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PubMed1999

Epidemiology of anaphylaxis in Olmsted County: A population-based study.

BACKGROUND: Awareness of the clinical features of anaphylaxis and its causative triggers is important if recurrent episodes are to be avoided. The incidence of anaphylaxis in the general population is often underreported, and epidemiologic studies are few. Because an accurate profile of anaphylaxis could heighten awareness of this problem, we investigated the epidemiology of anaphylaxis in the general population of Olmsted County, Minn. OBJECTIVE: The purpose of this study was to describe the epidemiology of anaphylaxis in Olmsted County residents from 1983 through 1987. METHODS: This was a retrospective population-based cohort study. The medical records of 1255 Olmsted County residents identified by computer-linked, medical diagnostic indices (the Rochester Epidemiology Study) were reviewed retrospectively to identify residents whose clinical episodes met the criteria for anaphylaxis. We determined the incidence and rate of occurrence of anaphylaxis, rate of recurrence, prevalence of atopy, cause of anaphylaxis, frequency of referral to an allergy specialist, hospital admission rate, and case-fatality rate. RESULTS: There were 133 residents who experienced 154 anaphylactic episodes during the 5-year period: 116 residents had 1 episode of anaphylaxis, 13 residents had 2 episodes, and 4 residents had 3 episodes. The anaphylaxis occurrence rate was 30 per 100,000 person-years (95% confidence interval, 25-35). There were 110 residents who had a first lifetime episode of anaphylaxis (that was medically evaluated) during the years 1983 to 1987. The average annual incidence rate of anaphylaxis was 21 per 100,000 person-years (95% confidence interval, 17-25). Atopy was present in 53% of the cohort, and allergy consultation was obtained in 52%. A suspect allergen was identified in 68% of the cohort, most frequently a food, medication, or insect sting. The hospitalization rate was 7%, and 1 patient died. CONCLUSION: The incidence of anaphylaxis is less than 1%, and death rarely occurs. People with atopy experience anaphylaxis more frequently than people without atopy. Anaphylaxis frequently is not recognized by patients and physicians.

Anaphylaxis↗
PubMed1997

Malignant and corticosteroid-dependent idiopathic anaphylaxis: successful responses to ketotifen.

BACKGROUND: Malignant idiopathic anaphylaxis refers to the most severe form of idiopathic anaphylaxis where defined episodes of idiopathic anaphylaxis are not controlled when the prednisone is reduced below at least 60 mg every other day or 20 mg daily. Corticosteroid-dependent idiopathic anaphylaxis refers to patients with idiopathic anaphylaxis who require continuous daily or alternate day prednisone at threshold doses for control of idiopathic anaphylaxis. Ketotifen has been reported to help induce remission in some patients with idiopathic anaphylaxis and has steroid sparing effects in other patients with idiopathic anaphylaxis. METHODS: We present five patients, two with malignant idiopathic anaphylaxis and three with corticosteroid-dependent idiopathic anaphylaxis, who responded to the administration of ketotifen. RESULTS: All five patients, while receiving ketotifen, had a reduction or resolution of their episodes of idiopathic anaphylaxis and prednisone was tapered and discontinued. CONCLUSION: Ketotifen is shown to be successful in inducing remission in two patients with malignant idiopathic anaphylaxis and in three additional patients with corticosteroid-dependent idiopathic anaphylaxis. An additional patient with malignant idiopathic anaphylaxis had prednisone stopped after elective hip surgery.

Adrenal Cortex Hormones↗
PubMed2004

History and classification of anaphylaxis.

