. A woman with factor V deficiency died from an internal bleeding episode.

CONCLUSION

Gathering data on the causes of death in rare bleeding disorders through worldwide registries can be helpful for the management of this rare group of bleeding disorders.

Clinical characteristics and management of iodine contrast media-related anaphylactic shock during cardiac catheterization

Objective

This study aimed to investigate the clinical characteristics and impact of intra-aortic balloon pump (IABP) implantation on the prognosis of patients with anaphylactic shock (AS) during cardiac catheterization.

Methods

We analyzed the medical records of 34 patients who had AS caused by iodine contrast media (ICM) between January 2009 and December 2019. Clinical features and treatments were analyzed, and patients were categorized into survival and dead groups. In addition, the patients were further divided into IABP and non-IABP (NIABP) groups to assess the impact on AS according to whether a IABP was used or not.

Results

Of the 417,938 patients in whom ICM was used, 34 with AS were monitored. The prevalence of AS was 0.008%. Among the 34 patients, 6 (0.001%) died from fatal anaphylactic reactions accompanying shock, 26 (76.5%) had hypotension as the first presentation of AS in the survival and dead groups (78.6% and 66.7%, respectively), and 5 (14.7%) had unconsciousness at the initial onset of AS. The subgroup analysis revealed a higher mortality in the IABP group than in the NIABP (4/9, 44.4% vs. 2/25, 8%; P = 0.031).

Conclusions

The present study suggests a low prevalence of ICM-related AS. Hypotension was more frequent in AS related to ICM, and unconsciousness at the initial onset of AS implied a poor prognosis. The use of an IABP did not improve the outcome of the patients with AS. IABP implantation should not be used as a routine treatment for patients with AS.

Risk Factors and Characteristics of Biphasic Anaphylaxis

BACKGROUND

Anaphylaxis is an immediate hypersensitivity reaction. However, a biphasic course with the second onset of symptoms can occur hours after the initial phase. Little is known about the causes of biphasic anaphylaxis making the identification of patients at risk difficult.

OBJECTIVE

To identify factors predisposing for biphasic anaphylaxis for the better understanding of these reactions.

METHODS

Data from the Anaphylaxis Registry (from 11 countries) including 8736 patients with monophasic and 435 biphasic anaphylaxis were analyzed.

RESULTS

The rate of biphasic reactions in this large cohort was 4.7%. The identified risk factors were reaction severity (grade III/IV vs grade II: odds ratio [OR] = 1.34; 95% confidence interval [CI]: 1.1-1.62); multiorgan involvement; skin, gastrointestinal, severe respiratory, and cardiac symptoms; anaphylaxis caused by peanut/tree nut (OR = 1.78; 95% CI: 1.38-2.23) or an unknown elicitor (OR = 1.96; 95% CI: 1.41-2.72); exercise as a cofactor (OR = 1.44; 95% CI: 1.17-1.78); chronic urticaria as a comorbidity (OR = 2.12; 95% CI: 1.19-3.78); a prolonged interval between the contact with the elicitor and start of primary symptoms (OR for >30 vs <30 min: 1.38; 95% CI: 1.08-1.76); and antihistamine treatment (OR = 1.52; 95% CI: 1.14-2.02).

CONCLUSION

A biphasic course of anaphylaxis occurs more frequently in severely affected patients with multiorgan involvement. However, we identified multiple additional predictors, suggesting that the pathogenesis of biphasic reactions is more complex than being a rebound of a severe primary reaction.

Two Cases of Rocuronium-Induced Anaphylaxis/Anaphylactic Shock Successfully Treated With Sugammadex

While anaphylaxis can occur at any time during general anesthesia, 90% of cases occur at induction of anesthesia. As several drugs are administered simultaneously at this time, it is difficult to identify the causative agent. However, it has been found that rocuronium is the most common drug associated with perioperative anaphylaxis. We treated 2 cases of patients who were administered sugammadex for anaphylactic symptoms thought to be caused by rocuronium, after which the anaphylactic symptoms disappeared. One of the most important aspects of treating anaphylactic shock is improving hemodynamics. If signs indicating circulatory collapse are observed, epinephrine should be administered immediately. However, because rocuronium was suspected of being the causative agent, and taking the patients' clinical course over time into consideration, sugammadex was initially administered. As a result, symptoms improved. Therefore, we believe that the administration of sugammadex may be effective for treating anaphylaxis caused by rocuronium and also help in identifying the causative agent.

