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Anaphylaxis is a life-threatening condition that involves severe cutaneous, respiratory, and cardiovascular symptoms. Disseminated intravascular coagulation (DIC) is an acquired, widespread activation of coagulation that can be caused by infectious conditions (e.g., sepsis) and noninfectious conditions. The onset of DIC following anaphylaxis is not commonly known, and information regarding the pathomechanism linking anaphylaxis to DIC is scarce. Further, demographic and clinical data in anaphylaxis-induced DIC are still missing to this day. Triggered by a case of anaphylaxis-induced DIC that seamlessly transitioned to lethal sepsis-induced DIC, we aimed to characterize the patient population affected by anaphylaxis-induced DIC by performing a review of existing literature and expand the discussion to underlying mechanisms. The overall mortality of the patient cohort ( n  = 30) identified by the literature review was 50%. All patients that died either suffered a bleeding event or a thrombotic event. The majority of patients ( n  = 25/30; 83%) had bleeding events; thrombotic events were only reported in nonsurvivors ( n  = 9/15 or 60% of nonsurvivors; vs. n  = 0/15 in survivors; p  < 0.001). Nonsurvivors of anaphylaxis-induced DIC were on average 25 years older than survivors ( p  = 0.068). In conclusion, DIC can complicate anaphylaxis and is expected to contribute to poor microvascular perfusion after anaphylaxis. Particularly, elderly patients with known cardiovascular disease and patients who develop thrombotic events are susceptible to lethal outcomes. As a rare and largely uncharacterized disease entity, further research is needed to investigate the link between DIC and anaphylaxis and to potentially identify better treatment strategies., Competing Interests: None declared., (Thieme. All rights reserved.)

This study investigated the characteristics and frequency of perioperative anaphylactic shock induced by cefuroxime, so as to provide a reference for the safe and rational use of cefuroxime in the perioperative period. Cases of perioperative anaphylactic shock caused by cefuroxime in our hospital from 2011 to 2021 were extracted from the Adverse Drug Reaction Monitoring System. Literature reporting adverse drug reactions (ADR) including cefuroxime-induced anaphylactic shock in perioperative settings was collected from the CNKI, VIP, Wanfang, PubMed, and Web of Science databases from their respective inception to May 2022. Statistical analysis was performed for all cases of cefuroxime-induced perioperative anaphylactic shock. A total of 31 patients were included [13 men (48.1%) and 14 women (51.9%)], most of whom were over 60 years old ( n =16, 59.3%); 9 (29.0%) patients had a history of drug allergy; 5 (16.1%) patients had received skin tests, but with negative results; 28 (90.3%) patients received treatment intravenously; 22 (71.0%) patients were treated after anesthesia. For 20 (64.5%) patients the ADR occurred within 10 minutes after anesthesia. The main manifestations were hypotension, dyspnea, rash, and tachycardia. For all patients, symptoms resolved after withdrawal of the drug and active rescue, and there were no deaths. A history of allergy and skin test findings may have limitations in predicting perioperative anaphylactic shock caused by cefuroxime; greater vigilance should be exercised when using cefuroxime in the perioperative period. Close monitoring is recommended for patients undergoing treatment with cefuroxime. Rescue therapy should be administered for allergic shock, and suitable response measures must be taken in a timely manner to ensure the safety of patients.

A 69-year-old woman suffering with multiple myeloma developed coronavirus disease 2019 (COVID-19). Shortly after administration of remdesivir, she presented with symptoms of facial flushing, wheezing, and hypoxemia. Subsequently, thrombocytopenia and hypofibrinogenemia rapidly manifested, leading to a diagnosis of enhanced fibrinolytic-type disseminated intravascular coagulopathy (DIC). This clinical presentation was considered an immediate hypersensitivity reaction with associated coagulation abnormalities induced by remdesivir. Although remdesivir is generally considered safe and efficacious in the treatment of COVID-19, physicians should remain vigilant regarding the potential for severe adverse events associated with this medication.

Background: Preterm labor is caused by multiple etiologies, including intra-amniotic infection and/or intra-amniotic inflammation, vascular disorders, cervical disease, decidual senescence, and breakdown of maternal-fetal tolerance. Accumulating evidence in vivo and in vitro has shown that an allergic reaction, including anaphylaxis, can induce preterm uterine contractions. This report describes a case of a pregnant woman who developed anaphylaxis and regular uterine contractions after the ingestion of a strawberry-coated biscuit. We also review the mechanism of allergic reaction (hypersensitivity)-induced preterm labor. Case presentation A 31-year-old woman (gravida 1, para 0) at 30 +2 weeks of gestation was admitted to the labor and delivery unit with regular uterine contractions and anaphylactic symptoms after she ingested a strawberry-coated biscuit as a snack. The uterine contractions resolved after the treatment of anaphylaxis by administering antihistamines and epinephrine. The patient subsequently delivered at 39 +3 weeks of gestation. The amniotic fluid profile showed no infection or inflammation. A postpartum skin-prick test confirmed a positive type 1 hypersensitivity reaction to the strawberry-coated biscuit., Conclusions: We report a case of anaphylaxis-induced uterine contractility in which uterine contractions subsided after the treatment of anaphylaxis. The absence of intra-amniotic infection and/or intra-amniotic inflammation and the cause of the anaphylaxis were confirmed. Our findings indicate that maternal allergic reactions may be one of the mechanisms of preterm labor., (© 2024. The Author(s).)

