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Brevik C, Zuckerman M. Cold Anaphylaxis: A Case Report. J Emerg Med 2020; 60:226-228. [PMID: 33121839 DOI: 10.1016/j.jemermed.2020.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/17/2020] [Accepted: 09/12/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cold anaphylaxis is a severe form of hypersensitivity reaction to cold temperatures. Such reactions include a spectrum of presentations that range from localized symptoms to systemic involvement. The condition can be acquired or heritable, although it may also be idiopathic. Treatment consists of second-generation H1 antihistamines, epinephrine, and supportive care. Prevention involves avoidance of known triggers, most commonly cold immersion due to environment or water exposure. CASE REPORT We report the case of a 34-year-old man with cold-induced urticaria/anaphylaxis who presented to our emergency department with hypotension and shortness of breath after exposure to cold air after getting out of a shower. He required two doses of intramuscular epinephrine and was ultimately started on an epinephrine infusion. He was admitted to the intensive care unit for anaphylaxis monitoring and was found to have a positive ice cube test, reinforcing the suspected diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cold anaphylaxis is a potentially life-threatening phenomenon with specific testing. It is occasionally described in the emergency medicine literature. Providers should be aware of the potential for cold anaphylaxis as it can change patient guidance and alter management. This condition can also contribute to otherwise unclear and sudden decompensation in critically ill patients, as has been reported in cases of cold anaphylaxis induced by cold IV infusions.
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Affiliation(s)
- Cody Brevik
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
| | - Matthew Zuckerman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Arlt E, Fraticelli M, Tsvilovskyy V, Nadolni W, Breit A, O'Neill TJ, Resenberger S, Wennemuth G, Wahl-Schott C, Biel M, Grimm C, Freichel M, Gudermann T, Klugbauer N, Boekhoff I, Zierler S. TPC1 deficiency or blockade augments systemic anaphylaxis and mast cell activity. Proc Natl Acad Sci U S A 2020; 117:18068-18078. [PMID: 32661165 PMCID: PMC7395440 DOI: 10.1073/pnas.1920122117] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Mast cells and basophils are main drivers of allergic reactions and anaphylaxis, for which prevalence is rapidly increasing. Activation of these cells leads to a tightly controlled release of inflammatory mediators stored in secretory granules. The release of these granules is dependent on intracellular calcium (Ca2+) signals. Ca2+ release from endolysosomal compartments is mediated via intracellular cation channels, such as two-pore channel (TPC) proteins. Here, we uncover a mechanism for how TPC1 regulates Ca2+ homeostasis and exocytosis in mast cells in vivo and ex vivo. Notably, in vivo TPC1 deficiency in mice leads to enhanced passive systemic anaphylaxis, reflected by increased drop in body temperature, most likely due to accelerated histamine-induced vasodilation. Ex vivo, mast cell-mediated histamine release and degranulation was augmented upon TPC1 inhibition, although mast cell numbers and size were diminished. Our results indicate an essential role of TPC1 in endolysosomal Ca2+ uptake and filling of endoplasmic reticulum Ca2+ stores, thereby regulating exocytosis in mast cells. Thus, pharmacological modulation of TPC1 might blaze a trail to develop new drugs against mast cell-related diseases, including allergic hypersensitivity.
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Affiliation(s)
- Elisabeth Arlt
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Marco Fraticelli
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | | | - Wiebke Nadolni
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Andreas Breit
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Thomas J O'Neill
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Stefanie Resenberger
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Gunther Wennemuth
- Institute for Anatomy, University of Duisburg-Essen, 45147 Duisburg, Germany
| | | | - Martin Biel
- Department of Pharmacy, Ludwig-Maximilians-Universität München, 81377 München, Germany
| | - Christian Grimm
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Marc Freichel
- Institute of Pharmacology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Thomas Gudermann
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany
| | - Norbert Klugbauer
- Institute for Experimental and Clinical Pharmacology and Toxicology, Medical Faculty, Albert-Ludwigs-Universität, 79104 Freiburg, Germany
| | - Ingrid Boekhoff
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany;
| | - Susanna Zierler
- Walther Straub Institute of Pharmacology and Toxicology, Ludwig-Maximilians-Universität München, 80336 München, Germany;
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Abstract
Urticaria and, to a lesser extent, angioedema are common occurrences in the pediatric population. There are multiple causes of acute and chronic urticaria and angioedema. Most causes are benign, although they can be worrisome for patients and their parents. An allergist should evaluate acute urticaria and/or angioedema if there are concerns of an external cause, such as foods or medications. Chronic urticaria and angioedema can severely affect quality of life and should be managed aggressively with antihistamines and immunomodulators if poorly controlled. Chronic symptoms are unlikely to be due to an external cause. Anaphylaxis is a more serious allergic condition characterized by a systemic reaction involving at least 2 organ systems. Anaphylaxis should be initially managed with intramuscular epinephrine. Patients who experience anaphylaxis should be evaluated by an allergist for possible causes; if found, avoidance of the inciting antigen is the best management. All patients should also be given an epinephrine autoinjector and an action plan. Foods are a common cause of anaphylaxis in the pediatric population. New evidence suggests that the introduction of highly allergic foods is safe in infancy and should not be delayed. In addition, the early introduction of foods such as peanuts may help prevent the development of food allergies.