Case report of a patient who survived after cardiac arrest and cardiogenic shock by anaphylactic reaction to gadolinium during magnetic resonance imaging

We report the case of a young adult which survived to anaphylactic shock caused by gadolinium-based contrast agent (GBCA) contrast agent infusion. The patient had no comorbidities and previous history of allergic reactions to contrast agents and underwent elective magnetic resonance imaging (MRI) for parotid swelling. Seven years before he received intravenous GBCA administration during an MRI, which exact chemical composition is unknown, without any allergic reaction. After intravenous injection of GBCA for MRI the patient developed anaphylactic shock, causing respiratory failure, cardiac arrest, and cardiogenic shock after return of spontaneous circulation. Because of the rarity of the described event, this report has the aim to raise awareness in the healthcare personnel of the possibility of these life-threatening adverse reactions from GBCAs also in a patient without history of allergy to contrast agents and suggest a possible clinical management of these patients.

Swan-Ganz catheter causing anaphylactic shock: A rare case report

Latex-induced anaphylactic reactions are often underestimated in patients having procedures in a catheterization lab, intensive care units, or in operating rooms. Most physicians are not aware that almost all balloons in the Swan-Ganz catheter (SGC) are made up of latex. Direct exposure of these latex balloons in the blood can cause severe anaphylactic reactions, even in patients with no previous history of allergies. We present a case of a 53-year-old male, who underwent a SGC placement for cardiovascular evaluation. Immediately after the SGC insertion, he developed circulatory shock. On further investigation, we discovered that SGC balloon contained latex as one of the components. Physicians should be aware of latex-based products such as SGC balloon, which can cause anaphylactic shock even in case of no prior allergies to latex.

Tonic contraction develops in the colon during anaphylactic hypotension in anesthetized rats

Diarrhea is a gastrointestinal symptom associated with systemic anaphylaxis and could be induced by increased colonic motility. We determined colonic motility and expulsion by measuring the intracolonic pressure (ICP) and expelled fluid weight in anesthetized rats during anaphylactic hypotension. Substantial systemic hypotension occurred in every sensitized rat after antigen injection. One min after antigen injection, ICP began to increase and remained elevated for 5 min, which was revealed to represent tonic contraction by the video-recording procedure, and was accompanied by increased colonic fluid expulsion. Parasympathectomy composed of subdiaphragmatic vagotomy combined with pelvic nerve transection reduced the duration of the tonic contraction, but not expelled colonic fluid. Furthermore, denervation of afferent parasympathetic nerves produced essentially the same effect as parasympathectomy. Sympathectomy did not significantly change any parameters. In conclusion, the colonic motility during anaphylactic hypotension is characterized by 5-min lasting tonic contraction which is associated with increased colonic fluid expulsion and is involved by parasympathetic nerves, especially their afferents, but not sympathetic nerves, in anesthetized rats.

Anaphylactic Shock After Indocyanine Green Video Angiography During Cerebrovascular Surgery

BACKGROUND

Indocyanine green (ICG) video angiography has been widely used in cerebrovascular surgery. ICG injection is generally safe, with a low incidence of complications. ICG-related anaphylactic reactions during neurosurgery have been rarely reported. We report the cases of 2 patients who had experienced anaphylactic shock in response to intravenous ICG injection (DID Indocyanine Green [Dongindang, Inc., Gyeonggi-do, Republic of Korea]) during intracranial aneurysm (IA) surgery.

