1
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Villarreal-González RV, González-Díaz S, Vidal-Gutiérrez O, Cruz-de la Cruz CDL, Pérez-Ibave DC, Garza-Rodríguez ML. Hypersensitivity reactions to anticancer chemotherapy and monoclonal antibodies: Safety and efficacy of desensitization. J Oncol Pharm Pract 2024; 30:811-822. [PMID: 37489025 DOI: 10.1177/10781552231189461] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Hypersensitivity reactions to anticancer chemotherapy and monoclonal antibodies may lead to discontinuation of first-line treatment options. Identification of these reactions can provide specific diagnosis and treatment by rapid drug desensitizations. OBJECTIVE To determine the hypersensitivity reactions involved in anticancer chemotherapy and monoclonal antibodies, and the safety and efficacy of rapid drug desensitization. METHODS We conducted an observational study of hypersensitivity reaction presented after the administration of anticancer chemotherapy and monoclonal antibodies in Mexico. We documented the symptoms of initial reaction and their severity, and the results of skin tests. We also report our experience of the administration of 12-step (mild-moderate reactions) and 16-step (severe reactions) desensitization protocols in these patients. RESULTS Overall, 93 patients received 336 rapid drug desensitization; 105 to taxanes, 115 to platinum drugs, 101 to monoclonal antibodies, and 15 other anticancer chemotherapy. Hypersensitivity reaction to taxanes occurred in the first or second administration, platinum drugs after the sixth cycle, and rituximab in the first cycle. The most common symptom in carboplatin was urticaria, paclitaxel back pain, oxaliplatin and docetaxel dyspnea, and in the monoclonal antibodies cardiovascular symptoms. Skin tests were positive in 75% of the carboplatin group, and only 16.7% in docetaxel. There was a rapid drug desensitization success rate of 99.4% and 85.7% did not present any related hypersensitivity reaction. CONCLUSION The diagnosis of hypersensitivity reaction to anticancer chemotherapy and monoclonal antibodies offers a panorama in the management of oncological diseases. Our standardized desensitization protocol is safe and effective and can be reproduced in other centers to treat patients who need to maintain first-line treatment.
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Affiliation(s)
- Rosalaura V Villarreal-González
- Faculty of Medicine, Oncology Service, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
| | - Sandra González-Díaz
- Faculty of Medicine, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Regional Center of Allergy and Clinical Immunology, Monterrey, Nuevo León, México
| | - Oscar Vidal-Gutiérrez
- Faculty of Medicine, Oncology Service, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
| | - Carlos de la Cruz-de la Cruz
- Department of Internal Medicine, Universidad de Monterrey. Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, México
| | - Diana C Pérez-Ibave
- Faculty of Medicine, Oncology Service, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
| | - María L Garza-Rodríguez
- Faculty of Medicine, Oncology Service, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Centro Universitario Contra el Cáncer (CUCC), Monterrey, Nuevo León, México
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2
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Anagnostou A, Greenhawt M, Rodríguez Del Río P, Pickett G, Szafron V, Stukus D, Abrams EM. Addressing common questions on food oral immunotherapy: a practical guide for paediatricians. Arch Dis Child 2024:archdischild-2023-326225. [PMID: 38216305 DOI: 10.1136/archdischild-2023-326225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/13/2023] [Indexed: 01/14/2024]
Abstract
Food allergy has been increasing in prevalence in most westernised countries and poses a significant burden to patients and families; dietary and social limitations as well as psychosocial and economic burden affect daily activities, resulting in decreased quality of life. Food oral immunotherapy (food-OIT) has emerged as an active form of treatment, with multiple benefits such as increasing the threshold of reactivity to the allergenic food, decreasing reaction severity on accidental exposures, expanding dietary choices, reducing anxiety and generally improving quality of life. Risks associated with food immunotherapy mostly consist of allergic reactions during therapy. While the therapy is generally considered both safe and effective, patients and families must be informed of the aforementioned risks, understand them, and be willing to accept and hedge these risks as being worthwhile and outweighed by the anticipated benefits through a process of shared decision-making. Food-OIT is a good example of a preference-sensitive care paradigm, given candidates for this therapy must consider multiple trade-offs for what is considered an optional therapy for food allergy compared with avoidance. Additionally, clinicians who discuss OIT should remain increasingly aware of the growing impact of social media on medical decision-making and be prepared to counter misconceptions by providing clear evidence-based information during in-person encounters, on their website, and through printed information that families can take home and review.