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Affiliation(s)
| | - Theresa A Bingemann
- University of Rochester, Rochester, NY.,Department of Allergy, Immunology, and Rheumatology, Rochester Regional Health, Rochester, NY
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Gaffar J, Gabrielli S, Lavine E, Pitt T, Abrams E, Atkinson A, Eiwegger T, Protudjer J, Wong T, O'Keefe A, Ben-Shoshan M. Diagnosis of Ibuprofen allergy through oral challenge. Clin Exp Allergy 2020; 50:636-639. [PMID: 32160351 DOI: 10.1111/cea.13596] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 02/26/2020] [Accepted: 03/08/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Judy Gaffar
- Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sofianne Gabrielli
- Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Elana Lavine
- Pediatric Clinical Immunology and Allergy, Humber River Hospital, Vaughan Pediatric Clinic, Toronto, ON, Canada
| | - Tracy Pitt
- Department of Pediatrics, Queen's University, Kingston, ON, Canada
| | - Elissa Abrams
- Department of Pediatrics, Queen's University, Kingston, ON, Canada.,Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MC, Canada
| | - Adelle Atkinson
- Division of Paeiatric Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Thomas Eiwegger
- Division of Paeiatric Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Protudjer
- The Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Tiffany Wong
- Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Andrew O'Keefe
- Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - Moshe Ben-Shoshan
- Division of Pediatric Allergy and Clinical Immunology, McGill University Health Centre, Montreal, Quebec, Canada
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55
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Bernstein D, Tankersley M, Russell H. Controversies in Allergy: Injectable Epinephrine Should Be Prescribed to All Patients on Subcutaneous Aeroallergen Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:1211-1215. [PMID: 32044307 DOI: 10.1016/j.jaip.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Affiliation(s)
- David Bernstein
- Department of Medicine and Environmental Health, University of Cincinnati, Cincinnati, Ohio
| | - Mike Tankersley
- Departments of Medicine, Pediatrics and Otolaryngology, University of Tennessee Health Science Center, Memphis, Tenn; The Tankersley Clinic, Memphis, Tenn.
| | - Hannah Russell
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tenn
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56
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Wilson JM, Platts-Mills TAE. α-Gal and other recent findings that have informed our understanding of anaphylaxis. Ann Allergy Asthma Immunol 2019; 124:135-142. [PMID: 31785367 DOI: 10.1016/j.anai.2019.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To summarize the current understanding of anaphylaxis, with an emphasis on major findings that have been reported within the last 10 years. DATA SOURCES Queries relating to anaphylaxis, immunoglobulin E (IgE), and mast cells were conducted with PubMed and Google Scholar, searching for primary articles and review papers. STUDY SELECTIONS We focused on articles written in English and which were reported in major allergy and immunology journals. RESULTS Anaphylaxis represents an extreme manifestation of a form of allergic immunity that appears to have evolved to protect against "toxic" threats that present at skin and mucosal barriers. The factors that have contributed to a rise in anaphylaxis are increasingly appreciated to relate to changes in hygiene and microbial ecology that have occurred with industrialization. Induction of allergen-specific IgG4 is often part of the allergic response and is associated with protection against anaphylaxis. The recognition of the α-Gal syndrome suggests that carbohydrates can be epitopes that are relevant to anaphylaxis and that IgE-mediated reactions do not always occur "immediately." CONCLUSION Our understanding of anaphylaxis has advanced significantly over the past 10 years. It is anticipated that ongoing research will build on this foundation to further advance our knowledge of anaphylaxis and also translate into clinically meaningful therapies.