Background: Undertreatment of anaphylaxis with epinephrine continues to be an unmet need and is a particular challenge among infants and toddlers., Objective: To address this gap by identifying barriers and solutions to appropriate and timely administration of epinephrine., Methods: We conducted a national online survey among primary caregivers of children who experienced a severe food-induced allergic reaction when younger than 36 months. Outcomes of interest included epinephrine use in community and health care settings to treat probable anaphylaxis., Results: Of 264 probable anaphylaxis cases, 39% of infants (aged <12 months) and 61% of toddlers (aged 12-35 months) received epinephrine at any time during the child's most severe allergic reaction (P = .001). A previous diagnosis of a food allergy was reported in 62% of cases where epinephrine was used compared with 26% of cases where epinephrine was not used (P < .001). In children with a previous diagnosis of a food allergy, epinephrine was used in 89% of those who were prescribed an anaphylaxis action plan compared with 50% of those without a plan (P = .001). The adjusted odds ratio for the association between having an anaphylaxis action plan and epinephrine use in cases of probable anaphylaxis was 5.39 (95% confidence interval, 2.18-13.30)., Conclusions: Epinephrine use at any time (including in health care settings) during probable anaphylaxis is more likely in infants and toddlers with a previously diagnosed food allergy than those without diagnosis. The provision of an anaphylaxis action plan is also associated with increased epinephrine use during probable anaphylaxis in this population., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: There is no consensus method to identify anaphylaxis in sublingual immunotherapy (SLIT) trials. Standardized Medical Dictionary for Regulatory Activities (MedDRA) queries (SMQs) are standardized groupings of MedDRA terms used in drug safety monitoring., Objective: To develop a method to identify potential anaphylaxis in SLIT-tablet trials using SMQ searches and case definitions of anaphylaxis adopted from the National Institute of Allergy and Infectious Disease., Methods: The SMQ search tool contained 2 criteria including treatment-emergent adverse events (AEs): (1) narrow MedDRA terms related to anaphylaxis and (2) all AEs with broad MedDRA terms from at least 2 of 3 categories (respiratory/skin/cardiovascular) occurring on the same day. Criteria were applied to a pooled data set of all subjects from 48 timothy grass, ragweed, house dust mite, and tree SLIT-tablet trials (SLIT-tablet, N = 8200; placebo, N = 7033). Additional search strategies were any treatment-emergent AE with MedDRA preferred term "hypersensitivity" and epinephrine administrations. Identified potential cases underwent blinded independent medical expert review. Nonanaphylaxis cases were designated local AEs or mild to moderate systemic reactions., Results: Using the SMQ search tool and after subsequent medical review, 8 anaphylaxis cases were identified; 3 were considered treatment-related, resulting in a proportion of anaphylaxis cases/subject of 0.02% (2 of 8200) with SLIT-tablet and 0.01% (1 of 7033) with placebo. One additional anaphylaxis case related to SLIT-tablet was identified by the preferred term "hypersensitivity." The 3 anaphylaxis cases associated with SLIT-tablet treatment were not life-threatening. The epinephrine administration rate was 17 of 8200 (0.2%) with SLIT-tablet treatment and 2 of 7033 (0.03%) with placebo., Conclusions: SMQ search criteria for identifying potential anaphylaxis related to SLIT were developed. Anaphylaxis was rare for SLIT-tablets., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Anaphylaxis is a severe, potentially life-threatening generalized or systemic hypersensitivity reaction. Sequential reports have cited anaphylaxis as the most common cause of anaesthesia-related deaths. We undertook an audit at a quaternary centre, examining the management of perioperative anaphylaxis and quality of referrals made to our anaesthesia allergy testing service., Methods: The data of 41 patients consulted at St Vincent's Hospital Melbourne for perioperative anaphylaxis between 17th of January 2020 and 20th of January 2022 were analysed. Intervention outcomes included total intravenous fluid administered, adrenaline administration, instigation of CPR and the collection and the timing of serum tryptase samples. We also assessed referral quality, provision of institutional allergy alert and time elapsed from the anaphylaxis event to allergy testing. Contemporaneous Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) guidelines were used as the reference standard for most outcomes., Results: Our data reveals compliance of <80% with respect to intravenous fluid administration, referral quality and tryptase sampling, particularly at the 4-h timepoint., Conclusion: Surgical leadership and patient advocacy in the post-acute phase would likely facilitate requisite testing and improve the quality of counselling. We recommend institutions adopt a case-by-case review of management compliance with recommendations. Additionally, we advocate for the inclusion of a prompt to the ANZAAG referral form, that encourages the operator to update their patient's institutional allergy alert while awaiting allergy testing., (© 2023 Royal Australasian College of Surgeons.)

