Pediatric idiopathic anaphylaxis: experience with 22 patients

Idiopathic anaphylaxis in the pediatric population is being increasingly recognized, with symptoms (and therefore classifications) the same as those described in adults. We present a series of 22 patients with special attention to considerations relatively unique to the pediatric population. Prednisone, hydroxyzine, and albuterol were used to control symptoms and induce remission. No deaths occurred during treatment. One adolescent who presented with corticosteroid-dependent idiopathic anaphylaxis was diagnosed with undifferentiated somatoform-idiopathic anaphylaxis. Local physician reluctance to participate in management complicated care for some patients.

Idiopathic anaphylaxis: a series of 335 cases

BACKGROUND

Idiopathic anaphylaxis is anaphylaxis with no definable etiology and no trigger by exogenous allergens. Initially described in 1978, idiopathic anaphylaxis has been subsequently characterized and treatment protocols have been established.

OBJECTIVE

The demographics and course of 335 patients (225 previously reported) treated with prednisone, hydroxyzine, and albuterol are now reported.

RESULTS

Ages ranged from 5 to 83 years. There were nine new pediatric patients in this series totaling 14 (4.2%). Atopy was common (48%) with 34 new patients with asthma. The duration of symptoms prior to presentation ranged from three days to 27 years. One hundred thirty-two patients with idiopathic anaphylaxis were available for follow-up. Twenty of these are currently receiving prednisone for control of idiopathic anaphylaxis, seven of them as part of their initial therapy, and ten for control of recurrence of symptoms. Three patients required continuous alternate day prednisone for control of symptoms (corticosteroid-dependent idiopathic anaphylaxis). Of the 335 patients, there were no longer any patients with the diagnosis of malignant idiopathic anaphylaxis defined as requiring prednisone, 20 mg daily, or 60 mg every other day, for control of idiopathic anaphylaxis. Of the six patients previously diagnosed with malignant idiopathic anaphylaxis, five no longer required prednisone and one has a decreased prednisone requirement of 20 mg on alternate days. Hospital visits were significantly reduced by the management regimens. There were no fatalities from idiopathic anaphylaxis in this series.

CONCLUSIONS

The incidence of idiopathic anaphylaxis is increasing in our practice with more patients being evaluated each year. During 1104 patient years of observation (the longest period of single patient observation being 24 years), no inciting agent has been found responsible for the anaphylactic symptoms. Prognosis continues to remain good with the majority of patients achieving remission with pharmacotherapy.

Idiopathic anaphylaxis: long-term follow-up, cost, and outlook

To determine the efficacy of oral corticosteroids, antihistamines, and sympathomimetics in treating patients with idiopathic anaphylaxis, the charts of 225 patients diagnosed with idiopathic anaphylaxis from 1971 to 1990 treated at a single center were reviewed. Sixty-one patients (34 females and 27 males) were available for long-term follow-up. Ages ranged from 10 to 68 years with an average of 39 years. Patients with frequent episodes were treated with a protocol of oral corticosteroids, antihistamines, and sympathomimetics. Patients with infrequent episodes were treated for acute episodes only. The number of emergency room visits, hospitalizations, intensive care unit admissions, and length of time in remission were recorded. Sixty-five percent of patients with infrequent episodes and 91% of patients with frequent episodes of idiopathic anaphylaxis went into remission. Significant decreases in emergency room visits occurred for the idiopathic anaphylaxis-generalized-frequent group (P < 0.016), the idiopathic-anaphylaxis-generalized-infrequent group (P < 0.0001), and the idiopathic anaphylaxis-angioedema-infrequent group (P < 0.039). Significant decreases in the number of hospitalizations (P < 0.022) and intensive care unit admissions (P < 0.009) occurred for the idiopathic anaphylaxis-generalized-infrequent and frequent groups, respectively. Overall, an estimated $184 740 was saved with the treatment program, for 546 patient-years. Idiopathic anaphylaxis can be controlled and remission induced in most patients. An estimated $11 million per year can be saved for patients in the USA on the basis of the estimated prevalence in this country.

A fatality from idiopathic anaphylaxis

BACKGROUND

Idiopathic anaphylaxis by definition is a form of anaphylaxis where no identifiable stimulus can be found. In our series of over 350 patients with idiopathic anaphylaxis there have been no reported deaths.

