Dupilumab for Treatment of Food-Dependent, Exercise-Induced Anaphylaxis: Report of One Case

Food-dependent,exercise-induced anaphylaxis(FDEIA)is a potentially life-threatening disorder that often occurs with exercise,and patients typically have eaten a specific food within hours before disease onset.This disease is exceedingly rare,with a prevalence of 0.02%.No well-recognized prevention or treatment strategy has been available for FDEIA except avoiding triggers strictly.Here we report an 11-year-old boy with a history of recurrent anaphylaxis of unknown etiology more than 10 times within two years.As the anaphylactic symptoms had not been controlled after traditional treatments,the patient was given subcutaneous injection of dupilumab seven times within 33 weeks.During dupilumab treatments,the patient was exposed to culprit mushrooms plus exercises at least twice a month but without notable anaphylaxis.Thus,dupilumab may improve the allergic reactions in FDEIA patients.

Post Antibiotic Grade IV Anaphylaxis: A Case Report from the Emergency Department of Chu Donka

Anaphylaxis is a serious systemic reaction that is part of the general pattern of potentially fatal hypersensitivity reactions requiring immediate management. We report the case of a patient presenting to emergency with signs of malaria and pneumonia who was diagnosed with grade 4 anaphylaxis following antibiotic injection in the emergency department. The patient was 30 years old, with no previous history of anaphylaxis, and presented to the emergency department with fever, dry cough, headache and dizziness associated with prostration. Physical examination showed stable hemodynamics (BP = 110/80 mmHg, HR = 95 p/min,) and respiratory function with SpO2 = 98%, HR = 22 c/min and crepitus rales at the base of the lungs. The laboratory work-up carried out in the emergency department revealed a biological inflammatory syndrome associated with hyperleukocytosis of 11,260/mm3, a positive thick drop with GE(+) dp = 1183 T/microlitre;blood glucose = 0.83 g/l;Covid 19 RDT = (negative). A diagnosis of malaria and pneumonia was made and antibiotic therapy (ceftriaxone) and artesunate were indicated. During the injection of ceftriaxone 1 g, the patient became agitated, followed by cardiorespiratory arrest, confirming the diagnosis of stage 4 anaphylaxis. Treatment consisted of stopping the ceftriaxone injection, external cardiac massage and ventilation, intravenous adrenaline and vascular filling, which enabled the patient to recover and stabilize. The diagnosis of anaphylaxis is clinical. Early administration of adrenaline is the mainstay of treatment.

Safety of epinephrine for anaphylaxis in the emergency setting

BACKGROUND:While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms,inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety.The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis,including other emergent conditions,treated in emergency care settings.METHODS:A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing,administration,and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.RESULTS:Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection.The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.CONCLUSION:Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.

Evaluating the management of anaphylaxis in US emergency departments:Guidelines vs.practice

BACKGROUND:Anaphylaxis is characterized by acute episodes of potentially life-threatening symptoms that are often treated in the emergency setting.Current guidelines recommend:1) quick diagnosis using standard criteria;2) first-line treatment with epinephrine;and 3) discharge with a prescription for an epinephrine auto-injector,written instructions regarding long-term management,and a referral(preferably,allergy) for follow-up.However,studies suggest low concordance with guideline recommendations by emergency medicine(EM) providers.The study aimed to evaluate how emergency departments(EDs) in the United States(US) manage anaphylaxis in relation to guideline recommendations.METHODS:This was an online anonymous survey of a random sample of EM health providers in US EDs.RESULTS:Data analysis included 207 EM providers.For respondent EDs,approximately 9%reported using agreed-upon clinical criteria to diagnose anaphylaxis;42%reported administering epinephrine in the ED for most anaphylaxis episodes;and <50%provided patients with a prescription for an epinephrine auto-injector and/or an allergist referral on discharge.Most provided some written materials,and follow-up with a primary care clinician was recommended.CONCLUSIONS:This is the first cross-sectional survey to provide "real-world" data showing that practice in US EDs is discordant with current guideline recommendations for the diagnosis,treatment,and follow-up of patients with anaphylaxis.The primary gaps are low(or no) utilization of standard criteria for defining anaphylaxis and inconsistent use of epinephrine.Prospective research is recommended.

Giant Asian honeybee or Bambara stings causing myocardial infarction,bowel gangrene and fatal anaphylaxis in Sri Lanka:a case series

The sting of Giant Asian honeybee(Apis dorsata) or Bambara in Sinhala and Kanmge Kulavi in Tamil is a common environmental hazard in Sri Lanka known to cause immediate allergic reactions,which could be fatal in sensitized individuals.We reported myocardial infarction, bowel gangrene and fatal anaphylaxis in a prospectively proven case series and the association of these uncommon complications with delayed removal of stingers from the patients’skin.