Rationale: Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome., Patient Concerns: A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach., Diagnoses: On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome., Interventions: Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min., Outcomes: After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae., Lessons: If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Kounis syndrome is a hypersensitivity disorder secondary to allergy or anaphylaxis that can result in acute coronary syndrome. Kounis syndrome has an increasing prevalence since its first identification in 1950. Divided into 3 subtypes, each with diagnostic criteria, the management of Kounis syndrome presents a clinical challenge. We aim to identify the pathophysiological mechanisms and review the diagnosis, epidemiology, management strategies, and future directions of Kounis syndrome. As Kounis syndrome becomes more widely recognized in the medical community, the role of diagnosis, treatment, and future immunomodulatory prevention strategies will continue to unfold., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Diagnostic testing of patients who present for evaluation of insect venom allergy can involve many levels of investigation. A detailed initial history is critical for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict severe future sting reactions and underlying mast cell disorders. Venom skin tests and specific IgE measurement can confirm the diagnosis but have limited positive predictive value for the frequency and severity of future sting reactions. Testing for serum IgE to recombinant venom component allergens can distinguish true allergy from cross-reactivity to honey bee and yellowjacket venoms. Basophil activation tests can improve the detection of venom allergy and predict the severity of reactions and the efficacy of venom immunotherapy but are limited in availability. An elevated basal serum tryptase level is an important marker for severe sting anaphylaxis and underlying mast cell disorders (eg, hereditary α-tryptasemia and clonal mast cell disease). When there is high suspicion (eg, using the Red Espanola de Mastocytosis score), bone marrow biopsy is the definitive tool to characterize mast cell disorders that are associated with the most severe outcomes in patients with insect sting allergy., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Enhancing agents in echocardiography are used frequently to improve endocardial border visualization and assessment of structural heart disease. We present a unique case of anaphylactic shock with acute coronary syndrome following administration of sulfur hexafluoride echo enhancing agent. This case emphasizes the importance of recognizing anaphylaxis to enhancing agents, as well as recognizing the potential relationship between anaphylaxis and acute coronary syndrome with in-stent thrombosis., (© 2023 Wiley Periodicals LLC.)

Background: Having a better understanding of the risk factors of severe anaphylaxis is a crucial challenge for physicians., Methods: To retrospectively analyse fatal/near-fatal anaphylaxis cases recorded by the Allergy-Vigilance® Network (2002-2020) and evaluate the characteristics associated with survival, age and allergens., Results: Among the 3510 anaphylaxis cases documented in the network, 70 (2%) patients (males: 57%; mean age: 35.4 y) presented grade 4 (Ring-Messmer) anaphylaxis and 25 died (19 food-related); 33% had a history of asthma. The main allergens were food (60%; peanut, 20%; milks, 11%) involved in 25/26 cases in children and in 17/44 (39%) cases in adults. Non-food anaphylaxis was related to drugs/latex (24%; neuromuscular blocking agents, 10%; betalactamins, 6%), Hymenoptera (16%). Three food-related cases (one death) occurred during oral food challenge in children. Patients with a food allergy were younger (22.2 years vs. 55 years, p < .001), had more likely a history of asthma (50% vs. 7%; p < .001), a pre-existing allergy (62% vs. 18%; p < .001) compared with other allergies. A cofactor was identified in 35 cases (50%) but predominantly in adults as opposed to children (64% vs. 27%; p = .01). The patients who died were younger (25.6 vs. 40.8 years; p = .01) than the survivors and mostly presented bronchospasm (56% vs. 29%; p = .05). Gaps in the prevention and management of anaphylaxis were noted in 15 cases (21%)., Conclusions: Severe food anaphylaxis has specific features compared with other causes such as young age, asthma history and exercise. Food is also involved in severe anaphylaxis in adults that should not be underestimated., (© 2023 European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Background: Multiple anaphylaxis mediators have been demonstrated to provoke migraine-like attacks following intravascular infusion, suggesting that anaphylaxis could cause headache; however, headache is rarely noted in anaphylaxis and is not included among diagnostic criteria., Objective: Our study objectives were to estimate the frequency of headache among prospectively enrolled emergency department (ED) patients with anaphylaxis and assess the association of headache with patient and anaphylaxis characteristics., Methods: A cross-sectional study of ED patients aged ≥5 years who met anaphylaxis diagnostic criteria from January 8, 2020 to September 9, 2022 was conducted. The primary outcome of interest was headache frequency among patients who met at least one anaphylaxis criterion. We explored the association of headache with patient characteristics and anaphylaxis characteristics., Results: We included 63 patients with anaphylaxis. In all, 17 (27%, 95% confidence interval [CI] 17%-40%) patients reported the presence of a headache. Female patients had more than a nine times increased odds of having headache (odds ratio [OR] 9.3, 95% CI 1.14-77.1, p = 0.016). Presentation with headache was associated with the presence of dyspnea (OR 5.5, 95% CI 1.56-19.7, p = 0.006)., Conclusion: Headache in anaphylaxis may be more common than previously recognized, especially in females. Larger prospective studies are needed to characterize headache as a marker of neurological involvement in anaphylaxis., (© 2023 American Headache Society.)