Anaphylaxis is the maximal variant of an acute allergic reaction involving several organ systems. The phenomenon itself is old, but it was recognized and named at the beginning of the 20th century by Richet and Portier. The clinical symptoms of anaphylaxis affect various organs, most commonly starting in the skin and proceeding to the respiratory tract, to gastrointestinal involvement and to cardiovascular symptoms, and finally to cardiac and/or respiratory arrest. Anaphylaxis stricto sensu is an immunological reaction, mostly mediated by IgE antibodies, but also by IgG or IgM antibodies (immune complex anaphylaxis). There are cases with similar clinical symptomatology without detectable immunological sensitization which are called pseudo-allergic or anaphylactoid reactions. In the newer nomenclature, some authors tend to include these under the heading of 'anaphylaxis' which has then to be defined as an acute systemic hypersensitivity reaction. The most common elicitors of anaphylaxis include drugs, foods, additives, but also other allergens as well as physical factors (cold, heat, UV radiation). The clinical outcome--the intensity of the reaction--is not only influenced by the degree of sensitization, but also by concomitant other factors: sometimes, individuals only develop anaphylaxis after simultaneous exposure to the allergen and an infection, physical exercise, psychological stress or concomitant medication (e.g. beta blockers). The term 'summation anaphylaxis' has been proposed for this phenomenon which probably underlies many cases of so-called idiopathic anaphylaxis. In patients with insect venom anaphylaxis, decreased levels of plasma angiotensin have been measured in inverse correlation to the severity of the reaction. Certain differential diagnoses have to be distinguished from anaphylaxis. Every patient with a history of anaphylaxis should undergo allergy diagnosis with the aim to detect the eliciting agent, characterize the relevant pathomechanism (e.g. IgE-mediated reaction) and to offer a tolerable alternative (in food or drug allergy). In clear-cut IgE-mediated anaphylaxis, allergen-specific immunotherapy (hyposensitization) is the effective causal treatment, with success rates of 90% in insect venom anaphylaxis.

Allergens↗
PubMed1998

Anaphylaxis in children: clinical and allergologic features.

BACKGROUND: Despite the importance of anaphylaxis, little information is available on its clinical features. OBJECTIVE: To evaluate the clinical and allergologic features of anaphylaxis in children referred to the allergology and immunology unit of A. Meyer Children's Hospital (Florence, Italy) from 1994 to 1996. RESULTS: Ninety-five episodes of anaphylaxis occurred in 76 children (50 boys and 26 girls). Sixty-six children (87%) had only one episode of anaphylaxis, while 10 (13%) had two or more episodes. Sixty-two (82%) of the 76 patients had a personal history of atopic symptoms, although 14 (18%) did not. Sixty (79%) of the 76 children studied had at least one positive skin prick test to one or more of the common inhalant and/or food allergens. Children with venom-induced anaphylaxis usually had negative skin tests to the allergens tested. A younger age and eczema were more frequent among children with food-dependent anaphylaxis, whereas an older age together with urticaria-angioedema were common among those with exercise-induced anaphylaxis. The mean latent period (+/-SD) of the anaphylaxis episodes was 15.4 +/- 27.5 minutes. Skin and respiratory manifestations had an earlier onset and were more common than the gastrointestinal and cardiovascular ones. The most frequent clinical manifestation in children with food anaphylaxis was gastrointestinal symptoms, whereas cardiovascular symptoms were rare. The most probable causative agents in the 95 episodes described were foods (57%), drugs (11%), hymenoptera venom (12%), exercise (9%), additives (1%), specific immunotherapy (1%), latex (1%), and vaccines (2%), but in 6 cases (6%) the agent was never determined. Among the foods, seafood and milk were the most frequently involved. As for location, 57% of the anaphylactic events occurred in the home (54/95), 12% outdoors (11/95); 5% in restaurants (5/95); 3% in the doctor's office (3/95); 3% in hospitals (3/95); 3% on football fields (3/95); 2% on the beach (2/95); 1% in the gym (1/95); 1% at school (1/95); and 1% in the operating room (1/95). In the remaining 12% of cases (11/95) the site remained unknown. Sixty-two percent of the patients (59/95) were treated in an emergency room or hospital, while 32% (30/95) were not (this information is lacking in 6% of the cases [6/95]). Patients were treated with corticosteroids in 72% of the cases (68/95), with antihistamines in 20% (19/95), with epinephrine in 18% (17/95), with beta2-agonists in 5% (5/95), and with oxygen in 4% (4/95). CONCLUSIONS: In our area, foods, particularly seafood and milk, seem to be the most important etiologic factors triggering anaphylaxis. Food-induced anaphylaxis often occurs in younger children with a severe food allergy, whereas exercise-induced anaphylaxis occurs more often in older children with a history of urticaria-angioedema. The venom-induced variant usually presents itself in nonatopic subjects. Given the fact that most of the children had only one anaphylactic reaction, prevention is almost impossible. Epinephrine, although it is the first-choice treatment of anaphylaxis, often goes unused, even in hospitals and doctors' offices.