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Affiliation(s)
- Jeffrey M Wilson
- Division of Allergy & Immunology, University of Virginia, Charlottesville, VA, 22908
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57
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Miller RL, Shtessel M, Robinson LB, Banerji A. Advances in drug allergy, urticaria, angioedema, and anaphylaxis in 2018. J Allergy Clin Immunol 2019; 144:381-392. [PMID: 31247266 DOI: 10.1016/j.jaci.2019.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/22/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022]
Abstract
Many notable advances in drug allergy, urticaria, angioedema, and anaphylaxis were reported in 2018. Broad-spectrum antibiotic use and, consequently, antibiotic resistance are widespread, and algorithms to clarify β-lactam allergy and optimize antibiotic use were described. Meaningful data emerged on the pathogenesis of delayed drug hypersensitivity reactions. Progress not only in defining biomarkers but also in understanding the effect on quality of life and developing better treatments has been made for patients with chronic idiopathic urticaria. Patients with hereditary angioedema (HAE) have gained additional access to highly efficacious therapies, with associated improvements in quality of life, and some progress was made in our understanding of recurrent angioedema in patients with normal laboratory results. Guidelines have defined clear goals to help providers optimize therapies in patients with HAE. The epidemiology and triggers of anaphylaxis and the mechanisms underlying anaphylaxis were elucidated further. In summary, these disorders (and labels) cause substantial burdens for individual persons and even society. Fortunately, publications in 2018 have informed on advancements in diagnosis and management and have provided better understanding of mechanisms that potentially could yield new therapies. This progress should lead to better health outcomes and paths forward in patients with drug allergy, urticaria, HAE, and anaphylaxis.
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Affiliation(s)
- Rachel L Miller
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY; Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY.
| | - Maria Shtessel
- Division of Allergy, Immunology, and Rheumatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Lacey B Robinson
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
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Rodriguez MJ, Palomares F, Bogas G, Torres MJ, Diaz-Perales A, Rojo J, Plaza-Seron MDC, Rodriguez-Nogales A, Orengo C, Mayorga C, Perkins JR. Transcriptional Profiling of Dendritic Cells in a Mouse Model of Food-Antigen-Induced Anaphylaxis Reveals the Upregulation of Multiple Immune-Related Pathways. Mol Nutr Food Res 2018; 63:e1800759. [PMID: 30458065 DOI: 10.1002/mnfr.201800759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/05/2018] [Indexed: 12/18/2022]
Abstract
SCOPE Much of the knowledge about gene expression during anaphylaxis comes from candidate gene studies. Despite their potential role, expression changes in dendritic cells (DCs) have not been studied in this context using high throughput methods. The molecular mechanisms underlying food-antigen-induced anaphylaxis are investigated using DCs from an animal model. METHODS AND RESULTS RNA sequencing is used to study gene expression in lymph-node-derived DCs from anaphylactic mice sensitized intranasally with the major peach allergen Pru p 3 during the acute reaction phase, induced intraperitoneally. In total, 237 genes changed significantly, 181 showing at least twofold changes. Almost three-quarters of these increase during anaphylaxis. A subset is confirmed using RT-PCR in a second set of samples obtained from a new batch of mice. Enrichment analysis shows an overrepresentation of genes involved in key immune system and inflammatory processes, including TGF-β signaling. Comparison with a study using anaphylactic human subjects show significant overlap. CONCLUSIONS The findings provide a comprehensive overview of the transcriptional changes occurring in DCs during anaphylaxis and help elucidate the mechanisms involved. They add further weight to the putative role of these cells in anaphylaxis and highlight genes that may represent potential therapeutic targets.