Protracted anaphylaxis developed after peginterferon α-2a administration for chronic hepatitis C

Peginterferon is a key drug used to treat chronic viral hepatitis that is known for causing various side effects.Side effects occurring immediately after administration include headache, nausea, and influenza-like symptoms, such as fever and joint pain.However, reports of anaphylactic shock are extremely rare.Here we report a patient with protracted anaphylaxis who suffered shock symptoms after peginterferon α-2a administration for chronic hepatitis C.Although the patient improved temporarily with shock treatment, symptoms of anaphylaxis recurred.As peginterferon is often administered on an outpatient basis, it is important to recognize life-threatening side effects that may develop in a protracted manner.

Clinical and Laboratory Features, and Quality of Life Assessment in Wheat Dependent Exercise-induced Anaphylaxis Patients from Central China

Wheat dependent exercise-induced anaphylaxis（WDEIA） is a rare but potentially severe food allergy caused by the combination of wheat ingestion and physical exercise. The impact of WDEIA on quality of life（QOL） is unclear. This study characterized the clinical and laboratory features and investigated the QOL in WDEIA patients from Central China. Twenty-eight WDEIA patients were analyzed, and QOL was measured by validated Chinese version Food Allergy Quality of Life Questionnaire-Adult Form（FAQLQ-AF） and Food Allergy Independent Measure（FAIM） after obtaining the diagnosis. The results showed that half of the patients were females. The median onset age was 37 years old. The symptoms occurred within 1 h after wheat ingestion（26/28）. Symptoms of anaphylaxis included cutaneous（26/28）, respiratory（11/28）, gastro-intestinal（5/28） and cardiovascular manifestations（27/28）. Skin prick tests were positive to salt soluble（89.3%） and salt insoluble wheat allergen extracts（100%）. Positive rate to wheat, gluten and omega-5 gliadin specific Ig E was 64.3%, 92.9% and 92.9% respectively. Specific Ig E to omega-5 gliadin with a cut-off value 0.83 KU/L offered highly efficient diagnostic criterion for WDEIA（sensitivity： 89.3%; and specificity： 88.9%）. The mean scores of FAQLQ-AF and FAIM were 4.70 and 4.98 respectively and level of anti-omega-5 gliadin Ig E had positive correlations with FAQLQ scores. Thereby, WDEIA is commonly found in mid-age adults. In most cases, multi-organs especially skin and cardiovascular systems are involved. Salt insoluble wheat allergen skin test and serum specific Ig E to gluten and omega-5 gliadin help to diagnose WDEIA. QOL in WDEIA patients is severely impaired.

Exercise-induced anaphylaxis with an Ayurvedic drug as cofactor:A case report

BACKGROUND The practice of Indian Ayurvedic medicine is spreading in Western countries and Shilajit is one of the most used drugs, for its antioxidant activities and immunomodulatory effects. Albeit Shilajit has showed a high degree of safety, it can act as cofactor of anaphylaxis, especially in condition at high risk, such as mast cell activation syndrome(MCAS). We reported this case to sensitize practitioners to investigate to the use of complementary and alternative medicine,in case of exercise-induced anaphylaxis(EIAn).CASE SUMMARY A 43-year-old woman, working as a dance teacher, developed urticaria after ingestion of rice, tuna and Shilajit, which did not respond to intramuscular corticosteroids. Subsequently, she developed dyspnoea and hypotension with loss of consciousness that arose 1 h after sexual activity. The patient did not refer personal history of atopy. Specific IgE for main food allergens resulted negative,with total IgE levels of 14 IU/L. Oral provocation test with Shilajit was not perfomed because the patient refused, but we performed prick-by-prick and patch test that resulted negative. Serum tryptase at the time of anaphylaxis was 20.6 μg/L that fell down to of 10.6 μg/L after therapy, but has remained at the high value after two days and during the follow-up. We performed an analysis of the c-KIT gene in peripheral blood, which was negative. We felt the diagnosis consistent with EIAn in a patient with a possible MCAS.CONCLUSION In Western countries the use of drugs from Ayurvedic medicine is more common than in the past. These substances can be cofactors of anaphylaxis in patients with risk factors.

