1
|
Calogiuri G, Savage MP, Congedo M, Nettis E, Mirizzi AM, Foti C, Vacca A, Kounis NG. Is Adrenaline Always the First Choice Therapy of Anaphylaxis? An Allergist-cardiologist Interdisciplinary Point of View. Curr Pharm Des 2023; 29:2545-2551. [PMID: 37877509 DOI: 10.2174/0113816128257514231019165809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/26/2023]
Abstract
Worldwide, adrenaline is considered the first choice therapy in the international guidelines for the management of anaphylaxis. However, the heart and cardiovascular apparatus are strongly involved in anaphylaxis; for that reason, there are some cardiac conditions and certain anaphylaxis patterns that make epinephrine use problematic without adequate heart monitoring. The onset of Kounis syndrome, takotsubo cardiopathy, or the paradoxical anaphylaxis require great attention in the management of anaphylaxis and adrenaline administration by clinicians, who should be aware of the undervalued evolution of anaphylaxis and the potential cardiologic complications of epinephrine administration. Numerous case reports and studies describe the unexpected onset of cardiac diseases following epinephrine treatment, despite the latter being the recommended therapy for anaphylaxis. Our review suggests that future anaphylaxis guidelines should incorporate cardiovascular specialists since the treatment of Kounis syndrome or takotsubo cardiopathy requires cardiologist skills.
Collapse
Affiliation(s)
| | - Michael P Savage
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, USA
| | | | - Eustachio Nettis
- Department of Emergency and Organ Transplantation, School and Chair of Allergy and Clinical Immunology, University of Bari "Aldo Moro", Bari, Italy
| | | | - Caterina Foti
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine 'G. Baccelli', University of Bari "Aldo Moro", Bari, Italy
| | - Nicholas G Kounis
- Department of Cardiology, University of Patras Medical School, Patras 26221, Greece
| |
Collapse
|
2
|
Kulthanan K, Ungprasert P, Jirapongsananuruk O, Rujitharanawong C, Munprom K, Trakanwittayarak S, Pochanapan O, Panjapakkul W, Maurer M. Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2280-2296. [PMID: 35752432 DOI: 10.1016/j.jaip.2022.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/24/2022] [Accepted: 06/06/2022] [Indexed: 05/03/2023]
Abstract
BACKGROUND Food-dependent exercise-induced wheals, angioedema, and anaphylaxis remain insufficiently characterized. OBJECTIVE We systematically reviewed the literature on clinical manifestations, laboratory investigations, culprit foods, triggering exercise, comorbidities, and treatment outcomes. METHODS Using predefined search terms and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) recommendations, we searched 3 electronic databases to identify relevant literature published before July 2021. RESULTS Of 722 patients (median age 25 years; 55.4% male) from 231 studies (43 cohort studies, 15 cases series, and 173 case reports), 79.6% and 3.7% had anaphylaxis with and without wheals and/or angioedema, respectively. The remaining 16.6% had wheals and/or angioedema without anaphylaxis. The duration from eating to exercising and from exercising to symptom onset ranged from 5 minutes to 6 hours (median 1 hour) and from 5 minutes to 5 hours (median 30 minutes), respectively, and virtually all patients exercised within 4 hours after eating and developed symptoms within 1 hour after exercising. Wheat was the most common culprit food. Running was the most common trigger exercise. Most patients were atopic, and 1 in 3 had a history of urticaria. Aspirin and wheat-based products were the most frequent augmenting factors. On-demand antihistamines, corticosteroids, and epinephrine were commonly used and reported to be effective. Patients who stopped eating culprit foods before exercise no longer developed food-dependent exercise-induced allergic reactions. CONCLUSIONS Food-dependent exercise-induced allergic reactions are heterogeneous in their clinical manifestations, triggers, and response to treatment. Patients benefit from avoidance of culprit foods before exercise, which highlights the need for allergological diagnostic workup and guidance.
