Management and Prevention of Anaphylaxis

Investigation of the underuse of adrenaline (epinephrine) and prognosis among patients with anaphylaxis at emergency department admission

Background

Anaphylaxis is a potentially fatal condition; in severe cases of anaphylaxis, the cardiovascular system is often heavily involved. Adrenaline (epinephrine) is a cornerstone of the initial treatment of anaphylaxis. The use of epinephrine remains below expectations in clinical practice. Whether the underuse of epinephrine affects the prognosis of patients with anaphylaxis is still unclear.

Materials and methods

This retrospective study included patients with anaphylaxis between 2011 and 2020 who were admitted to an emergency department (ED) in Taiwan. All patients were divided into two groups based on the use of epinephrine (or not), and we compared the demographic characteristics, allergens, clinical manifestations, management, and patient outcomes.

Results

We reviewed the records of 314 subjects (216 males, 98 females; mean age: 52.78 ± 16.02 years) who visited our ED due to anaphylaxis; 107 (34.1%) and 207 (65.9%) patients were categorized into the epinephrine use group and the non-epinephrine use group, respectively. Arrival via ambulance (p = 0.019), hypotension (p = 0.002), airway compromise (p < 0.001) and altered consciousness (p < 0.001) were the deciding factors for epinephrine use among anaphylactic patients in the ED. The epinephrine use group had higher rates of other inotropic agent usage and fluid challenge. More than 90% of patients received bed rest, steroids, antihistamines, and monitoring. The epinephrine use group had a longer ED length of stay (387.64 ± 374.71 vs. 313.06 ± 238.99 min, p = 0.03) and a greater need of hospitalization. Among all severe symptoms, hypotension was the most tolerated decision factor for not using epinephrine. In this retrospective analysis, some patients with serious anaphylaxis did not experience adverse outcomes or death even without the use of epinephrine at ED admission. Emergent care focuses first on the airway, breathing, and circulation (ABC) and may compensate for the underusage of epinephrine. This could be the reason why epinephrine was underused among patients with anaphylaxis in the ED.

Conclusion

In summary, early ABC management continues to play an important role in treating patients with severe anaphylaxis, even when epinephrine is not immediately available in clinical scenarios.

Identification of the biological processes, immune cell landscape, and hub genes shared by acute anaphylaxis and ST-segment elevation myocardial infarction

Background: Patients with anaphylaxis are at risk for ST-segment elevation myocardial infarction (STEMI). However, the pathological links between anaphylaxis and STEMI remain unclear. Here, we aimed to explore shared biological processes, immune effector cells, and hub genes of anaphylaxis and STEMI. Methods: Gene expression data for anaphylactic (GSE69063) and STEMI (GSE60993) patients with corresponding healthy controls were pooled from the Gene Expression Omnibus database. Differential expression analysis, enrichment analysis, and CIBERSORT were used to reveal transcriptomic signatures and immune infiltration profiles of anaphylaxis and STEMI, respectively. Based on common differentially expressed genes (DEGs), Gene Ontology analysis, cytoHubba algorithms, and correlation analyses were performed to identify biological processes, hub genes, and hub gene-related immune cells shared by anaphylaxis and STEMI. The robustness of hub genes was assessed in external anaphylactic (GSE47655) and STEMI (GSE61144) datasets. Furthermore, a murine model of anaphylaxis complicated STEMI was established to verify hub gene expressions. The logistic regression analysis was used to evaluate the diagnostic efficiency of hub genes. Results: 265 anaphylaxis-related DEGs were identified, which were associated with immune-inflammatory responses. 237 STEMI-related DEGs were screened, which were involved in innate immune response and myeloid leukocyte activation. M0 macrophages and dendritic cells were markedly higher in both anaphylactic and STEMI samples compared with healthy controls, while CD4⁺ naïve T cells and CD8⁺ T cells were significantly lower. Enrichment analysis of 33 common DEGs illustrated shared biological processes of anaphylaxis and STEMI, including cytokine-mediated signaling pathway, response to reactive oxygen species, and positive regulation of defense response. Six hub genes were identified, and their expression levels were positively correlated with M0 macrophage abundance and negatively correlated with CD4⁺ naïve T cell abundance. In external anaphylactic and STEMI samples, five hub genes (IL1R2, FOS, MMP9, DUSP1, CLEC4D) were confirmed to be markedly upregulated. Moreover, experimentally induced anaphylactic mice developed impaired heart function featuring STEMI and significantly increased expression of the five hub genes. DUSP1 and CLEC4D were screened as blood diagnostic biomarkers of anaphylaxis and STEMI based on the logistic regression analysis. Conclusion: Anaphylaxis and STEMI share the biological processes of inflammation and defense responses. Macrophages, dendritic cells, CD8⁺ T cells, and CD4⁺ naïve T cells constitute an immune cell population that acts in both anaphylaxis and STEMI. Hub genes (DUSP1 and CLEC4D) identified here provide candidate genes for diagnosis, prognosis, and therapeutic targeting of STEMI in anaphylactic patients.