Adolescent↗
PubMed2004

Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization.

BACKGROUND: There is little information about the incidence of anaphylaxis from all causes. OBJECTIVE: The objects of this study were (1) to estimate the incidence of anaphylaxis; (2) to explore the range of diagnoses attributed to an anaphylactic episode; and (3) to describe the clinical features of anaphylaxis. METHODS: The study population consisted of children and adolescents enrolled at a health maintenance organization. We identified potential episodes of anaphylaxis occurring between 1991 and 1997 from automated databases and reviewed the medical record to confirm the diagnosis. We reviewed all diagnoses specific for anaphylaxis (eg, ICD-9 995.0, anaphylactic shock) and sampled from among other related diagnoses (eg, ICD-9 995.3, allergy unspecified). Estimation of the incidence of provider-diagnosed anaphylaxis was based on cases confirmed from among the specific diagnosis codes. Description of the clinical features of anaphylaxis involved all confirmed cases regardless of diagnosis. RESULTS: We identified 67 episodes of anaphylaxis among children with diagnosis codes specific for anaphylaxis (10.5 episodes per 100,000 person-years). There was no increase in incidence over time. Review of samples of diagnoses not specific for anaphylaxis yielded an additional 18 episodes. Among all identified episodes (n = 85), mucocutaneous and respiratory manifestations were the most common. Seventy-one percent of episodes were treated in the emergency department. Nine episodes (11%) resulted in hospitalization. CONCLUSIONS: The incidence of anaphylaxis did not increase during these years. A majority of episodes were treated in the emergency department. Anaphylaxis in this population was frequently diagnosed as another related condition, and the basis and implications of diagnostic practices in this disorder warrant further exploration.

Adolescent↗
PubMed2001

Clinical features of acute anaphylaxis in patients admitted to a university hospital: an 11-year retrospective review (1985-1996).

BACKGROUND: Although anaphylaxis is considered a life-threatening event, there is a lack of information on the clinical characteristics at presentation, both in adults and in children. OBJECTIVE: To describe in a nonselected population the clinical characteristics and the treatments of acute anaphylaxis triggered by different agents. METHODS: This is a retrospective review of the clinical features of 113 episodes of acute anaphylaxis resulting in admission to a university hospital. Initially, the 107 patients visited the emergency room and were then admitted to the hospital. RESULTS: Most anaphylactic events (63%) occurred at home. The most frequent symptoms involved the respiratory system (78%) and the skin (90%). Drugs, especially nonsteroidal anti-inflammatory drugs and antibiotics, were the most frequent cause of anaphylaxis in adults (49%). Patients with drug-induced anaphylaxis were older and more often had cardiovascular symptoms (hypotension and tachycardia) (P = 0.0064). Hymenoptera venom was the second most frequent cause of anaphylaxis (29%). Most of the patients with hymenoptera venom anaphylaxis were male (80%) and more frequently they had no history of atopy (P = 0.012). In food-induced anaphylaxis, the cardiovascular system was less likely to be involved (P < 0.05) (39%). Seafood seems to be frequently involved in food-induced anaphylaxis in our area. Specific immunotherapy-induced anaphylaxis occurred more often in younger patients (P = 0.032). Epinephrine seems to be underused in Italy (only 15% of patients received it), especially for respiratory symptoms. CONCLUSIONS: Anaphylaxis triggered by different agents may have different clinical presentations and may occur in different types of patients. In Italy, the inadequate use of epinephrine for anaphylaxis treatment needs to be publicized to both physicians and the general population.

