The diagnosis and management of anaphylaxis

A case of levofloxacin-induced anaphylaxis with elevated serum tryptase levels

Levofloxacin, a fluoroquinolone and L-isomer of the racemate ofloxacin, has been approved for the treatment of acute and chronic bacterial infections. Gastrointestinal complaints are the most frequently reported adverse drug reactions to fluoroquinolones. Other adverse events include headache, dizziness, increased liver enzyme levels, photosensitivity, tachycardia, QT prolongation, and eruptions. Anaphylaxis has been documented as a rare adverse drug reaction to levofloxacin; however, diagnostic tests are needed to evaluate whether these reactions are the result of levofloxacin treatment. While the results of skin tests are considered unreliable due to false-positive responses, the oral provocation test is currently considered to be the most reliable test. Tryptase, a neutral protease, is the dominant protein component of secretory granules in human mast cells, and an increased serum concentration of tryptase is a highly sensitive indicator of anaphylaxis. Herein, we report a case of levofloxacin-induced anaphylaxis in which the patient exhibited elevated serum tryptase levels and a positive oral levofloxacin challenge test result. As anaphylaxis is potentially life-threatening, the administration of fluoroquinolones to patients who have experienced a prior reaction to this type of agent should be avoided.

Anaphylactic shock in pregnancy: a case study and review of the literature

We describe a 22-year-old previously healthy primigravida who presented with spontaneous rupture of membranes at 40 weeks of gestation. Because of her history of inadequate prenatal care, a chemoprophylaxis regimen against group B streptococcal infection was prescribed upon admission. Within a few minutes after initiation of an i.v. infusion of penicillin G, the patient developed generalized erythema and severe hypotension, which was essentially unresponsive to intravenous boluses of ephedrine. Following stabilization of maternal blood pressure with incremental doses of epinephrine, emergency cesarean section was performed with delivery of a severely depressed neonate. Postoperative recovery of the mother was uneventful, although the baby was diagnosed to have suffered significant neurological damage. This unfortunate event highlights the therapeutic dilemma in anaphylaxis during pregnancy, a relatively rare but potentially life-threatening event. A critical review of the scientific literature reveals several etiological agents for anaphylaxis during the perioperative period, with penicillin as the leading cause of anaphylaxis-related mortality. Although epinephrine is the vasopressor of choice during hemodynamic resuscitation in the non-pregnant patient, during pregnancy it may pose a risk to the placental-fetal circulation. Additionally, upon review of the various published reports to date, timing and mode of delivery of the neonate in the face of anaphylactic shock remains controversial.

[Advanced life support under special circumstances: part 1]

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances sometimes must be considered in patient treatment resulted in a separate chapter. This first part of a two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of life-threatening drowning, asthma, anaphylaxis, and poisoning. The second part will deal with electrolyte disorders, hypothermia, electrical emergencies, trauma, cardiac arrest during pregnancy, and cardiac surgery.

Forensic Lung Pathology

Sudden and unexpected natural deaths and nonnatural deaths may result from various pulmonary conditions. Additionally, several nonpulmonary conditions of forensic significance may be complicated by the development of respiratory lesions. Certain situations with pulmonary pathology are particularly likely to be critically scrutinized and may form the basis of allegations of medical negligence, other personal injury liability, or wrongful death.1