Perioperative anaphylaxis in patients underqoinq cardiac surqery

Objective Patients undergoing cardiac surgery are exposed to a large range of drugs and foreign substances,which might result in anaphylaxis.Severe anaphylaxis in cardiac surgical patients could be life-threatening.Therefore,timely diagnosis and proactive treatment are crucial.Definition of anaphylaxis,epidemiology of anaphylaxis and common allergens,specific anaphylaxis,diagnosis and management of peri-operative anaphylaxis in cardiac surgery patients were discussed in this review.

IgE Reactivity of Potential Allergens from the Swimming Crab Portunus trituberculatus and the Research of ELISA Reagent for Detecting Crab Food Anaphylaxis

Crustacean is one of the major allergic foods.It is of great significance to identify more crab allergens and research the detection methods for crab food anaphylaxis.In this study,IgE reactivity to three recombinant proteins from Portunus trituberculatus,including tropomyosin(rPtTM),myosin light chain(rPtMLC),and pancreatic lipase(rPtPL),were detected by enzyme-linked im-munosorbent assay(ELISA).The expressions of tropomyosin(TM)in various tissues of P.trituberculatus were detected by Western blot(WB).Furthermore,microplates were coated with rPtTM and the ELISA conditions were optimized.The cut-off value was deter-mined by the receiver operating characteristic(ROC)curve.Among 51 crab-allergic sera,21(41.2%)showed positive IgE to rPtTM.Other 70 crab-allergic sera more frequently recognized rPtPL(9/70;12.9%),followed by rPtMLC(1/70;1.4%).WB results showed that TM was mainly expressed in the muscle,followed by the heart and a small amount in gills and the testis.The optimal results showed that the coating condition of rPtTM was 50 ng per well with coating for 3 h at 37℃.The optimal blocking condition was 1.2%BSA with blocking for 3 h at 37℃,and the optimal dilution of the second antibody was 1:1500.The ROC curve showed that the ELISA reagent had high sensitivity(83.52%)and specificity(98.00%)when the cut-off value was 0.45.All results indicated that tropomyosin is the major allergen of P.trituberculatus,and myosin light chain and pancreatic lipase are the potential allergens.Addi-tionally,the ELISA reagent developed with the rPtTM was feasible for laboratory detection of crab anaphylaxis.

Skin Anaphylaxis Test of Purified Protein HAS1 in Cavies

The antifungal protein HAS1 is a new antifungal protein isolated from the genome of Bacillus subtilis HAS,which has a good inhibitory effect on various pathogenic fungi in sugarcane.This study aimed at evaluating the immunological transfer reaction of the test sample through repeated skin contact by observing whether the cavy skin repeatedly exposed to purified protein HAS1 suffers from allergic reaction and how strong is the allergic reaction.The results showed that the test group and the vehicle control group exhibited no allergic reaction in the skin immediately and at 24,48 and 72 h and had an mean reaction score and a sensitization rate both of 0,so the results of the naked eye observation were both nonallergenic to cavy skin;and in the positive control group,the cavies were observed to be highly sensitized immediately after removing the drug,mildly sensitized at 24 h,and not sensitized at 48 and 72 h,which meant the skin allergy was alleviated with the observation time.It is suggested that the purified protein HAS1 is negative for cavy skin anaphylaxis test (nonallergenic to cavy skin),which provides an experimental basis for further utilization of the protein and its coding gene.

Establishment of Cytokines Quantitative PCR Methods and Its Application in Anaphylaxis Study of Houttuynia Cordata Injection

We design specific primers, according to the four kinds of important macaque cytokines, based on macaque β-action genes, then extract total RNA in peripheral blood mononuclear cells of macaques, and trascriptase cDNA reversely after establishing real-time quantitative PCR, and test the relative expression amount of several kinds of important cytokines during the hypersensitive process. The testing method of quantitative PCR in this experiment is highly sensitive, all cytokines are up to 102 copies/μL and highly reproducible, the intraassay and interassay coefficients of variation are less than 6%. The method applied to the sensitive reaction experiment on cytokines induced by houttuynia cordata turns out that the cytokines relative expression of houttuynia cordata distillate with low dose group and high dose group is significantly higher than that of saline group (P > 0.01). Meanwhile, significantly increased IL-4, IL-10 and IL-13 and decreased IFN-γ are found in both group A and group B after houttuynia injection (P > 0.05).