CASE DESCRIPTION

The first patient, a 69-year-old woman with an unruptured IA, had been undergoing clipping surgery under general anesthesia. Immediately after ICG injection, her blood pressure suddenly decreased from 140/80 mm Hg to 50/30 mm Hg and she developed a skin rash on her abdomen and all extremities. Chest compression was initiated, and her vital signs gradually recovered to their pre-ICG levels within 10 minutes. The second patient was a 58-year-old woman with an unruptured IA who had been undergoing clipping surgery. After ICG injection, her blood pressure had decreased from 130/80 mm Hg to 60/40 mm Hg, and a rash-like skin lesion was observed on her abdomen. After intravenous injection of norepinephrine and dexamethasone, her blood pressure recovered to its pre-ICG level within 30 minutes and remained stable thereafter. The postoperative ICG skin provocation test findings were positive for both patients; however, only 1 patient showed markedly increased serum tryptase levels.

CONCLUSION

Despite the rarity of ICG-related anaphylaxis, clinicians should be aware of this unexpected, but potentially life-threatening, drug reaction in patients undergoing cerebrovascular surgery.

A Case of a Child With Several Anaphylactic Reactions to Drugs

Adverse drug reaction is defined as any harmful, unintended, and undesired effect of a drug that occurs at doses used for treatment, prevention, or diagnoses. Most of these reactions are classified as type A reactions, which by definition are predictable, common, dose-dependent, and caused by known pharmacological actions of the drug, drug toxicity, and side effects. Allergic reactions are qualified as type B reactions independent of dose, affecting a small population, suggesting that individual patient host factors are important. In pediatric population, β-lactam antibiotics are the most common reason for adverse drug reactions, followed by nonsteroidal anti-inflammatory drugs. In this article, we report the case of a child with several anaphylactic reactions to several drugs, including cefuroxime, amoxicillin/clavulanate, clarithromycin, ibuprofen, and budesonide, in a context of suspected Helicobacter pylori infection.

Allergy-like reactions to methylene blue following laparoscopic chromopertubation: A systematic review of the literature

Methylene blue is commonly used as a tracer in sentinel lymph node mapping for many malignant diseases or chromopertubation during gynecologic laparoscopy. In contrast with other blue dyes such as patent blue V or isosulfan blue, methylene blue rarely causes an allergy-like reaction in patients undergoing sentinel lymph node mapping. However, in chromopertubation, some cases of allergy-like reaction to methylene blue have been reported; these comprise two types: an allergic reaction and methemoglobinemia. In this study, a systematic literature review of allergy-like reactions caused by methylene blue dye following laparoscopic chromopertubation was conducted. A search was conducted in PUBMED, Web of Science, and Scopus from inception until June 2018, using the terms: "methylene blue", "complication", "allergic", "hypersensitive", "lung/pulmonary edema"," methemoglobinemia", "anaphylactic shock", "chromopertubation", "pertubation", "laparoscopic", and "laparoscopy". Ultimately, the eligibility criteria were fulfilled by only 12 case reports. Among 13 cases including our case of severe anaphylactic shock after chromopertubation, allergic reactions were diagnosed in four cases, methemoglobinemia in six, and there was no confirmed diagnosis in three cases; the clinical course consisted of skin changes, blue discoloration of body fluids, respiratory failure, and hemodynamic failure, regardless of the underlying diagnoses. Regarding diagnosis, methemoglobinemia was confirmed with co-oximetry (spectrophotometry). First-line therapy included supportive care for both cases of allergic reactions and methemoglobinemia.