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Affiliation(s)
- Aikaterini Anagnostou
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Matthew Greenhawt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Grant Pickett
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | | | - David Stukus
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Elissa M Abrams
- Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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4
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Villarreal-González RV, González-Díaz S, Vidal-Gutiérrez O, de la Cruz-de la Cruz C, Pérez-Ibave DC, Garza-Rodríguez ML. Interleukin-6 as a biomarker of hypersensitivity reactions in chemotherapeutics and monoclonal antibodies. J Oncol Pharm Pract 2023:10781552231204367. [PMID: 37817577 DOI: 10.1177/10781552231204367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND In recent years, a new type of immediate hypersensitivity reaction known as cytokine release began to emerge, and within this phenotype of reactions, interleukin-6 is the most frequently associated with the presence during drug administration. Chemotherapeutic agents (QT) and monoclonal antibodies. OBJECTIVE Determine interleukin-6 levels in hypersensitivity reactions to QT and monoclonal antibodies. METHODS Observational and prospective study that was carried out from March 1, 2021 to March 1, 2022 in a university hospital in northeastern Mexico. Symptoms, severity, interleukin-6 levels, and skin tests of hypersensitivity reaction were evaluated at QT and monoclonal antibodies. RESULTS A total of 41 patients with oncological disease were included, the most frequent being ovarian cancer. Symptoms as initial hypersensitivity reaction were neuromuscular in taxanes and cutaneous in Platinums.41.5% presented elevation of interleukin-6, and it was found more frequently in presence of metastases. Positive skin tests were found more frequently in the carboplatin and doxorubicin groups. The most frequently presented phenotype was type I in paclitaxel, carboplatin, and doxorubicin, and mixed-reaction (type I and cytokine release) in oxaliplatin. CONCLUSION With the increasing prevalence of hypersensitivity reactions to biologic and antineoplastic therapies, interleukin-6 should be recognized as a biomarker in immediate hypersensitivity reactions to QT and monoclonal antibodies.
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Affiliation(s)
- Rosalaura V Villarreal-González
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Sandra González-Díaz
- Faculty of Medicine, Regional Center of Allergy and Clinical Immunology, Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Oscar Vidal-Gutiérrez
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - Carlos de la Cruz-de la Cruz
- Department of Internal Medicine, Universidad de Monterrey, Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | - Diana C Pérez-Ibave
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
| | - María L Garza-Rodríguez
- Faculty of Medicine, Oncology Service, Centro Universitario Contra el Cáncer (CUCC), Universidad Autónoma de Nuevo León, Hospital Universitario "Dr José Eleuterio González", Monterrey, Nuevo León, Mexico
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5
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Hammond C. Revisiting the Definition of Anaphylaxis. Curr Allergy Asthma Rep 2023; 23:249-254. [PMID: 37171671 DOI: 10.1007/s11882-023-01077-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE OF REVIEW Anaphylaxis is a common phenomenon that has been studied for many decades. Despite this, there is still disagreement among organizations regarding the precise definition for anaphylaxis. This article discusses the difference between the proposed definitions of anaphylaxis. Furthermore, the most up-to-date literature on specific subtypes of anaphylaxis is reviewed, and implications for clinical practice are discussed. RECENT FINDINGS Recent literature on various subtypes of anaphylaxis has been conducted. This has helped clarify guidelines for conditions such as allergy to radiocontrast media, idiopathic anaphylaxis, and food-dependent exercise-induced anaphylaxis. Recent literature has also studied available biomarkers for anaphylaxis and the cost-effectiveness of current standard-of-care prescription of epinephrine autoinjectors. Anaphylaxis is an increasingly more frequent phenomenon and remains a hot topic in current research. Much progress has been made in clarifying the definition of anaphylaxis and differentiating between subtypes, but more research is needed to identify a readily available biomarker for anaphylaxis and identify the standard of care for various subtypes of anaphylaxis.
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Affiliation(s)
- Catherine Hammond
- Department of Pediatrics, Allergy/Immunology, Faculty Office Building, University of Tennessee Health Science Center, 49 North Dunlap, Room #296, 38103, Memphis, TN, USA.