Acute Disease↗
PubMed1996

Drug-associated anaphylaxis: 20 years of reporting in The Netherlands (1974-1994) and review of the literature.

BACKGROUND: Since 1963, the Drug Safety Unit of the Dutch Inspectorate for Health Care (DSU) holds a voluntary reporting system. OBJECTIVE: To analyse all reports received in the years 1974 to 1994, registered as anaphylaxis or as a diagnosis that could contain cases of anaphylaxis. METHODS: All reports were classified as probable or possible anaphylaxis according to previously described criteria and the causal relationship between exposure and anaphylaxis was assessed. RESULTS: Nine hundred and ninety-two reports possibly concerning anaphylaxis were received between 1974 and 1994. Fifty-six were unclassifiable. The remaining 936 reports concerned 326 men and 610 women. Three hundred and forty-five reports were classified as anaphylaxis probable, 485 as anaphylaxis possible, and 106 as anaphylaxis unlikely by previously specified criteria. Drugs frequently associated with anaphylaxis (causal relationship certain or probable) were: glafenine (326 reports classified as anaphylaxis probable or possible), combination preparations with (propy)phenazone or propyphenazone/phenacetine (39), diclofenac (30), dextran (20), ibuprofen (14), floctafenine (12), allergen extracts (12), sulfamethoxazole with trimethoprim (12), and trimethoprim (11). There is probably substantial under-reporting as well as reporting bias in these data. Furthermore, many reports were classified as possible and not as probable anaphylaxis because the temporal relationship was unknown or not reported. CONCLUSION: Drugs that caused anaphylaxis most frequently were glafenine, NSAID and certain antibiotics. Data from a voluntary reporting system such as the DSU are valuable as an early warning system for drugs that may induce anaphylactic reactions.

Adult↗
PubMed1998

[Anaphylaxis: clinical aspects, etiology and course in 118 patients].

Systemic anaphylaxis is a potentially life-threatening clinical syndrome resulting from the release of biologically active substances such as histamine or prostaglandins upon a target organ. The aims of our study were to analyze clinical data, causative agents and follow-up in subjects with severe anaphylaxis. Of 5689 subjects who were referred from May 1994 through October 1996 to the allergy-immunology out-patient clinic of the University of Berne, 118 (2.1%; 68 females and 50 males; mean age 41 years) had experienced severe systemic anaphylaxis with hypotension, loss of consciousness or shock. 104 individuals (88.1%) showed accompanying dermal symptoms, 85 (72.0%) respiratory and 52 (44.1%) gastrointestinal signs. Causative agents were identified in 93.2% of these attacks; they included drugs (33.9%), insect stings (23.7%), foods (18.6%), exercise (8.5%), latex (7.6%), and immunotherapy (0.9%) with pollen extracts. A suspected cause could not be determined in 8 subjects. Atopy was present in 64 individuals (54%). Prior to the index anaphylaxis, 21 of 110 subjects (19.1%) with an identified cause had experienced more than one episode of anaphylaxis. Follow-up survey showed that 29 of these 110 individuals (26.4%) were accidentally reexposed to the causative agents. 19 of 24 patients (79.2%) used their emergency kits, while 5 were not equipped with. Only one severe systemic reaction occurred in a subject who intentionally reexposed himself to the identified cause of anaphylaxis. Besides cardiovascular symptoms, systemic anaphylaxis most often involves the skin and respiratory tract. Since prevention of anaphylaxis focuses upon avoidance of precipitating factors, all individuals with anaphylaxis should be referred to an allergologist for identification of the causative agents. The cause of anaphylaxis could be determined in the majority of patients with anaphylaxis. However, unexpected exposures are frequent. Thus, all patients who have had one or more episodes of anaphylaxis should carry an emergency kit for self-administration, and should be instructed in its use.

Adolescent↗