Cellular and Immunohistochemical Changes in Anaphylactic Shock Induced in the Ovalbumin-Sensitized Wistar Rat Model

Anaphylactic shock (AS) is a life-threatening, multisystem disorder arising from sudden release of mast cell- and basophil-derived mediators into the circulation. In this study, we have used a Wistar rat model to investigate AS-associated histopathologic changes in various organs. Rats were sensitized with ovalbumin (1 mg s.c), and AS was induced by intravenous injection of ovalbumin (1 mg). Experimental groups included nonallergic rats (n = 6) and allergic rats (n = 6). Heart rate and blood pressure were monitored during one hour. Organs were harvested at the end of the experiment and prepared for histologic and immunohistochemical studies. Lung, small bowel mucosa and spleen were found to undergo heavy infiltration by mast cells and eosinophils, with less prominent mast cell infiltration of cardiac tissue. The mast cells in lung, small bowel and spleen exhibited increased expression of tryptase, c-kit and induced nitric oxide synthase (iNOS). Increased expression of endothelial nitric oxide synthase (eNOS) by vascular endothelial cells was noted principally in lung, heart and small bowel wall. The Wistar rat model of AS exhibited accumulation of mast cells and eosinophils in the lung, small bowel, and spleen to a greater extent than in the heart. We conclude that lung and gut are principal inflammatory targets in AS, and likely contribute to the severe hypotension of AS. Targeting nitric oxide (NO) production may help reduce AS mortality.

Mastocytosis and the Fig Wasp (Blastophaga psenes)

BACKGROUND

Mastocytosis involves the abnormal proliferation of mast cells and clinical variability. In the case of anaphylaxis, the triggering antigen, often associated with Hymenoptera allergens, must be identified. The common fig (Ficus carica) requires the fig wasp (Blastophaga psenes) for pollination.

OBJECTIVE

We evaluated the ingestion of B. psenes as a trigger of anaphylaxis in patients with mastocytosis.

MATERIAL AND METHODS

Skin prick tests (SPTs) and specific immunoglobulin E to the possible involved allergens were carried out in the patient and in 4 controls allergic to Hymenoptera and fig. Given the possibility of hidden allergens, we studied the source (figs of various origins) and possible hypersensitivity to Hymenoptera allergens, including the fig wasp (B. psenes).

RESULTS

In all subjects, the SPT resulted in a wheal (larger than with histamine) with the extract of the inferior part of the female fig but not with the male extract (lower pole and stem). Immune detection was made with the stem and inferior part of figs and venom of Polistes and Vespula. Recognition bands were observed at 25 kDa with female fig extracts that were also recognized by the patient with anaphylaxis to Hymenoptera venom.

CONCLUSIONS

We cannot exclude the possibility that the ingestion of fig with Blastophaga antigens may have triggered anaphylaxis in our patient.

Authors' reply - anaphylactic shock with methylprednisolone, Kounis syndrome and Hypersitivity to corticosteroids: a clinical paradox

In our letter, we comment the paper of Kounis et al., that highlights a poor-known clinical entity determined by systemic use of corticosteroids, the so-called “Kounis syndrome type I”. We appreciated and shared the intent of Authors to treat the important issue of high risk of adverse drug reaction in patients with atopic diathesis and we confirm the need to administer corticosteroids with caution in patients suffering from allergic disease.

Carbimazole-induced Anaphylactic Shock: A Case Report

Carbimazole is an antithyroid drug that rarely presents as anaphylactic shock. We hereby report a case of 40-year-old female who was treated with carbimazole for thyrotoxicosis. Patient developed sweating, shortness of breath and altered sensorium after taking single dose of carbimazole. Patient was treated for anaphylactic shock. From this, we want to emphasize that carbimazole can rarely present as anaphylactic shock without any other allergic manifestation. So, patient should be counselled about this rare side effect and early approach to health care facility.

Key messages

Patient on carbimazole should be aware of all side effects including rare side effects like anaphylactic shock. Studies are required to identify risk factors and new drugs for carbimazole allergy patients. Patient with thyrotoxicosis should also be screened for autoimmune thyrotoxicosis.

How to cite this article

Keyal NK, Thapa S, Yadav MK. Carbimazole-induced Anaphylactic Shock: A Case Report. Indian J Crit Care Med 2019;23(8):380-381.