Laryngeal edema following remimazolam-induced anaphylaxis: a rare clinical manifestation

Background

Remimazolam is an ultra-short-acting intravenous benzodiazepine, which has been used as sedative/anesthetic in procedural sedation and anesthesia. Although peri-operative anaphylaxis due to remimazolam has been reported recently, the spectrum of the allergic reactions is still not fully known.

Case presentation

We describe a case of anaphylaxis following remimazolam administration in a male patient undergoing colonoscopy under procedural sedation. The patient presented complex clinical signs including airway changes, skin symptoms, gastrointestinal manifestations and hemodynamic fluctuations. Different from other reported cases, laryngeal edema was the initial and main clinical feature of remimiazolam-induced anaphylaxis.

Conclusions

Remimazolam-induced anaphylaxis has a rapid onset and complex clinical features. This case reminds anesthesiologists should be particularly alert to the unknown adverse reactions of new anesthetics.

Potential prophylactic efficacy of mast cell stabilizers against COVID-19 vaccine-induced anaphylaxis

To fight against coronavirus disease 2019 (COVID-19), the vaccination is currently the most effective approach. However, in addition to common systemic side effects, the vaccines can cause serious allergic reactions or anaphylaxis. In anaphylaxis, the exposure to the allergen causes a sudden release of chemical mediators from mast cells, for which adrenaline is the drug of first choice. In our previous basic studies, in addition to adrenaline, anti-allergic drugs (olopatadine, loratadine, tranilast and ketotifen), antibiotics (clarithromycin), corticosteroids (hydrocortisone and dexamethasone) and certain food constituents (caffeine and catechin) inhibited the process of exocytosis and showed their effectiveness as highly potent mast cell stabilizers. In these studies, since mast cells were pre-incubated with these drugs or the food constituents before exocytosis was induced, the findings strongly indicated their prophylactic efficacy in stabilizing mast cells. Considering such pharmacological properties of these commonly prescribed medications or the food constituents, their prophylactic use may potentially be beneficial in preventing anaphylaxis caused by COVID-19 vaccination.

Clinical Manifestations and Causes of Anaphylaxis. Analysis of 382 Cases from the Anaphylaxis Registry in West Pomerania Province in Poland