Background: Food-dependent exercise-induced allergic reactions can manifest with wheals, angioedema, and anaphylaxis, alone or in combination., Objective: To systematically review the clinical manifestation, culprit foods and exercise, augmenting factors, comorbidities, and treatment options of each phenotype., Methods: Using predefined search terms, we assessed and analyzed the relevant literature until June 2021. Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations were applied to this systematic review., Results: A total of 231 studies with 722 patients were included. The most common phenotype was anaphylaxis with wheals, angioedema, or both, reported in 80% of patients. This was associated with a higher number of anaphylactic episodes, augmenting factors, and use of on-demand antihistamine compared with the least common phenotype, anaphylaxis without wheals or angioedema, reported in 4% of patients. Anaphylaxis with wheals/angioedema was also associated with distinct characteristics compared with stand-alone wheals, angioedema, or both, in 17% of patients. Patients with anaphylaxis were older at the time of disease onset, less often had a history of atopy, showed more positive results in response to food and exercise provocation tests, had a more restricted spectrum of culprit foods, and more often used on-demand epinephrine., Conclusions: The three phenotypes of allergic reactions to food and exercise differ in clinical characteristics, triggers, and response to treatment. Knowledge of these differences may help with patient education and counseling as well as disease management., (Copyright © 2023 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: Emerging literature has detailed the safe use of cefazolin in patients with immunoglobulin E-mediated penicillin allergy labeling (PAL) such as hives and anaphylaxis. The purpose of this article is to detail efforts led by an antimicrobial stewardship pharmacist working with an interdisciplinary team to optimize preoperative antimicrobials in patients with PAL., Methods: A pharmacist-led, interdisciplinary collaborative practice agreement (CPA) was activated in January 2020 to permit pharmacists to independently optimize preoperative antibiotics to the preferred cefazolin in patients with PAL if nonsevere or severe reactions had been reported. A patient registry was established covering the timeframe between January 8, 2020, and January 6, 2022. Reaction during surgery was assessed via 2-provider documentation, which included surgeon and anesthesiology staff documentation of any complications during the procedure related to a suspected allergic safety event. Utilization of cefazolin, clindamycin, and vancomycin for preoperative prophylaxis was monitored before and after implementation of the CPA., Results: During the stated timeframe, 10,182 procedures and/or surgeries were completed on 1,572 (15.4%) patients with PAL and 659 (41.9%) patients previously reporting at least one reaction categorized as a severe reaction, which was hives for 71.2% of these patients. Of the 659 patients with PAL reporting a severe reaction, 356 received a preoperative cephalosporin (cefazolin, 98.8%; ceftriaxone, 1.2%) and tolerated it without a reported safety event, including 52 patients with PAL previously reporting anaphylaxis. An increase in preferred preoperative antimicrobial prophylaxis utilization was noted (cefazolin: 86% to 96.3%, P < 0.001; 2019 to 2021) with reductions noted in the use of nonpreferred preoperative antibiotics (clindamycin: 2.1% to 0.2%, P < 0.001; vancomycin: 3.2% to 0.4%, P < 0.001; 2019 to 2021)., Conclusion: A pharmacist-led, interdisciplinary CPA increased preferred preoperative antimicrobial use in patients with PAL reporting severe allergic reactions, including hives and anaphylaxis, without reported safety events., (© American Society of Health-System Pharmacists 2022. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Stress cardiomyopathy is a transient left ventricular dysfunction caused by physiologic or pathologic stressors. Anaphylaxis is a hypersensitivity disorder that can lead to a rapid life-threatening respiratory collapse. It happens due to exposure to allergens including medications. During anaphylaxis, there is a compensatory release of catecholamines that can lead to stress cardiomyopathy. In this case, nab-paclitaxel infusion led to anaphylaxis with respiratory failure. Echocardiogram showed features of diffuse hypokinesis with preserved basal segment contractility, and cardiac catheterization did not show any evidence of obstructive coronary artery disease. The overall clinical picture suggested stress cardiomyopathy. The patient was treated with guideline-directed medical therapy which resulted in normalization of the ejection fraction with no symptoms of congestive heart failure at any point. The patient was thereafter resumed on a reduced dose of nab-paclitaxel. This case report adds to the spectrum of infusion-related reactions associated with paclitaxel and demonstrates the course of events in the management of anaphylaxis and stress cardiomyopathy in this scenario., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Vector-borne diseases are a growing burden worldwide. In particular, the risks of allergic reactions to bites are associated with growing arthropod populations in contact with the public. The diversity of allergic reactions associated with host and arthropod factors difficult disease diagnosis, prognosis and prevention. Therefore, arthropod-associated allergies are underdiagnosed and require better surveillance of arthropod populations and disease diagnosis and management., Methods: To face these challenges, in this study, we describe five cases to illustrate arthropod-associated allergies with different symptomatology, including alpha-gal syndrome (AGS) associated with anti-alpha-gal IgE antibody titres. Information on symptoms in response to arthropod bites was collected from patients and medical doctors., Results: The five cases included patients bitten by a robber fly and different tick species. Cases were in Spain or U.S.A. Two cases were diagnosed with AGS and one case was diagnosed with anaphylaxis in response to tick bite with high anti-alpha-gal IgE levels. The symptoms in response to arthropod bites vary between different cases., Conclusion: Allergic reactions and symptoms in response to arthropod bites vary in association with host and arthropod factors. Herein we propose recommendations to control allergic symptoms, associated disease risk factors and the way forward to advance in the prevention and control of arthropod-associated allergies.