Identification and characterization of the causative triatomine bugs of anaphylactic shock in Zhanjiang, China

Background

Two health concerns primarily related to triatomine bugs are transmission of Trypanosoma cruzi through infective feces, and allergic reactions induced by triatomine bites. In the Southwestern United States, reduviid bugs bites commonly cause insect allergy. In South China, four cases of anaphylactic shock have been reported after this bite exposure. To further classify the species of these bugs and confirm the sensitization of the triatomine saliva, we caught triatomine bugs from the region where the bites occurred and performed phylogenetic and immunohistochemical (IHC) analysis.

Methods

Triatomine bugs were collected in Donghai Island of Zhanjiang City in South China. The genomic DNA was extracted from three legs of the bugs. The fragments of mitochondrial 16S rRNA, cytochrome c oxidase subunit I (COI) gene and nuclear ribosomal 18S and 28S rRNA genes were obtained by PCR and sequenced. A phylogenetic tree was constructed based on the sequence of 16S rRNA gene using a maximum likelihood method with MEGA 7.0 software. Trypanosomal specific fragments and vertebrate COI genes were amplified from the fecal DNA to detect the infection of trypanosomes and analyze the blood feeding patterns, respectively. Paraffin-embedded sections were then prepared from adult triatomines and sent for IHC staining.

Results

We collected two adult triatomine bugs in Donghai Island. Morphological and molecular analyses indicated that the triatomines were Triatoma rubrofasciata. No fragments of T. cruzi or other trypanosomes were detected from the fecal DNA. Mitochondrial gene segments of Homo sapiens and Mus musculus were successfully amplified. The allergens which induced specific IgE antibodies in human serum were localized in the triatomine saliva by IHC assay.

Conclusions

The two triatomine bugs from Donghai Island were T. rubrofasciata. They had bitten humans and mice. Their saliva should contain the allergens related to the allergic symptoms and even anaphylactic shock of exposed residents. Great consideration should be given to this triatomine bugs due to their considerable distribution and potential threat to public health in South China.

Anaphylactic shock after sugammadex administration, induced by formation of a sugammadex-rocuronium complex -a case report

Background

Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers and widely used worldwide on account of its rapid and effective reversal from neuromuscular blockade, despite its advantages, multiple cases of sugammadex-induced anaphylactic shock have been reported.

Case

A 42-year-old man developed anaphylactic shock in the postanesthesia care unit. Initially, sugammadex was suspected as the causative agent, but an intradermal skin test revealed negative results. A further skin test was performed with sugammadex-rocuronium complex that yielded positive results.

Conclusions

Anesthesiologists and healthcare providers should be aware of the possibility of anaphylaxis from the sugammadex-rocuronium complex, as well as from sugammadex or rocuronium alone.

A Case of Rocuronium-Induced Anaphylactic Shock in an Asthmatic Child

We experienced a case of anaphylactic shock in a young asthmatic child immediately after administering rocuronium during the induction of anesthesia. Because urticaria did not develop immediately after ventilation difficulty, we diagnosed and responded to asthma, rather than to anaphylactic shock. Correct and rapid response to anaphylactic is extremely important.

Renal response to anaphylaxis in anesthetized rats and isolated perfused rat kidneys: roles of nitric oxide

We determined the renal responses to anaphylaxis and the effects of a nitric oxide synthesis inhibitor, L-NAME, in anesthetized rats and isolated perfused rat kidneys. After the ovalbumin antigen injection, the sensitized rats showed transient and substantial decreases in mean blood pressure and renal blood flow and an increase in renal vascular resistance. Creatinine clearance, a measure of renal function, decreased to 53% baseline at 2 h after antigen. L-NAME pretreatment significantly enhanced the antigen-induced renal vasoconstriction and renal dysfunction. Moreover, plasma creatinine levels significantly increased only in the L-NAME pretreated rats. Separately, in isolated perfused kidneys, we observed the antigen-induced renal vasoconstriction and its augmentation by L-NAME. In conclusion, the renal vascular response to the antigen is vasoconstriction, which is enhanced by L-NAME in both isolated perfused rat kidneys and anesthetized rats; it is accompanied by renal dysfunction, which is also augmented by L-NAME.