Anaphylaxis and Undiagnosed Aspirin Exacerbated Respiratory Disease in the Ambulatory Surgery Center: A Case Report

Severe bronchospasm and anaphylaxis are unanticipated emergencies that may occur in the ambulatory surgery setting. I present a case in which an asthmatic male with nasal congestion has anaphylaxis after induction, with severe bronchospasm as the primary manifestation. During the course of hospitalization, he was exposed to aspirin and a second episode of severe bronchospasm occurred. He was diagnosed with both anaphylaxis to an anesthetic medication and Aspirin Exacerbated Respiratory Disease, or Samter’s Triad.

Anaphylaxis to Skin Prick Testing in a 29-Year-Old Woman

Introduction: Skin prick testing (SPT) is a common test to diagnose IgE sensitization and the rate of adverse reactions is very low. Case Presentation: 29-year-old woman with anaphylactic reaction to routine SPT with 11 allergens (aero and food). Discussion: Allergy profile included multiple food and inhalant allergies, polysensitization, prior episode of anaphylaxis to mushrooms, active eczema and active hay fever but not active asthma. Conclusion: Anaphylaxis to SPT, although a rare event, is unpredictable necessitating availability of appropriate personnel and adequate resuscitation facilities for all testing.

Anaphylaxis in Pregnancy

Anaphylaxis is a serious, generalized, hypersensitivity reaction which can be life threatening and one of the most serious medical emergencies. Anaphylaxis in pregnancy although rare, is attributed to the use of various drugs in pregnancy mainly following an administration of antibiotics. This review article describes several aspects of anaphylaxis such as aetiology, pathophysiology and management. Immediate recognition and initiation of treatment are the keys for satisfactory outcome. A multidisciplinary care and provision are other keys for achieving this good outcome.

Barriers and challenges affecting parents’use of adrenaline autoinjector in children with anaphylaxis

BACKGROUND Anaphylaxis is a life-threatening condition that develops as a reaction to exposure to an allergen which can be found in common foods such as cow's milk,egg,fish,and nuts in children.The use of an intramuscular adrenaline auto-injector(AAI)is considered the most essential treatment in these situations and parents and caregivers are always encouraged to carry this device for use in an emergency which commonly takes place in public places such as restaurants,schools,and parks,where medical staff are not guaranteed to be available.However,previous studies,in different settings,have reported underuse of the AAI by parents.AIM To explore the reasons for underutilisation of the AAI in our community.METHODS A cohort of parents attending the paediatric allergy clinic at Al Ain Hospital in the United Arab Emirates completed a questionnaire survey aimed at assessing their understanding and knowledge of their child's allergy management,including their aptitude with the use of the AAI,as well as their competence and comfort in providing this treatment in an emergency.RESULTS Of 47 parents participating in the study,39 were Emirati parents(83%and most parents who completed the survey were mothers(66%).As expected,food was the main cause of allergic reactions requiring prescription of the auto-injector device.Tree nuts and peanuts were noted to be the most common offending food in these children(62%and 38%,respectively).A doctor provided demonstrations and training on using the auto-injector device to 94%of the parents.More than two-thirds of the parents and caregivers(79%)were deemed knowledgeable on the indication for use of the device.Reluctance to administer the device was expressed by many of the parents,despite their satisfaction with the coaching they received on using the device in the study.CONCLUSION Ongoing coaching and teaching of parents on use of the AAI is paramount.However,this should be carried out together with psychological support to aid the parents to eliminate their hesitancy and acquire sufficient confidence in using the device when needed.Group teaching and sharing experiences is an excellent educational technique in a non-formal setting.Paediatric clinic play therapists can also have a role in needle phobia desensitisation for parents and children.More research is needed to explore the lack of empowerment and other reasons behind their fear and anxiety in using the device to plan effective interventions.

Managing Exercise Induced Anaphylaxis in Labour

Exercise induced anaphylaxis is an uncommon condition first reported by Sheffer and Austen in 1980. In this condition there is an exercise-induced lowering of the mast cell degranulation threshold, causing release of histamine and other mediators leading to the progression of symptoms of anaphylaxis. These can range from mild cutaneous pruritis and urticaria to severe systemic manifestations such as hypotension, cardiovascular collapse, syncope and even death. In Pregnancy and Labour, this can result in a number of complications and challenges. We will describe a case we were involved with.