Background: Anaphylaxis is a potentially life-threatening condition that occurs in the emergency department (ED). Although anaphylaxis is rapidly recognized and treated in the hospital compared with that in the community, in some cases, it does not respond to proper management., Objective: The aim of this study is to describe our experience of cases of refractory anaphylaxis leading to cardiac arrest in hospital, to review their characteristics compared with those seen in the community, and to discuss the best management practices for anaphylaxis-induced cardiac arrest with a literature review., Methods: We reviewed the medical records of patients referred to the ED with possible in-hospital anaphylaxis between January 2017 and May 2021. According to the anaphylaxis protocol, epinephrine, corticosteroid, and antihistamine were administered immediately on-site at our institution before the study period. Refractory anaphylaxis was defined as the development of anaphylaxis-induced cardiac arrest even after following the anaphylaxis protocol., Results: A total of 246 cases were evaluated for possible anaphylaxis, with 236 cases meeting the criteria for a diagnosis of anaphylaxis. Among them, 178 patients showed the signs and symptoms of shock, and cardiac arrest occurred in 6 patients (2.5%). Of the six patients, three had a return of spontaneous circulation before admission to the ED, while two died due to refractory cardiac arrest despite resuscitation in the ED. Following post-cardiac arrest care, including temperature management, one patient who received extracorporeal cardiopulmonary resuscitation survived neurologically intact., Conclusion: We present our case series to highlight the risk of developing refractory anaphylaxis with subsequent in-hospital cardiac arrest. Patients may progress to cardiac arrest within minutes despite prompt recognition and management. If patients present with potentially fatal symptoms, a more aggressive approach, including intravenous adrenaline infusion, should be taken., Competing Interests: Declaration of Competing Interest No conflict of interest was declared by the authors., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Describe the epidemiologic features of out-of-hospital cardiac arrest (OHCA) caused by anaphylaxis and identify outcome-associated factors., Design: Observational study., Setting: Data from the Japanese Fire and Disaster Management Agency database., Participants: A total of 292 patients from 879 057 OHCA events between 2013 and 2019 with OHCA caused by anaphylaxis and for whom prehospital resuscitation was attempted were included in the analysis., Outcome Measures: The incidence of anaphylaxis-induced OHCA, neurologically favourable 1-month survival, defined as cerebral performance category 1 or 2, and 1-month survival., Results: The proportion of OHCAs caused by anaphylaxis was high in non-elderly and male patients from July to September and during business hours. Bystander-witnessed (adjusted OR=4.43; 95% CI 1.84 to 10.7) and emergency medical service-witnessed events (adjusted OR=3.28; 95% CI 1.21 to 8.87) were associated with higher rates of neurologically favourable 1-month survival as well as better 1-month survival. Shockable initial ECG rhythms were recorded in only 19 patients (6.5%), and prehospital defibrillation was attempted in 16 such patients (84.2%). Neither shockable initial rhythms nor prehospital defibrillation was associated with better outcomes. Patients requiring advanced airway management had poor neurological outcomes (adjusted OR=0.17; 95% CI 0.07 to 0.42) and worse 1-month survival (adjusted OR=0.28; 95% CI 0.14 to 0.58)., Conclusions: Few cases of OHCA were attributable to anaphylaxis. Witnessed OHCAs, particularly those witnessed by bystanders, were associated with better neurological outcomes. Airway complications requiring advanced airway management were likely associated with poor outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Dengue, with four viral serotypes, causes epidemics in tropical and sub-tropical regions. Allopathic antiviral therapies and a vaccine of general use are lacking. The homeopathic medicine Apis mellifica, advised in anaphylaxis from honeybee sting, is proposed to address the life-threatening dengue shock syndrome, which develops from dengue hemorrhagic fever and has features of anaphylaxis. In both dengue and anaphylaxis, immunoglobulin E activates, and released vasoactive mediators (importantly histamine, tryptase and platelet-activating factor) cause, a vascular permeability enabling shock. In dengue, another mechanism, namely antibody-dependent enhancement, due to secondary infection with a heterologous dengue serotype, is associated with release of vasoactive mediators. The homeopathic medicine Apis mellifica indicates plasma leak, shock, and the serous effusion that is noted in dengue patients, and is a suggested prophylactic and therapeutic medicine for dengue shock syndrome., Competing Interests: None declared., (Faculty of Homeopathy. This article is published by Thieme.)

Case reports and a pharmacovigilance analysis have linked glucagon-like peptide 1 receptor agonists (GLP-1 RAs) with anaphylactic reactions, but real-world evidence for this possible association is lacking. Using databases from the United Kingdom (Clinical Practice Research Datalink) and the United States (Medicare, Optum (Optum, Inc., Eden Prairie, Minnesota), and IBM MarketScan (IBM, Armonk, New York)), we employed a new-user, active comparator study design wherein initiators of GLP-1 RAs were compared with 2 different active comparator groups (initiators of dipeptidyl peptidase 4 (DPP-4) inhibitors and initiators of sodium-glucose cotransporter 2 (SGLT-2) inhibitors) between 2007 and 2019. Propensity score fine stratification weighted Cox proportional hazards models were fitted to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for an anaphylactic reaction. Database-specific HRs were pooled using random-effects models. Compared with the use of DPP-4 inhibitors (n = 1,641,520), use of GLP-1 RAs (n = 324,098) generated a modest increase in the HR for anaphylactic reaction, with a wide 95% CI (36.9 per 100,000 person-years vs. 32.1 per 100,000 person-years, respectively; HR = 1.15, 95% CI: 0.94, 1.42). Compared with SGLT-2 inhibitors (n = 366,067), GLP-1 RAs (n = 259,929) were associated with a 38% increased risk of anaphylactic reaction (40.7 per 100,000 person-years vs. 29.4 per 100,000 person-years, respectively; HR = 1.38, 95% CI: 1.02, 1.87). In this large, multisite population-based cohort study, GLP-1 RAs were associated with a modestly increased risk of anaphylactic reaction when compared with DPP-4 inhibitors and SGLT-2 inhibitors., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Food-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon IgE-mediated hypersensitivity disease with limited prevalence data. Recently, reported cases of FDEIA have been increasing both in adults and children. FDEIA is the end condition depending on a summation process, and its pathogenetic mechanisms are not yet completely understood. Factors that add up their effects are food ingestion and physical effort and, in some cases, concomitant diseases, alcohol, drugs, emotional stress, menstruation, and particular weather conditions contribute to enhancing the reaction. Food-specific FDEIA (sFDEIA) implies the presence of an IgE-mediated sensitization to one or more foods, while in unspecific FDEIA (nsFDEIA), any food can induce anaphylaxis without sensitization.  Among causative foods, the most dominant trigger of FDEIA is wheat, in particular the allergen ω-5 gliadin (Tri a 19). Other common foods are seafood, seeds, grains, nuts, vegetables and fruit, cow's milk, meat, and eggs. We present three cases of sFDEIA in children with clinical features and laboratory findings; the first was induced by a culprit food less frequently involved in sFDEIA than the others.