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6
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Ritter S, Fowler J, Lieberman J. Temporal Variation of Tryptase and Inter-Lab Variability. Ann Allergy Asthma Immunol 2022; 129:640-642. [PMID: 35914660 DOI: 10.1016/j.anai.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Shaunah Ritter
- Shaunah Ritter, Division of Allergy and Immunology, Le Bonheur Children's Medical Center, University of Tennessee Health Science Center.
| | - Joshua Fowler
- University of Tennessee Health Science Center, Memphis, TN
| | - Jay Lieberman
- Division of Allergy and Immunology, Le Bonheur Children's Medical Center, University of Tennessee Health Sciences Center, Memphis TN
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Quoc QL, Bich TCT, Jang JH, Park HS. Recent update on the management of anaphylaxis. Clin Exp Emerg Med 2021; 8:160-172. [PMID: 34649404 PMCID: PMC8517462 DOI: 10.15441/ceem.21.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is a life-threatening systemic allergic reaction presenting various clinical manifestations. Its prevalence has increased in almost all age groups and both sexes. Food, venom, and drugs are major causes in both children and adults; a higher prevalence of food-induced anaphylaxis is noted in children, while a higher prevalence of drug-induced anaphylaxis is noted in adults. The pathogenic mechanism is mediated by immunologic and nonimmunologic mechanisms, where mast cells and basophils are key cells that release mediators. A diagnosis of anaphylaxis is mainly based on clinical symptoms and physical findings; however, an increased serum tryptase level is a useful biomarker. Epinephrine is the first-line drug to treat acute symptoms, and an epinephrine auto-injector should be prescribed for each patient. Antihistamines and systemic corticosteroids are used to relieve symptoms. This review updates current issues in the management of anaphylaxis as well as the new guidelines for proper diagnosis and treatment.
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Affiliation(s)
- Quang Luu Quoc
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Tra Cao Thi Bich
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Hyuk Jang
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, Korea
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8
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Motomura C, Ide K, Shimoda T, Odajima H. Exercise-induced anaphylaxis unrelated to food ingestion and with hyperleukotrieneuria during challenge testing. Allergy Asthma Clin Immunol 2021; 17:89. [PMID: 34496945 PMCID: PMC8424941 DOI: 10.1186/s13223-021-00593-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exercise-induced anaphylaxis (EIA) is a rare and potentially life-threatening disorder that can develop independently without food ingestion. Cold drinks can also trigger symptoms in some patients with cold-induced anaphylaxis. We present a case of a patient with EIA that was diagnosed on the basis of positive exercise loading test with hyperleukotrieneuria. CASE PRESENTATION A 12-year-old girl presented with acute flushing, cyanosis, swollen eyelids, and dyspnea after an endurance run in winter or swimming in a cold-water pool. She also developed dyspnea after having a cold drink. She had no history of food allergies, atopy, or asthma. No association was noted between anaphylaxis and food intake in her history. On the first day, she ingested 200 mL of 5 °C cold water in 30 s, which did not trigger symptomatic responses, but her urinary leukotriene E4 (LTE4) level increased (pre-challenge test: 295 pg/mg-creatinine (cr), post-challenge test: 400 pg/mg-cr). On the second day, she underwent the exercise loading test according to the Bruce protocol by using an ergometer to increase the power of exercise every 2 min. She had been fasting for > 15 h and did not have breakfast. Just after the exercise loading test, the plasma adrenaline and noradrenaline increased. At 15 min after the exercise loading test, her plasma adrenaline and histamine (pre-challenge test: 0.7 ng/mL, 15 min post-challenge test: 81 ng/mL) rose sharply with anaphylaxis symptoms accompanied by increasing urinary LTE4 (pre-challenge test: 579 pg/mg-cr, post-challenge test: 846 pg/mg-cr). After she was discharged, she was restricted from strenuous exercise especially in cold environments and prescribed an adrenaline autoinjector. CONCLUSION Cold stimulation can become a co-effector of EIA. Measurements of urinary LTE4 levels during challenge testing are useful for diagnosing EIA and capture the pre-anaphylaxis stage.