Successful resuscitation after cardiac arrest secondary to carboplatin infusion: A case report

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Sudden cardiac arrest can be a form of carboplatin hypersensitivity reaction.

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Platinum retreatment and cumulative cycles of ≥ 8 are risk factors.

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Awareness of the reaction related to carboplatin infusion is necessary.

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Successful resuscitation with high quality CPR is achievable with trained staffs.

Anaphylactic hypotension causes renal and adrenal sympathoexcitaion and induces c-fos in the hypothalamus and medulla oblongata

NEW FINDINGS

What is the central question of this study? Whether anaphylaxis affects sympathetic outflows to the brown adipose tissue (BAT) and adrenal gland and whether anaphylaxis affects some brain areas in association with sympathetic regulation. What is the main finding and its importance? Sympathoexcitatory responses to anaphylaxis occurred regionally in the kidney and adrenal gland, but not in the thermogenesis-related BAT. Further, anaphylactic hypotension also caused increase in c-fos immunoreactivity in the hypothalamic and medullary areas. Moreover, catecholaminergic neurons of the brainstem cause adrenal sympathoexcitation in a baroreceptor-independent manner.

ABSTRACT

We previously reported that sympathetic nerve activity (SNA) to the kidney and the hindlimb increases during anaphylactic hypotension in anaesthetized rats. Based on this evidence, we examined effects of anaphylactic hypotension on SNA to the brown adipose tissue (BAT), and the adrenal gland and kidney in anaesthetized rats. We demonstrated that adrenal and renal SNA, but not BAT-SNA, were stimulated. In addition, the effects of anaphylaxis on neural activities of the hypothalamic and medullary nuclei, which are candidates for relaying efferent SNA to the peripheral organs, were investigated via immunohistochemical staining of c-fos. Anaphylaxis increased c-fos expression in the neurons of the paraventricular nucleus (PVN) of the hypothalamus and in those of the nucleus tractus solitarii (NTS) and rostral ventrolateral medulla (RVLM) of the medulla oblongata; c-fos was expressed in γ-aminobutyric acid (GABA)-ergic neurons of the NTS and in the catecholaminergic neurons of the RVLM. In addition, c-fos expression in the rostral NTS and mid NTS during anaphylaxis was reduced by sinoaortic baroreceptor denervation; however, increased c-fos expression in the caudal NTS and RVLM or adrenal sympathoexcitation were not affected by sinoaortic baroreceptor denervation. These results indicated that anaphylactic hypotension activates the hypothalamic PVN and the medullary NTS and RVLM independently of the baroreflex pathway. Further, it stimulated efferent SNA to the adrenal gland and kidney to restore blood pressure.

Different clinical features of anaphylaxis according to cause and risk factors for severe reactions

BACKGROUND

Anaphylaxis is a life-threatening allergic reaction. Several studies reported different anaphylactic reactions according to the causative substances. However, a comparison of anaphylaxis for each cause has not been done. This study was conducted to identify common causes of anaphylaxis, characteristics of anaphylactic reaction for each cause and to analyze the factors related to the severity of the reaction.

METHODS

Medical records of patients who visited the emergency room of Ewha Womans University Mokdong Hospital from March 2003 to April 2016 and diagnosed with anaphylactic shock were retrospectively reviewed. We compared the clinical features of anaphylaxis according to the cause. In addition, the severity of anaphylaxis was analyzed and contributing factors for severe anaphylaxis were reviewed.

RESULTS

A total of 199 patients with anaphylaxis were analyzed. Food was the most common cause (49.7%), followed by drug reaction (36.2%), bee venom (10.1%), and unknown cause (4.0%). Cardiovascular symptoms of syncope and hypotension were more common in drug-induced anaphylaxis. The incidence of severe anaphylaxis was the highest in anaphylaxis due to drugs (54.2%). Urticaria and other skin symptoms were significantly more common in food-induced anaphylaxis. Risk factors for severe anaphylaxis included older age, male, and drug-induced one. Epinephrine treatment of anaphylaxis was done for 69.7% and 56.9% of patients with food-induced and drug-induced anaphylaxis, respectively.