Collapse
Affiliation(s)
- Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Orathai Jirapongsananuruk
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chuda Rujitharanawong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanyalak Munprom
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Oraya Pochanapan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Waratchaya Panjapakkul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
| |
Collapse
|
3
|
Toya T, Kagami K, Adachi T. Friend or foe: food-dependent exercise-induced anaphylaxis associated with acute coronary syndrome aggravated by adrenaline and aspirin: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:ytz143. [PMID: 31660504 PMCID: PMC6764556 DOI: 10.1093/ehjcr/ytz143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/10/2019] [Accepted: 08/12/2019] [Indexed: 11/12/2022]
Abstract
Background Although aspirin and adrenaline are the guideline-recommended treatments for acute coronary syndrome (ACS) and anaphylaxis, both regimens can contribute to clinical worsening in the setting of concurrent ACS and anaphylaxis which is called allergic angina or Kounis syndrome. Case summary A 62-year-old woman with food-dependent exercise-induced anaphylaxis developed ACS after intramuscular injection of adrenaline for the treatment of anaphylaxis, whereas administered aspirin for the treatment of ACS exacerbated anaphylaxis. Discussion Our case underlines the importance of tailored treatment based on the underlying pathophysiology of individual patients. Clopidogrel and glucagon might be a better alternative for the treatment of Kounis syndrome.
Collapse
Affiliation(s)
- Takumi Toya
- Department of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Japan
- Corresponding author. Tel: +81 4 2995 1597,
| | - Kazuki Kagami
- Department of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Japan
| |
Collapse
|
4
|
Scherf KA, Brockow K, Biedermann T, Koehler P, Wieser H. Wheat-dependent exercise-induced anaphylaxis. Clin Exp Allergy 2016; 46:10-20. [PMID: 26381478 DOI: 10.1111/cea.12640] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/05/2015] [Accepted: 09/13/2015] [Indexed: 12/31/2022]
Abstract
Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare, but potentially severe food allergy exclusively occurring when wheat ingestion is accompanied by augmenting cofactors. It is clinically characterized by anaphylactic reactions ranging from urticaria and angioedema to dyspnoea, hypotension, collapse, and shock. WDEIA usually develops after ingestion of wheat products followed by physical exercise. Other cofactors are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, alcohol, and infections. The precise mechanisms of WDEIA remain unclear; exercise and other cofactors might increase gastrointestinal allergen permeability and osmolality, redistribute blood flow, or lower the threshold for IgE-mediated mast cell degranulation. Among wheat proteins, ω5-gliadin and high-molecular-weight glutenin subunits have been reported to be the major allergens. In some patients, WDEIA has been discussed to be caused by epicutaneous sensitization with hydrolysed wheat gluten included in cosmetics. Diagnosis is made based on the patient's history in combination with allergy skin testing, determination of wheat-specific IgE serum antibodies, basophil activation test, histamine release test, and/or exercise challenge test. Acute treatment includes application of adrenaline or antihistamines. The most reliable prophylaxis of WDEIA is a gluten-free diet. In less severe cases, a strict limitation of wheat ingestion before exercise and avoidance of other cofactors may be sufficient.
Collapse
Affiliation(s)
- K A Scherf
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| | - K Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - T Biedermann
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - P Koehler
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| | - H Wieser
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| |
Collapse
|
5
|
Kounis NG, Kounis GN, Soufras GD. Exercise-induced urticaria, cholinergic urticaria, and Kounis syndrome. J Pharmacol Pharmacother 2016; 7:48-50. [PMID: 27127399 PMCID: PMC4831493 DOI: 10.4103/0976-500x.179355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Nicholas G Kounis
- Department of Medical Sciences, Western Greece Highest Institute of Education and Technology, Patras, Greece
| | - George N Kounis
- Department of General Practice, University of Patras Medical School, Patras, Greece
| | - George D Soufras
- Department of Cardiology, Saint Andrew's State General Hospital, Patras, Greece
| |
Collapse
|
6
|
Erne P, Bertel O, Urban P, Pedrazzini G, Lüscher TF, Radovanovic D. Inpatient versus outpatient onsets of acute myocardial infarction. Eur J Intern Med 2015; 26:414-9. [PMID: 26033503 DOI: 10.1016/j.ejim.2015.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/14/2015] [Accepted: 05/16/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are few studies on patients suffering acute myocardial infarction (AMI) when already in hospital for other reasons; therefore, this study aimed to compare patients with in-hospital-onset AMI admitted for either medical or surgical reasons versus patients with outpatient-onset AMI. METHODS Patients enrolled in the AMIS Plus registry from 2002 to 2014 were analyzed. The main endpoint was in-hospital mortality. RESULTS Among 35,394 AMI patients, 356 (1%) had inpatient-onset AMI following hospital admission due to other pathologies (surgical 175, non-surgical 181). These patients were older (74 vs. 66 years; P<0.001), more often female (35% vs. 27%; P<0.001), had less frequently ST-elevation myocardial infarction (35.5% vs. 55.5%; P<0.001), but higher risk profiles: hypertension (83% vs. 62%; P<0.001), diabetes (28% vs. 20%; P=0.001), known coronary artery disease (54% vs. 35%; P<0.001), and more comorbidities (Charlson Comorbidity Index above 1 in 51% vs. 22%; P<0.001) than those with outpatient-onset AMI. Percutaneous coronary intervention was less frequently applied (OR 0.45; 95% CI 0.36-0.57), and they were less likely to be treated with aspirin (OR 0.43; 95% CI 0.37-0.59), P2Y12 blockers (OR 0.42; 0.34-0.52) or statins (OR 0.51; 95% CI 0.41-0.63). Crude mortality was higher (14.3% vs. 5.5%; P<0.001) and inpatient-onset AMI was an independent predictor of in-hospital mortality (OR 2.35; 95% CI 1.63-3.39; P<0.001). CONCLUSIONS Patients with in-hospital-onset AMI were at greater risk of death than those with outpatient-onset AMI. More work is needed to improve the identification of hospitalized patients at risk of AMI in order to provide the appropriate management.