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Affiliation(s)
- Chikako Motomura
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, 4-39-1 Yakatabaru, Minamiku, Fukuoka city, Fukuoka, 811-1394, Japan.
| | - Koji Ide
- Ide Kid's Allergy Clinic, 3-32-19 Yokote, Minamiku, Fukuoka, 811-1311, Japan
| | - Terufumi Shimoda
- Department of Clinical Research, National Hospital Organization Fukuoka National Hospital, 4-39-1 Yakatabaru, Minamiku, Fukuoka, 811-1394, Japan
| | - Hiroshi Odajima
- Department of Pediatrics, National Hospital Organization Fukuoka National Hospital, 4-39-1 Yakatabaru, Minamiku, Fukuoka city, Fukuoka, 811-1394, Japan
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9
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A severity grading system of food-induced acute allergic reactions to avoid the delay of epinephrine administration. Ann Allergy Asthma Immunol 2021; 127:462-470.e2. [PMID: 33895419 DOI: 10.1016/j.anai.2021.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/11/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Substantial discrepancies among anaphylaxis severity scores may delay epinephrine administration. OBJECTIVE The study aims to develop a transparent severity grading system of food-induced acute allergic reactions with a decision model for epinephrine use. METHODS The natural course of 315 acute food-induced allergic reactions in children hospitalized at the Allergology department between May 2016 and July 2019 owing to follow-up treatment and allergy diagnostics was evaluated. The severity of episodes was classified according to the 5 most accepted grading systems. The interrater reliability of classification between anaphylaxis severity scores was assessed. All symptoms were grouped into a heat map according to their real-life incidence and clinical relevance. Based on the heat map analysis, a severity grading system of food-induced acute allergic reactions in children with the epinephrine administration decision model was created. RESULTS Data from 259 food-induced anaphylaxis episodes in 157 children were included in the analysis. Comparing the grading systems, we observed a 24.7% to 70.2% disagreement between severity scores. The heat map illustrated a strong association between 29 symptoms and their categorization. A new severity grading system was developed and a 2-stage decision model was proposed: "epinephrine yes" (any rapidly progressing symptoms, even mild ones or from 1 organ system; any symptoms from more than 1 organ system; or every grade of anaphylaxis), and "epinephrine available and prepared to use" (nonprogressing mild systemic allergic reaction from 1 system area only; no anaphylaxis). CONCLUSION A new severity grading system of food-induced acute allergic reactions in children could serve as a clinical tool for health care professionals to avoid epinephrine administration delay.
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10
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Lieberman JA, Camargo CA, Pistiner M, Wang J. Pediatrician perspectives on symptom presentation and treatment of acute allergic reactions. Ann Allergy Asthma Immunol 2020; 126:273-277. [PMID: 33232828 DOI: 10.1016/j.anai.2020.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anaphylaxis remains difficult to diagnose and epinephrine underused. OBJECTIVE To better understand the thoughts of pediatricians regarding when acute allergic reactions constitute anaphylaxis and when epinephrine should be given by conducting an anonymous online survey. METHODS The survey consisted of 8 case-based scenarios of allergic reactions with the following 2 questions on each case: (1) does this case represent anaphylaxis? and (2) if this patient immediately presented to you, would you treat the patient with epinephrine during the reaction? RESULTS A total of 1001 responses were analyzed. When assessing all cases combined, there was discordance in whether a case represented anaphylaxis and administration of epinephrine was warranted in 8% of the cases. An average of 5% of all the respondents suggested that the case represented anaphylaxis but would not warrant epinephrine, whereas an average of 3% suggested that the case did not represent anaphylaxis but that epinephrine was warranted. CONCLUSION The results of this survey reveal that there is discordance among pediatricians on when an allergic reaction is considered anaphylaxis and when epinephrine is warranted. These data highlight the need for continued improvement of the definition of anaphylaxis and continued need for education regarding the diagnosis and management of anaphylaxis.
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Affiliation(s)
- Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee; Division of Pulmonology, Allergy, and Immunology, Department of Pediatrics, Le Bonheur Children's Hospital, Memphis, Tennessee.
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael Pistiner
- Division of Allergy and Immunology, Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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11
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Castells MC, Li JT. Anaphylaxis: Parts Unknown. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:1216-1218. [PMID: 32276690 DOI: 10.1016/j.jaip.2020.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Mariana C Castells
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - James T Li
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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