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Background: Anaphylaxis is an infrequent cause of sudden death. Death often results from circulatory collapse, respiratory arrest, or both., Objective: To investigate the causes of death, anatomical findings, and comorbid diseases in cases of fatal anaphylaxis., Methods: This is a retrospective case review of 25 unselected cases of documented fatal anaphylaxis. Each case report contained details of the fatal reaction, a review of the medical record, and laboratory and autopsy findings. Serum tryptase concentrations were measured in 7 cases., Results: The anaphylactic deaths included 7 reactions to medications, 6 to radiocontrast material, 6 to Hymenoptera stings, and 4 to foods. The mean age was 59 years. The anaphylactic reaction began within 30 minutes of exposure in 21 of 25 cases, with death occurring within 60 minutes in 13 of 25 cases. Urticaria occurred in only 1 of 25 cases. Anatomical findings consistent with anaphylaxis were present in 18 of 23 patients undergoing autopsy. At least 1 significant comorbid disease was identified in 22 of 25 cases., Conclusions: (1) Elderly patients with substantial comorbid conditions constituted a significant number of the anaphylactic fatalities; (2) the onset of severe anaphylaxis occurred in less than 30 minutes in nearly every case; (3) 18 of 23 cases were associated with specific anatomical findings of anaphylaxis; (4) self-administered epinephrine was used in just 1 of 5 cases; and (5) serum total tryptase concentrations were elevated markedly in 4 of 7 cases tested.

Background: Pediatric asthma is the No. 1 chronic disease in childhood and is responsible for significant morbidity and mortality. In Nebraska, the number of asthma-related deaths is greater than the national average, and in 1998, 2 students died of acute asthma attacks while attending school in the Omaha public schools (OPSs). In response, we designed and implemented a program to respond to this problem., Objective: To implement and study a school-based program for the treatment of life-threatening asthma and anaphylaxis in the OPSs., Methods: The Emergency Response to Life-Threatening Asthma or Systemic Allergic Reactions (Anaphylaxis) Protocol was designed and evaluated in 78 OPSs from 1998 to 2003. Nurses and school staff were trained in the protocol, which required the use of nebulized albuterol and/or intramuscular epinephrine in conjunction with an emergency response procedure. Outcomes were measured by improvement in acute care in schools and survival of students., Results: In the 5 years of evaluation, 98 students were treated successfully. One student died. Of those treated with the protocol, equal numbers had at school both asthma action plans (AAPs) and metered-dose inhalers (MDIs), MDIs only, or neither AAPs nor MDIs. As a result of the program, there has been an increased awareness from parents, teachers, and physicians about the necessity of an emergency response program. In 2002, an outcome of the OPS program resulted in the formation of Attack on Asthma Nebraska to ensure that Nebraska schools have the education, training, and medications to respond to anyone experiencing a life-threatening asthma or anaphylaxis attack at school. The following year, a revised protocol was approved by the Nebraska State Board of Education for use in all Nebraska schools., Conclusions: Emergency response protocols provide protection for children while in school. This program should serve as a national model for other school-based programs for children and adolescents with asthma and anaphylaxis.

Background: Psyllium use has increased significantly in the United States in part due to its lipid-lowering property. The increased prevalence of consumption has led to its recognition as an emerging food allergen., Objectives: To report the case of a 42-year-old woman who experienced fatal anaphylaxis after ingesting a psyllium-based product and to review the literature., Methods: The MEDLINE database was searched for articles from 1966 to 2002 using the keywords psyllium or ispaghula and each of the following: allergy, hypersensitivity, anaphylaxis, and asthma. Both English and non-English articles were included., Results: Psyllium hypersensitivity has been well described in health care workers and pharmaceutical plant employees. Clinical manifestations of allergy range from upper respiratory tract symptoms on inhalation to anaphylaxis on ingestion. The prevalence of sensitization varies between these 2 groups. The allergenic epitope is not known., Conclusions: We present a case of psyllium hypersensitivity that resulted in death. There is a clear association between atopy and psyllium allergy. The case underscores the fact that even nonprescription "natural" products can be harmful to people with allergies.

Background: Peanut allergy is common, potentially severe, and there has been a recent surge in clinical investigation of this important food allergen., Objective: To provide the reader with a clinically oriented update on peanut allergy., Data Sources: English language articles were selected from PubMed searches (search terms: peanut allergy, food allergy, anaphylaxis) and selected abstracts with a bias toward recent (3 years) studies judged to have immediate, practical clinical implications., Results: Peanut allergy is an increasing problem in western diets that include this food. Both genetic and environmental factors influences the expression of this allergy. The at-risk subject is an atopic individual, with heightened risk for those with atopic dermatitis and/or other food allergies. The allergy is long-lived for most, may increase slightly in severity over time, but approximately 20% of young children will develop tolerance. Parameters that may identify the subset likely to achieve tolerance have been identified. Several large studies have determined laboratory parameters (skin tests, peanut-specific serum immunoglobulin E concentrations) with excellent predictive value (>95%) to diagnose current clinical reactivity or tolerance, although oral food challenges are necessary for a definitive diagnosis. Numerous practical lessons concerning management (avoidance, treatment, and prevention) have been identified., Conclusions: Recent studies provide the clinician with an armament of improved diagnostic and treatment modalities for peanut allergy. Studies are underway that are likely to provide more definitive therapies in the near future.