OBJECTIVE

To report the clinical course of the first fatality in our series from idiopathic anaphylaxis.

METHODS

A patient was evaluated for idiopathic anaphylaxis and started on our previously published protocol of corticosteroids, sympathomimetics, and antihistamines.

RESULTS

Despite following our protocol--which has been effective in decreasing the number of emergency room visits, hospitalizations, and intensive care unit admissions--controlling the disease, and placing a high percentage of patients into remission, the patient with idiopathic anaphylaxis died unexpectedly after experiencing symptoms similar to previous episodes of idiopathic anaphylaxis.

CONCLUSION

This is the first reported fatality from idiopathic anaphylaxis in our extensive series.

Allergic bronchopulmonary aspergillosis presenting with cough variant asthma and identifiable source of Aspergillus fumigatus

BACKGROUND

A 76-year-old man developed allergic bronchopulmonary aspergillosis initially presenting with cough variant asthma. Symptoms worsened after exposure to ground mulch which was an identifiable source of Aspergillus fumigatus. Symptoms improved after corticosteroids and avoidance measures were instituted.

OBJECTIVE

To report a case of allergic bronchopulmonary aspergillosis presenting as cough variant asthma with identifiable source of Aspergillus fumigatus.

METHODS

Single case report. Serum precipitating antibodies against Aspergillus fumigatus were tested using gel diffusion techniques. Total IgE, specific IgE, and IgG indices were measured by ELISA. Cutaneous reactivity to Aspergillus fumigatus was also tested.

RESULTS

Skin test and serum precipitating antibodies to Aspergillus fumigatus were positive. Precipitins were also detected between Aspergillus fumigatus and the mulch. Total serum IgE was 538 IU/mL (1290 ng/mL) which declined to 228 IU/mL (544 ng/mL) after corticosteroid therapy. IgE index = 1.10 and IgG index = 2.86.

CONCLUSION

Allergic bronchopulmonary aspergillosis can present as cough variant asthma. Identification of exacerbating factors such as sources of Aspergillus fumigatus are important in management.

Multifactorial immunologic lung disease: a case report

BACKGROUND

Allergic asthma, allergic bronchopulmonary aspergillosis, and hypersensitivity pneumonitis are all forms of immunologically mediated lung disease. Recognition that more than one of these diseases may co-exist is necessary for proper patient management.

OBJECTIVE

To report a case of extrinsic (cat) asthma, allergic bronchopulmonary aspergillosis, hypersensitivity pneumonitis, and potentially fatal asthma. Immunologic mechanisms and treatment of these diseases are discussed.

METHODS

The study is a case report from a university hospital setting. Serum precipitating antibodies against avian antigens were measured using gel-diffusion technique. Serum IgE levels were measured and skin testing was performed to selected antigens.

RESULTS

The patient had positive cutaneous reactivity to cat antigen and Aspergillus. Serology for allergic bronchopulmonary aspergillosis and serum precipitating antibodies to finch extract were positive. Symptoms improved and prednisone requirements decreased after removal of finches.

CONCLUSION

A case of cat asthma, potentially fatal asthma, allergic bronchopulmonary aspergillosis, and hypersensitivity pneumonitis is presented. Early recognition and treatment of multifactorial immunologic lung disease with avoidance measures and use of corticosteroids can prevent progressive respiratory damage.

Allergic bronchopulmonary aspergillosis: serologic update for 1995

Allergic bronchopulmonary aspergillosis (ABPA) is a complex disease occurring in 1-2% of patients with asthma involving hypersensitivity to Aspergillus species. The diagnosis is made correlating clinical history and supporting serologic tests. Over many years various serologic tests have been used to both diagnose and follow disease activity. Initial serology from patients with all four positive tests (total serum IgE, IgE and IgG antibody indices, serum precipitins to Aspergillus fumigatus) were compared with the patients' most recent serology. The total serum IgE, IgE antibody index and serum precipitins had the most initial positive tests which stayed positive throughout treatment. The IgG antibody index was the most inconsistent. There were no significant differences between all four tests. We concluded that all four serologic tests are important in the diagnosis of ABPA.