CONCLUSIONS

More severe anaphylaxis developed with drug treatment and in males. Low rate of epinephrine prescription was also observed. Male patients with drug induced anaphylaxis should be paid more attention.

β₂-Adrenoceptor Blockade Deteriorates Systemic Anaphylaxis by Enhancing Hyperpermeability in Anesthetized Mice

Purpose

Patients treated with propranolol, a nonselective β-adrenoceptor antagonist, develop severe anaphylaxis, but the mechanism remains unknown. We determined effects of β₁- and β₂-adrenoceptor antagonists on the anaphylaxis-induced increase in vascular permeability in mice.

Methods

In anesthetized ovalbumin-sensitized C57BL mice, mean arterial blood pressure (MBP) was measured, and Evans blue dye extravasation and hematocrit (Hct) were assessed at 20 minutes after antigen injection. The following pretreatment groups (n=7/group) were studied: (1) sensitized control (non-pretreatment), (2) propranolol, (3) the selective β₂-adrenoceptor antagonist ICI 118,551, (4) the selective β₁-adrenoceptor antagonist atenolol, (5) adrenalectomy, (6) the selective β₂-adrenoceptor agonist terbutaline, and (7) non-sensitized groups.

Results

The antigen injection decreased MBP, and increased Hct and vascular permeability in the kidney, lung, mesentery, and intestine, but not in the liver or spleen. Pretreatment with ICI 118,551, propranolol and adrenalectomy, but not atenolol, reduced the survival rate and augmented the increases in Hct and vascular permeability in the kidney, intestine, and lung as compared with the sensitized control group. Pretreatment with terbutaline abolished the antigen-induced alterations. Plasma epinephrine levels were increased significantly in the sensitize control mice.

Conclusions

Blockade of β₂-adrenoceptor can deteriorate systemic anaphylaxis by augmenting hyperpermeability-induced increase in plasma extravasation by inhibiting beneficial effects of epinephrine released from the adrenal glands in anesthetized mice.

Anaphylaxis following intralesional triamcinolone acetonide (Kenacort) injection

Intralesional triamcinolone acetonide injection is indicated for multiple skin conditions such as keloid scars, alopecia areata, and hypertrophic lichen planus. Immediate hypersensitivity reaction remains uncommon. We report on a 24-year-old woman who had received multiple intralesional injections with triamcinolone acetonide (Kenacort) plus lidocaine for keloid scar treatment without any reaction for the previous 10 years. The immediate reaction occurred 15 minutes after injection, with numbness on her face and 5 minutes later with urticaria on her chest wall and upper extremities, together with hypotension (blood pressure of 90/60 mmHg). Allergology workup revealed positive skin prick test for triamcinolone acetonide (Kenacort). Skin tests for other corticosteroids (hydrocortisone, methylprednisolone, and dexamethasone), excipients (carboxymethylcellulose, benzyl alcohol, and polysorbate 80) and lidocaine were negative, including subcutaneous challenge for lidocaine and oral challenge for carboxymethylcellulose. IgE-mediated hypersensitivity reaction must be considered in cases of multiple applications of triamcinolone acetonide injection.

Anaphylactic Shock After Intravenous Administration of Indocyanine Green During Robotic Partial Nephrectomy

Indocyanine Green (ICG) is frequently used during urologic robotic procedures and is generally considered to be safe. However, there are reported cases of severe complications from ICG when used for non-urologic purposes. We present the first case to our knowledge of anaphylactic shock in response to intravenous ICG during a robotic partial nephrectomy.