Abstract: In Tunisia, hydatid cyst is an endemic parasitic disease. The cyst may remain asymptomatic, discovered accidentally, or in case of a complication, the most serious of which is sudden death. We propose, in this article, to analyze the degree of involvement of the cyst in the mechanism of death, through the review of 25 cases. A total of 7932 autopsy cases were performed during the study period. Twenty-five cases of hydatid cyst discovered at autopsy were collected and death was attributed to hydatid cyst in 13 cases. The seat of the cyst was variable and death was due to anaphylaxis in 10 cases, to hydatious embolism in 2 cases and to cardiac arrhythmia, resulting from a cardiac localization of a large hydatid cyst, in 1 case.Although rare, echinococcosis can be a life-threatening disease. Its involvement in the death mechanism remains difficult in many cases., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

A young male patient with abdominal pain and fever was diagnosed as acute hyper-triglyceridemicpancreatitis is clear. During the recovery of pancreatitis, the patient developed acute acalculous cholecystitis, as well as carbapenem-resistant Enterobacter infection and Cytomegaloviremia, and had anaphylaxis for several times after the use of antibiotics, which cannot be completely explained by drug allergy. This paper analyzes the possible causes of multiple diseases in the same patient in detail.

Background: The frequency of tattoos varies from 10% to 30% across the population worldwide. The growing popularity of tattooing increases the number of cutaneous reactions connected with this procedure. As we have not found any previous studies in the literature concerning tattoo complications in Poland and other Eastern European countries, we believe this to be the first study of this kind., Objective: The primary objective of this study was to evaluate the clinical spectrum of complications associated with the procedure of permanent tattooing among patients from Northern Poland., Methods: Medical data of 53 patients who developed tattoo-related cutaneous conditions were analyzed. All of the patients were consulted in the Dermatology, Venereology and Allergology Clinic in Gdańsk in the years 2018-2021. Medical history, dermatological assessment, and photographic documentation of skin lesions were performed in each case. Dermoscopic examination was carried out in 16 cases and 20 skin biopsies of the tattoo reactions were performed., Results: Twenty-one patients (40%) presented tattoo ink hypersensitivity reactions, out of which 18 were triggered by the red ink. In 11 cases (21%), contact dermatitis has developed after tattooing, while 9 of the patients (17%) presented tattoo infectious complications, including local bacterial infections, common warts, molluscum contagiosum, and demodicosis. We collected 8 cases (15%) of papulonodular reactions in black tattoos, and in 6 of them, histology showed granuloma formation. In 2 cases (4%), symptoms of anaphylaxis were observed after the tattooing procedure, and in another 2 cases (4%), Koebner phenomenon in the tattoo was diagnosed. Dermoscopy was the clue to the diagnosis in 4 cases., Conclusions: This is the first report presenting multiple cases of tattoo complications from Eastern Europe. The results of the study are consistent with other researches, showing a similar distribution of tattoo complications and that across the different pigments used, the red ink is most frequently responsible for tattoo reactions. We emphasize the usefulness of dermoscopic examination in the diagnosis of tattoo-related infections and draw the reader's attention to the rare, yet hazardous complications connected with peri-tattooing anaphylaxis., (© 2021 S. Karger AG, Basel.)

Seasonal influenza epidemics of variable severity pose challenges to public health. Annual vaccination is the primary way to prevent influenza, and a wide range of vaccines are available, including inactivated or live attenuated standard-dose, recombinant vaccines, as well as adjuvanted or high-dose vaccines for persons aged 65 years or older. Persons at increased risk for influenza complications include young children, persons with underlying medical conditions, and older adults. Prompt diagnosis of influenza can facilitate early initiation of antiviral treatment that provides the greatest clinical benefit. This article summarizes recommendations for providers on influenza vaccination, diagnostic testing, and antiviral treatment.

Background: Allergic reactions are common symptoms in the emergency department (ED), with anaphylaxis comprising 1-3% of ED visits. Anaphylaxis is a clinical diagnosis. Treatment of anaphylaxis starts with airway, oxygenation, and decontamination, followed by medication administration., Case Report: We describe a patient who presented to the ED with anaphylaxis complicated by a persistent exposure to the allergen with need for emergent decontamination. Why Should an Emergency Physician be Aware of This? Knowing the treatment of anaphylaxis is critical to prevent morbidity and mortality. This case is a reminder to always remove the offending agent and nuances involved with treating critically ill pregnant patients., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts., Competing Interests: Declaration of interests JS is an editor of the journal Resuscitation and receives payment from the publisher Elsevier, outside the submitted work. LBB reports grants from Philips, US National Institutes of Health, ZOLL Medical, Nihon Kohden, PCORI, BrainCool, and United Therapeutics, outside the submitted work. LBB has patents for a cooling technology, and a patent for a reperfusion methodology issued. SE reports personal fees from Springer Verlag, non-financial support from Zoll, personal fees from Medtronic (Oridion), grants and other from Diasorin, outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

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., (Copyright © 2021 European Federation of Immunological Societies. Published by Elsevier B.V. All rights reserved.)