Anaphylaxis is most commonly defined as an acute, severe, potentially life-threatening systemic hypersensitivity reaction. Current expert consensus has defined anaphylaxis as a serious reaction that is rapid in onset and can be fatal, and is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes of this reaction. There are no data from other health care centres in Poland presenting characteristics of anaphylactic reactions. Clinical manifestations of anaphylaxis should be analysed, because some patients (10-30%) with anaphylaxis can present without cutaneous findings. This lack of skin/mucosa involvement can lead to misdiagnosis or delayed diagnosis of anaphylaxis. Objectives-to gather epidemiological data on anaphylactic reactions, to identify clinical manifestations of anaphylaxis (organ systems involved), to present diagnostic methods useful for the identification of anaphylaxis triggers, and most importantly, to find causes of anaphylaxis. In this retrospective analysis, we used a questionnaire-based survey regarding patients visiting the Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, between 2006 and 2015. The registry comprised patients with grade II (Ring and Messmer classification) or higher anaphylaxis. Patients with grade I anaphylaxis (e.g., urticaria) were not included in the registry. The incidence of anaphylaxis was higher in women. Clinical manifestations included cutaneous and cardiovascular symptoms, but more than 20% of patients did not present with cutaneous symptoms, which may create difficulties for fast and correct diagnosis. Causes of anaphylaxis were identified and confirmed by means of detailed medical interview, skin tests (STs), and measurement of specific immunoglobulin E (sIgE) and tryptase levels. In the analysed group, the most common cause of anaphylaxis (allergic and nonallergic) was Hymenoptera stinging (wasp), drugs (nonsteroidal anti-inflammatory drugs, NSAIDs) and foods (peanuts, tree nuts, celery). The incidence of anaphylaxis is low, but because of its nature and potentially life-threatening consequences it requires a detailed approach. Comprehensive management of patients who have had anaphylaxis can be complex, so partnerships between allergy specialists, emergency medicine and primary care providers are necessary. Monitoring its range is very important to monitor changes in allergy development.

Saudi teachers' confidence and attitude about their role in anaphylaxis management

Background and Aims

Anaphylaxis is a common emergency and life-threatening hypersensitivity reaction defined as a rapid generalized allergic reaction. Prior international studies have shown that school personnel is often not familiar with the signs of hypersensitivity or with appropriate management strategies that should be initiated at school for children with an anaphylactic reaction. Moreover, no studies have evaluated the awareness of anaphylaxis by school teachers in Saudi Arabia. The aim of this study was to determine teachers' knowledge, attitudes, and practices toward anaphylaxis in Al-Qassim, Saudi Arabia.

Methods

This was a cross-sectional study conducted at a public school in Al-Qassim, Saudi Arabia via a validated fourteen items questionnaire aimed to survey teacher knowledge, attitudes, and practices toward anaphylaxis. The questionnaires were disseminated using a multistage random sampling technique to Saudi national's teachers from different regions in Al-Qassim.

Results

Most teachers had a low level of knowledge (85.3%) of anaphylaxis and positive attitudes (72.9%), and the level of practice was reported as low (48.9%) to moderate (47.5%). The most common sources of information regarding anaphylaxis were the internet and social media. When considering significant factors associated with knowledge, attitudes, and practices (KAP), we found that sex, years of experience in teaching and witnessing students suffering from anaphylaxis were all positively associated with KAP.

Conclusion

The overall knowledge and practices of teachers regarding anaphylactic reactions were poor, although teachers' attitudes toward learning this information were positive. Thus, teachers need further education regarding the management of allergic reaction.

Venom immunotherapy and pregnancy

Introductions

The efficiency of venom immunotherapy (VIT) has been well documented by many studies. However, the most important for VIT is safety, particularly for a pregnant woman and a fetus.

Aim

To establish the influence of continuation of VIT on pregnant women and offspring.

Material and methods

The 6 women became pregnant during a specific immunotherapy. We retrospectively analyzed the influence of the immunotherapy on any complications for the pregnant women and their infants.

Results

Of the 6 patients who participated in this study, four had hyperemesis gravidarum, nausea, and heartburn, and two of them had gestational diabetes mellitus symptoms, typical of pregnancy. The observation indicated that VIT was safe for the pregnant women and their offspring.

Conclusions

The VIT is an appropriate therapeutic method for most patients with severe anaphylactic reactions after a hymenoptera sting. The observation indicated that VIT is safe for pregnant women and for their infants.

Anaphylactic reaction following reversal of nondepolarizing muscle relaxant during general anesthesia: a case report

An anaphylactic reaction during general anesthesia may cause fatal complications. Perioperative anaphylaxis can occur in response to different medications. To our knowledge, pyridostigmine or combination of pyridostigmine with glycopyrrolate-induced anaphylactic reaction during general anesthesia has not been reported. We report a case of a suspected anaphylactic reaction to these drugs. To reduce the risk of complicated perioperative anaphylactic events, prompt assessment and treatment are needed. Moreover, any undesirable exposure to confirmed allergens should be avoided as part of secondary prevention.