Collapse
Affiliation(s)
- Paul Erne
- AMIS Plus, Hirschengraben 84, CH-8001 Zurich, Switzerland; Department of Cardiology, Cardiology Clinic, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Osmund Bertel
- Cardiology Center, Klinik im Park, Seestrasse 220, CH-8027 Zurich, Switzerland
| | - Philip Urban
- Cardiovascular Department, La Tour Hospital, 3, avenue J.-D. Maillard, CH-1217 Geneva, Switzerland
| | - Giovanni Pedrazzini
- Division of Cardiology, Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Thomas F Lüscher
- University Heart Center, Department of Cardiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Dragana Radovanovic
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Hirschengraben 84, CH-8001 Zurich, Switzerland.
| |
Collapse
|
7
|
|
8
|
2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol 2012; 12:389-99. [PMID: 22744267 DOI: 10.1097/aci.0b013e328355b7e4] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis published in early 2011 provide a global perspective on patient risk factors, triggers, clinical diagnosis, treatment, and prevention of anaphylaxis. In this 2012 Update, subsequently published, clinically relevant research in these areas is reviewed. RECENT FINDINGS Patient risk factors and co-factors that amplify anaphylaxis have been documented in prospective studies. The global perspective on the triggers of anaphylaxis has expanded. The clinical criteria for the diagnosis of anaphylaxis that are promulgated in the Guidelines have been validated. Some aspects of anaphylaxis treatment have been prospectively studied. Novel investigations of self-injectable epinephrine for treatment of anaphylaxis recurrences in the community have been performed. Progress has been made with regard to measurement of specific IgE to allergen components (component-resolved testing) that might help to distinguish clinical risk of future anaphylactic episodes to an allergen from asymptomatic sensitization to the allergen. New strategies for immune modulation to prevent food-induced anaphylaxis and new insights into subcutaneous immunotherapy to prevent venom-induced anaphylaxis have been described. SUMMARY Research highlighted in this Update strengthens the evidence-based recommendations for assessment, management, and prevention of anaphylaxis made in the WAO Anaphylaxis Guidelines.
Collapse
|
9
|
Sun RH, Hu BC, Li Q. Stress-induced cardiomyopathy complicated by multiple organ failure following cephalosporin-induced anaphylaxis. Intern Med 2012; 51:895-9. [PMID: 22504246 DOI: 10.2169/internalmedicine.51.6887] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Stress-induced cardiomyopathy, a reversible left ventricular dysfunction, has been reported following anaphylaxis; this clinical circumstance seems to be linked to elevated levels of circulating catecholamines. We present a 36-year-old woman diagnosed as stress-induced cardiomyopathy following ceftriaxone-induced anaphylaxis. After anaphylactic reaction, the patient initially presented with cardiogenic shock, and subsequently developed multiple organ failure. She recovered basically by multiple organ supportive therapies including intra-aortic balloon pump and continuous veno-venous hemofiltration. This case provides a unique opportunity to observe the triggering of stress-induced cardiomyopathy, and also it provides evidence to support the role of catecholamine in the pathogenesis of this disease.
Collapse
Affiliation(s)
- Ren-Hua Sun
- Intensive Care Unit, Zhejiang Provincial People's Hospital, China.
| | | | | |
Collapse
|
10
|
Kounis NG, Almpanis G, Tsigkas G, Kounis GN, Mazarakis A. Kounis syndrome following food-dependent exercise-induced anaphylaxis. Intern Med 2011; 50:1451. [PMID: 21847855 DOI: 10.2169/internalmedicine.50.5448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
|