Cefaclor, a second-generation oral cephalosporin, is the most frequently prescribed cephalosporin in Korea. Studies, however, have yet to analyze the incidence of cefaclor-associated adverse drug reactions (ADRs), including hypersensitivity (HS), according to total national usage rates. This study aimed to investigate the incidence rates and clinical features of cefaclor ADRs reported to the Korean Adverse Event Reporting System (KAERS) and Health Insurance Review and Assessment Service (HIRA) database for the most recent 5 years. Reviewing the HIRA database, which contains information on all insurance claims, including prescribed medications and patient demographics, we identified the total number of individuals who had been prescribed cefaclor and other cephalosporins including 2nd generation without cefaclor and 3rd generation antibiotics from January 2014 to December 2018. Additionally, we retrospectively analyzed all ADRs reported to the KAERS for these drugs over the same study period. Incidence rates for ADRs, HS, and anaphylaxis to cefaclor were 1.92/10,000 persons, 1.17/10,000 persons, and 0.38/10,000 persons, respectively, lower than those to other 2nd and 3rd cephalosporins. Among all ADRs, HS (60.9% vs. 43.6% vs. 44.8%, P <0.001) and anaphylaxis (19.8% vs. 4.6% vs. 4.7%, P <0.001) were more common for cefaclor than for other 2nd and 3rd cephalosporins. Females, individuals under 65 years of age, concomitant use of drugs, and serious ADRs were more strongly associated with HS to cefaclor than with HS to other 2nd and 3rd cephalosporins. In a nationwide database for the Korean population, the incidence of cefaclor-induced ADRs, particularly HS and anaphylaxis, was high. Female sex, age younger than 65 years, and concomitant use of drugs may be associated with HS to cefaclor., Competing Interests: There are no financial or other issues that might confer a conflict of interest.

Abstract: Biphasic anaphylaxis is an uncommon IgE-mediated condition whose pathophysiological mechanisms, risk factors, and predictive signs are not properly understood. Fortunately, the lethality of biphasic anaphylaxis, although probably underestimated, is low. Preventive clinical measures for biphasic anaphylaxis are neither standardized nor commonly applied. Furthermore, there are no laboratory protocols or anaphylactic markers to help identify the onset of biphasic anaphylaxis in clinical settings. The aim of this review is to highlight the medicolegal difficulties facing coroners and forensic pathologists in terms of the diagnosis and assessment of harm for victims and survivors of biphasic anaphylaxis., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe the unique complication of hemoperitoneum associated with anaphylaxis., Design: Retrospective case series from September 2012 to August 2017., Setting: Two private emergency and specialty referral hospitals., Animals: Eleven client-owned dogs diagnosed with anaphylaxis and hemoperitoneum upon presentation or referral., Interventions: None., Measurements and Main Results: Inclusion criteria included clinical signs consistent with anaphylaxis (hypotension, tachycardia, vomiting, diarrhea, weakness, collapse, with or without the presence of dermal signs) due to witnessed or unwitnessed presumed bee sting, an elevated alanine aminotransferase (ALT), performance of abdominal FAST (AFAST) examination with an abdominal fluid score, the sonographic presence of gallbladder wall edema, and hemoperitoneum. All dogs (n=11) were managed medically without surgical intervention. 91% (n=10) of dogs survived to discharge., Conclusions: Hemoperitoneum development can be seen with anaphylactic reactions, though the exact mechanism remains to be fully understood. Medical therapy is warranted and can be successful in these patients; surgery is not indicated to address hemoperitoneum., (© Veterinary Emergency and Critical Care Society 2020.)

Background: Anaphylaxis is a constant perioperative concern due to the exposure to several agents capable of inducing hypersensitivity reactions. Patent blue V (PBV), also known as Sulfan Blue, a synthetic dye used in sentinel node research in breast surgery, is responsible for 0.6% of reported anaphylactic conditions. We present a case of a 49-year-old female patient who underwent left breast tumorectomy with sentinel lymph node staging using PBV and experienced an anaphylactic reaction., Methods: We conducted a literature search through PubMed for case reports, case series, reviews, and systematic reviews since 2005 with the keywords "anaphylaxis" and "patent blue". We then included articles found in these publications' reference sections., Results: We found 12 relevant publications regarding this topic. The main findings are summarized, with information regarding the clinical presentation, management, and investigation protocol. Hypotension is the most common clinical manifestation. The presentation is usually delayed when compared with anaphylaxis from other agents, and cutaneous manifestations are occasionally absent. Patients may have had previous exposure to the dye, used also as a food, clothes and drug colorant., Conclusion: The diagnosis of anaphylaxis in patients under sedation or general anesthesia may be difficult due to particularities of the perioperative context. According to the published literature, the presentation of the reaction is similar in most cases and a heightened clinical sense is key to address the situation appropriately. Finding the agent responsible for the allergic reaction is of paramount importance to prevent future episodes., (Copyright © 2020 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. All rights reserved.)