Anaphylaxis to Cisplatin after Carboplatin Hypersensitivity Reaction in Advanced Non-Small Cell Lung Cancer

Patients with non-small cell lung cancer (NSCLC) who have received more than one cycle of platinum-based chemotherapy in their lifetime may be at risk of hypersensitivity. The overall incidence of hypersensitivity to carboplatin ranges from 1% to 27% and that of hypersensitivity to carboplatin is between 5% and 20%. However, the actual incidence of cross-reactivity between platinum salts has not yet been known. In this paper, we reported a case of a 39-year-old man with advanced non-small cell lung cancer, who had cisplatin anaphylaxis after having had carboplatin hypersensitivity at the previous cycle. The anaphylactic reaction was managed successfully with adrenaline, corticosteroids, antihistamines, oxygen mask and isotonic fluid support. No further reactions were observed and after that he stopped the platinum regimen. This case illustrates that NSCLC patients may experience hypersensitive and cross-reactivity to both carboplatin and cisplatin. It is important to be aware of the possibility of anaphylaxis so that appropriate premedication or effective treatment can be promptly instituted.

ew Diagnostic Criteria of Wheat-Dependent, Exercise-Induced Anaphylaxis in China

Background： Wheat-dependent, exercise-induced anaphylaxis （WDEIA） is an allergic reaction induced by intense exercise combined with wheat ingestion. The gold standard for diagnosis of WDEIA is a food exercise challenge： however, this test is unacceptable for Chinese WDEIA patients and unable to be approved by the Ethics Committee of Chinese hospitals due to substantial risk. There are no diagnostic criteria tbr Chinese WDEIA patients. The aim of present study was to propose new practical diagnosis criteria t＇or Chinese WDE1A patients. Methods： We prospectively included 283 clinically diagnosed WDEIA patients from January 1,2010 to June 30, 2014, and in tile meanwhile, three groups were enrolled which included 133 patients with the history of anaphylaxis induced by lbod other than wheat. 186 recurrent urticaria patients, and 94 healthy participants. Clinical comprehensive evaluation by allergists used as the reference gold standard, receiver operator characteristic （ROC） curves were plotted, areas under curve （AUC） tbr specific immunoglobin E （slgE） were compared to evaluate the diagnostic value of lgE specific to wheat, gluten, and 0）-5 gliadin. Patients were followed up by telephone questionnaire 1 year after diagnosis. Results： We reviewed 567 anaphylactic reactions in 283 WDEIA patients. Of these anaphylactic reactions, 415 （73.3%） reactions were potentially life-threatening anaphylaxis. Among the 567 anaphylactic reactions, 75% （425/567） occurred during exercise. The highest AUC （0.910） was observed for sIgE for gluten, followed by omega-5 gliadin （AUC 0.879）. Combined gluten- and co-5 gliadin-specific IgE testing provided sensitivity and specificity of 73.1% and 99.0%, respectively. During the 1-year follow-up period, repeat anaphylaxis was rare when patients observed strict avoidance of wheat products combined with exercise or other triggering agents. Conclusions： In this study, we proposed diagnostic criteria and management of WDEIA patients in China, Our present study suggested that confirmed anaphylactic reactions triggered by wheat with positive slgE to gluten and omega-5-gliadin may provide supportive evidence for clinicians to make WDEIA diagnosis without perforating a food exercise challenge.

Anaphylaxis effect and substance basis of honeysuckle extract

Objective:To explore the anaphylaxis effect and anaphylaxis substances of honeysuckle.Methods:Rat peritoneal mast cells(PMC)were separated and purified,the cells were incubated with compound 48/80(0.02 g/L),physiological saline and honeysuckle extract(120 g/L)at 37°C for 0,15,30,45 and 60 min.Degranulation were observed by optical microscope and transmission electron microscope.Annexin V positive cell rate was detected by flow cytometry to reflect the degranulation rate of PMC.SD rats were supplied with honeysuckle extract by intravenous injection at a dose of 2.25 g/L.After administration,different parameters were analyzed,including the symptoms,histamine(HIS)and tryptase(MCT)levels,which were determined to explore the effect of anaphylaxis.Regression analysis was used to calculate the relationships between the peaks and the pharmacological effects to explore potentially anaphylactoid components.Results:The percentage of Annxin V positive cells and the degranulation ratio were markedly elevated in PMC treated with honeysuckle extract for more than 15 min(P<0.05).HIS and MCT level were significantly elevated after injection of honeysuckle extract for more than 15 min.Morphology of PMC and systemic symptoms were also changed compared with the controlled group(P<0.05).Regression analysis was used to calculate the relationship between peaks and pharmacological effects,and to determine peaks 7,10 and 13 as possible anaphylactoid ingredients.Conclusion:This study established a prospective method to clarify the anaphylactoid components of honeysuckle extract,which would provide guidance for screening anaphylactoid components in traditional Chinese medicine injections containing honeysuckle in the prescription.