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Affiliation(s)
- Maria Jose Rodriguez
- Research Laboratory, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - Francisca Palomares
- Research Laboratory, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - Gador Bogas
- Allergy Unit, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - Maria Jose Torres
- Allergy Unit, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - Araceli Diaz-Perales
- Centro de Biotecnología y Genómica de Plantas (CBGP, UPM-INIA), Universidad Politécnica de Madrid (UPM), 28223, Pozuelo de Alarcon, Spain
| | - Javier Rojo
- Laboratory, Instituto de Investigaciones Químicas (IIQ), CSIC-Universidad de Sevilla, 41092, Sevilla, Spain
| | | | - Alba Rodriguez-Nogales
- Research Laboratory, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - Christine Orengo
- Institute of Structural and Molecular Biology, Division of Biosciences, University College London, London, WC1E 6BT, UK
| | - Cristobalina Mayorga
- Research Laboratory, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain.,Allergy Unit, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
| | - James Richard Perkins
- Research Laboratory, IBIMA-Regional University Hospital of Malaga, UMA, 29009, Malaga, Spain
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59
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Vetander M, Protudjer JLP, Lilja G, Kull I, Hedlin G, van Hage M, Östblom E, Bergström A, Wickman M. Anaphylaxis to foods in a population of adolescents: incidence, characteristics and associated risks. Clin Exp Allergy 2017; 46:1575-1587. [PMID: 27790764 DOI: 10.1111/cea.12842] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/28/2016] [Accepted: 10/06/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Information about severe reactions to foods in adolescence is limited. OBJECTIVE To describe reactions to foods, including anaphylaxis, with regard to incidence, characteristics and associated risks, among 16-year-olds (adolescents) in a large, population-based birth cohort. METHODS Parent-reported questionnaire data from ages 2-3 months, and 1, 2 and 16 years were used (N = 3153). Anaphylaxis at age 16 years was defined per NIAID/FAAN criteria. Immunoglobulin E (IgE) antibodies to 14 common food and inhalant allergens were analysed at ages 4 (n = 2283) and 16 years (n = 2510). Among adolescents with food-related symptoms (FRS) and for whom blood was available (n = 221), 25 additional food allergen extracts or allergen components were analysed. Associations between reactions to foods, and sensitization and allergic multimorbidity were investigated. RESULTS In the 12 months prior to the 16-year assessment, 8.5% of adolescents had FRS. This included 0.8% (n = 24) adolescents who were classified as having anaphylaxis, yielding an incidence rate of 761/100 000 person-years. One-third of adolescents accessed health care during anaphylaxis. Allergic multimorbidity in infancy, as well as sensitization to foods and airborne allergens at age 4 years, was associated with an increased risk for FRS in adolescence. Peanuts and tree nuts were the most common culprit foods for anaphylaxis, and fruits and vegetables for non-anaphylactic reactions. Adolescents with anaphylaxis were significantly more likely to be sensitized to storage proteins (Ara h 2, Cor a 9, Cor a 14) and to be polysensitized to foods (P < 0.001 vs. non-anaphylactic reactions). CONCLUSIONS AND CLINICAL RELEVANCE The incidence of food-induced anaphylaxis during adolescence in our population-based birth cohort is higher than previously reported. Adolescents with anaphylaxis differ from adolescents with non-anaphylactic FRS with regard to culprit foods and sensitization. Adolescents with previous anaphylaxis are likely to be polysensitized to foods, particularly tree nut and peanut storage proteins, and which warrants consideration at follow-up.
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Affiliation(s)
- M Vetander
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - J L P Protudjer
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - G Lilja
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - I Kull
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - G Hedlin
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - M van Hage
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Medicine Solna, Immunology and Allergy Unit, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - E Östblom
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - A Bergström
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - M Wickman
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
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60
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Abstract
Anaphylactic fatalities are rare; however, mild reactions can rapidly progress to cardiovascular and respiratory arrest. The clinical course of anaphylaxis can be unpredictable. Prompt and early use of epinephrine should be considered. Most anaphylaxis episodes have an immunologic mechanism involving immunoglobulin E (IgE). Foods are the most common cause in children; medications and insect stings are more common in adults. When the cause is not completely avoidable or cannot be determined, a patient should be supplied with autoinjectable epinephrine and be instructed its use. They should keep the device with them at all times and taught the signs and symptoms of anaphylaxis.
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Affiliation(s)
- Scott P Commins
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Thurston Research Center, University of North Carolina, 3300 Thurston Building, CB 7280, Chapel Hill, NC 27599-7280, USA; Division of Rheumatology, Allergy and Immunology, Department of Pediatrics, Thurston Research Center, University of North Carolina, 3300 Thurston Building, CB 7280, Chapel Hill, NC 27599-7280, USA.
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