Background: Hymenopteran stings are the most common animal insult injury encountered in the emergency department. With increasing global spread of imported fire ants in recent decades, the rate of Formicidae assault has become a serious problem in many countries. Formicidae-associated injuries gradually increased in Taiwan in recent decades and became the second most common arthropod assault injury in our ED. The present study aimed at comparing the clinical characteristics of Formicidae sting patients with those of the most serious and common group, Vespidae sting patients, in an emergency department (ED) in Taiwan., Methods: This retrospective study included patients who were admitted between 2015 to 2018 to the ED in a local teaching hospital in Taiwan after a Vespidae or Formicidae sting. Cases with anaphylactic reaction were further compared., Results: We reviewed the records of 881 subjects (503 males, 378 females; mean age, 49.09 ± 17.62 years) who visited our emergency department due to Vespidae or Formicidae stings. A total of 538 (61.1%) were categorized into the Vespidae group, and 343 (38.9%) were sorted into the Formicidae group. The Formicidae group had a longer ED length of stay (79.15 ± 92.30 vs. 108.00 ± 96.50 min, p < 0.01), but the Vespidae group had more cases that required hospitalization (1.9% vs. 0.3%, p = 0.04). Antihistamines (76.8% vs. 80.2%, p < 0.01) were more frequently used in the Formicidae group, while analgesics were more frequently used in the Vespidae group (38.1% vs. 12.5%, p < 0.01). The Vespidae group had more local reactions, and the Formicidae group had more extreme, systemic, or anaphylactic allergic reactions. Creatine kinase was significantly higher in the Vespidae group with an anaphylactic reaction. Sting frequency in both groups exhibited the same positive associations with average temperature of the month and weekend days., Conclusion: Formicidae sting patients presented to the ED with higher rate allergic reactions and spent more time in the ED than Vespidae sting patients. However, Vespidae sting patients had more complications and higher rates of admission, especially with anaphylactic reaction. Laboratory data, especially creatine kinase data, were more valuable to check in Vespidae sting patients with an anaphylactic reaction in the ED. Both groups exhibited positive correlations with temperature and a higher rate on weekend days.

Anaphylactic cardiovascular events constitute an underrated cause of medical emergencies in hospitalized patients. Coronary arteries and myocardium are targeted by anaphylactic mediators leading to acute coronary syndrome and imminent cardiovascular collapse. Early diagnosis and high clinical suspicion are required to secure prompt life-saving treatment in these cases. However, physicians of both Cardiology and Internal Medicine Departments are not familiar with this condition. Recently, we diagnosed and treated a case of anaphylactic cardiovascular collapse manifesting as acute myocardial infarction following salad consumption. Notably, Kounis anaphylaxis-associated acute coronary syndrome is a rare cause of ST segment elevation myocardial infarction with normal or diseased coronary arteries. We recommend that Kounis syndrome and its variants should be taken into consideration in the differential diagnosis of ischemic heart disease in patients with signs of allergic reaction and/or medical history of previous allergic reactions, who experience acute coronary syndrome after exposure to certain environmental stimuli.

Atrial fibrillation is the most common cardiac arrhythmia in western society affecting more than 35 million individuals worldwide annually. It is a common postoperative complication and may also occur spontaneously during general and local anesthesia administration. Aging, diabetes mellitus, hypertension, and cardiovascular diseases including cardiomyopathies, congenital cardiac anomalies, heart failure, myocardial ischemia, pericarditis, previous cardiac surgery, vascular disease, and valvular heart disease are some correlated factors. Beyond age, increased incidence of atrial fibrillation has been correlated to autoimmune system activation as it is the underlying mechanism of persistent atrial fibrillation development. Current research supports an association between the complement system activation and lymphocyte-pro-inflammatory cytokines release with the cardiac conduction system and atrial fibrosis. The loss of CD28 antigen from CD4+ CD28+ T lymphocytes seems to play a major role in atrial fibrillation development and prognosis. Except atrial fibrillation, a variety of additional electrocardiographic changes, resembling those with digitalis intoxication may accompany anaphylaxis and particularly Kounis syndrome. Histamine is one well-known mediator in allergic and inflammatory conditions as physiologically regulates several cardiovascular and endothelial functions with arrhythmogenic potential. The increased oxidative stress, measured by the redox potentials of glutathione, has been correlated with atrial fibrillation incidence and prevalence. The use of antazoline, a first-generation antihistamine agent used for rapid conversion of recent-onset atrial fibrillation in patients with preserved left ventricular function and for rapid atrial fibrillation termination during accessory pathway ablation denotes that anaphylaxis-induced histamine production could be the cause of atrial fibrillation at least in some instances. The anaphylaxis diagnosis in anesthesia can be challenging owing to the absence of cutaneous manifestetions such as flushing, urticaria, or angioedema. Anticoagulation for stroke prevention, rate and rhythm control medications, invasive methods such as radiofrequency ablation or cryoablation of pulmonary veins as well surgical ablation constitute the treatment basis of atrial fibrillation. Understanding the underlying mechanisms of atrial fibrillation by cardiologists, anesthesiologists and surgeons, as well as potential treatments, to optimize care is of paramount importance.

Anaphylactic symptoms and anaphylactic shock are serious, rapidly developing and potentially fatal systemic reactions occurring after contact with the trigger, followed by release of a number of substances that affect vascular permeability, smooth muscle tone of blood vessels and bronchi with activation of the systemic inflammatory cascade. From a pathophysiological point of view, it can be an IgE-mediated immune response followed by massive release of biologically active mediators from mast cells and basophils (IgE dependent). If the mastocyt/basophil is degranulated via a direct IgE-free pathway, it is non-allergic (non-IgE dependent, anaphylactoid anaphylaxis). The diagnosis of anaphylaxis is determined on the basis of clinical criteria, taking into account the need to initiate therapy in a life-threatening condition without delay. Adrenaline is the first-line drug in the treatment of anaphylaxis and there is no contraindication to its use. Early provision of venous intake is essential for the patient to develop hypotension.