Gastric vascular and motor responses to anaphylactic hypotension in anesthetized rats, in comparison to those with hemorrhagic or vasodilator-induced hypotension

Anaphylactic shock is life-threatening, but pathophysiology of the stomach lesion remains unclear. We determined gastric hemodynamics and gastric functions during anaphylactic hypotension, as compared to hypotension induced by hemorrhage or sodium nitroprusside (SNP) in anesthetized and ovalbumin-sensitized Sprague–Dawley rats. Systemic arterial pressure, portal venous pressure, and gastric arterial blood flow were measured, and gastric vascular resistance (GVR) was determined. Separately, the intragastric pressure (IGP) and gastric effluent, as a measure of gastric flux, were continuously measured. During anaphylaxis, GVR decreased only transiently at 0.5 min, followed by an increase. IGP increased markedly, while gastric flux decreased. During hemorrhage, GVR and IGP increased, while gastric flux did not change. When SNP was injected, both GVR and IGP decreased and gastric flux increased only just after injection. In conclusion, gastric vasodilatation occurs only transiently after antigen injection, and gastric motility increases, but gastric emptying deceases during anaphylactic hypotension in anesthetized rats.

Anaphylaxis after intravenous infusion of dexketoprofen trometamol

Dexketoprofen trometamol (DT), a nonsteroidal anti-inflammatory drug, is a highly water-soluble salt and active enantiomer of rac-ketoprofen. Its parenteral form is commonly used for acute pain management in emergency departments of our country. Side effects such as diarrhea, indigestion, nausea, stomach pain, and vomiting may be seen after the use of DT. Anaphylactic shock (AS) secondary to infusion of DT is very rare and, to our knowledge, it is the first case report describing this side effect. This case report was presented to emphasize that AS may be seen after the use of DT.

Management of maternal anaphylaxis in pregnancy: a case report

Case

A 26‐year‐old woman (gravida 2, para 1) at 25 weeks’ gestation was brought to the emergency department because of anaphylactic symptoms. She reported eating Japanese soba and developed symptoms of dyspnea, generalized itchy rash, abdominal pain, and severe uterine contractions within 15–30 min of eating. She was immediately treated by normal saline infusion, two injections of epinephrine (intramuscularly), and a nebulized short‐acting β₂‐receptor agonist, followed by H₁‐antihistamine and methylprednisolone. Obstetrical management was undertaken by an obstetrician.

Outcome

The patient recovered rapidly without a biphasic reaction of anaphylaxis. After 11 weeks, a healthy, neurologically intact baby was born.

Conclusion

Management of anaphylaxis in pregnant patients is basically the same of that in non‐pregnant ones. Treatment should commence immediately to prevent further development of the anaphylaxis reaction and fetal neurological deficiency.

Fatal Kounis syndrome with stent thrombosis secondary to amoxicillin/clavulanic acid use: A case report and literature review

Anaphylactic reactions are often induced by drugs, and the most frequent ones are penicillin derivates. The concurrence of acute coronary syndrome with hypersensitivity and anaphylactic or anaphylactoid reactions constitutes the Kounis syndrome. We report a case of a coronary stent thrombosis with a fatal outcome complicating an anaphylactic shock induced by amoxicillin-clavulanic acid association. A 58-year-old woman with a history of triple coronary stenting was treated by amoxicillin/clavulanic acid association for pharyngitis. One hour after the first drug intake, she developed an anaphylactic shock with acute constricting chest pain. She received intravenous hydrocortisone and was transferred to emergency department. The patient received epinephrine intravenously with fluid perfusion and oxygen. Electrocardiogram showed Pardee waves in the anterior precordial leads. Cardiac enzyme levels (troponin I) were disturbed. The patient was transferred to the coronary care unit with a diagnosis of acute myocardial infarction. The coronary angiography revealed anterior interventricular stent thrombosis. The patient experienced a cardiogenic shock with an important hemodynamic repercussion, and she died few hours later despite emergency care. The responsibility of amoxicillin-clavulanic acid association was retained in the genesis of this anaphylactic shock in front of a suggestive delay, a compatible evolution and a high semiotic score. Amoxicillin/clavulanic acid use may cause Kounis syndrome. The use of epinephrine is a challenging decision. We suggest that Kounis syndrome should be considered in the differential diagnosis of acute coronary syndrome.