Epidemiology

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Etiology

IgE-Mediated Mast Cell Activation (Type I Hypersensitivity) (see Immune Hypersensitivity)

Foods/Food Additives (see Food Allergy)

• General Comments: specific food triggers vary geographically (due to different foods consumed and methods of preparation)
  • North America/Some Countries in Europe and Asia: cow milk, hen’s egg, peanut, tree nuts, shellfish, and fish are common triggers
  • European Countries: peach is a common trigger
  • Middle East: sesame is common trigger
  • Asia: buckwheat, chickpea, rice, and bird’s nest soup are common triggers
• Annatto (see Annatto): yellow food colorant
• Carmine (see Carmine): insect-derived red colorant
• Eggs
• Legumes: beans, lentils, peanuts, peas, soybeans/soy
• Milk: cow milk, goat milk, sheep milk
• Peach
• Red Meat
  • Epidemiology: has also been described with lamb and some cuts of pork
  • Physiology
    • Tick Acquires the Oligosaccharide, Alpha-Gal, After Feasting on a Mammal, Retaining it in its Gastrointestinal Tract Until it Bites a Human: the bite provokes an IgE response in the human
    • Alpha-Gal is Found in Red Meats
    • Alpha-Gal is Also Found in Cetuximab (Erbitux) (see Cetuximab)
    • Alpha-Gal May Also Be Found in Porcine Products, Such as Heart Valves and Heparin
  • Clinical
    • Alpha-Gal Related Meat Allergy is Unusual in that it has a Delayed Onset, Occurring 4-6 hrs After Meat Ingestion
    • Alpha-Gal Associated Cetuximab (Erbitux) Allergy (see Cetuximab): may occur on first exposure and may be severe, resulting in anaphylaxis
    • Allergy May Recede Over Months-Years if Red Meat is Avoided
• Seafood: crustaceans, shellfish, finned fish, shrimp
• Sesame
• Spices
• Tree Nuts: almonds, cashews, walnuts
• Vegetable Gums
• Wheat

Stings/Bites/Envenomations

• Phylum Arthropoda -> Class Insecta -> Order Hymenoptera
  • Bumble Bee Sting (see Bee Sting)
  • Fire Ant Bite (see Fire Ant Bite)
  • Honey Bee Sting (see Bee Sting)
  • Hornet Sting (see Hornet Sting,)
  • Paper Wasp Sting (see Wasp Sting)
  • Wood Ant Bite
  • Yellowjacket Sting (see Bee Sting)
• Phylum Arthropoda -> Class Insecta -> Order Hemiptera
  • Bed Bug Bite (Cimex) (see Bed Bug Bite): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
  • Kissing Bug Bite (Triatoma) (see Kissing Bug Bite)
• Phylum Arthropoda -> Class Insecta -> Order Diptera
  • Blackfly Bite (see Blackfly Bite)
  • Deerfly Bite (Chrysops) (see Deerfly Bite)
  • Horsefly Bite (see Horsefly Bite)
  • Louse Fly Bite (see Louse Fly Bite)
  • Mosquito Bite (see Mosquito Bite): anaphylaxis rarely occurs following mosquito bite
  • Sandfly Bite (see Sandfly Bite)
  • Tsetse Fly Bite (Glossina) (see Tsetse Fly Bite)
• Phylum Arthropoda -> Class Insecta -> Order Lepidoptera
  • Pine Processionary Caterpillar Envenomation
  • Puss Caterpillar Envenomation (see Puss Caterpillar Envenomation): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
• Phylum Arthropoda -> Class Arachnida
  • Ixodes Holocyclus (Australian Paralysis Tick) Bite (see Tick Bite)
  • Argas Reflexus (Pigeon Tick) Bite (see Tick Bite)
  • Scorpion Sting (see Scorpion Sting): particularly Centruroides (common striped scorpion)
  • Ixodes Pacificus (Western Black-Legged Tick) Bite (see Tick Bite)
• Phylum Cnidaria
  • Box Jellyfish (Carybdea Alata) Sting (see Jellyfish Sting): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
  • Portuguese Man-of-War (Physalia Physalis) Sting: may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
  • Sea Nettle Sting
• Phylum Chordata -> Class Reptila
  • European Viper (Vipera) Snake Bite
  • Gila Monster Bite (see Poisonous Lizard Bite): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
  • Mexican Beaded Lizard Bite (see Poisonous Lizard Bite): may induce an anaphylaxis-like reaction (unknown if IgE-mediated)
  • Rattlesnake (Crotalus) Bite (see Rattlesnake Bite)
• Phylum Chordata -> Class Mammalia
  • Gerbil Bite
  • Hamster Bite
  • Mouse Bite
  • Rat Bite

Drugs

• Abacavir (see Abacavir)
• Acetaminophen (Tylenol) (see Acetaminophen)
  • Epidemiology: cases of anaphylaxis have been reported
• Allergen Immunotherapy (Subcutaneous) (see Allergen Immunotherapy)
• Alpha-1 Antitrypsin (Aralast, Glassia, Prolastin, Zemaira) (see Alpha-1 Antitrypsin): occurs in <1% of cases
• Angiotensin Converting Enzyme (ACE) Inhibitors (see Angiotensin Converting Enzyme Inhibitors)
• Acyclovir (Zovirax) (see Acyclovir)
• Anti-Thymocyte Globulin (ATG) (see Anti-Thymocyte Globulin)
• Antivenoms
  • Crofab (see Crofab and Rattlesnake Bite): incidence from meta-analyses has been reported to be 8% [MEDLINE]
  • Widow Spider Antivenom (see Widow Spider Bite)
• β-Lactam Antibiotics (see β-Lactam Antibiotics)
  • Cephalosporins (see Cephalosporins)
  • Imipenem (see Imipenem): cross-reactivity in 50% of patients with allergy to penicillins
  • Penicillins (see Penicillins): occurs in 0.05% of cases, fatal in 5-10% of cases
• Demeclocycline (see Demeclocycline)
• Gemcitabine (Gemzar) (see Gemcitabine): cases of laryngeal edema have been reported
• Heparin (see Heparin): anaphylaxis is a manifestation of heparin-induced thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia)
• Insulin (see Insulin)
• Iodinated Drugs
  • See Also Radiographic Contrast Below
• Local Anesthetics
  • Lidocaine (see Lidocaine)
  • Procaine (Novocaine, Novocain) (see Procaine)
• Monoclonal Antibodies/Biologics
  • Cetuximab (Erbitux) (see Cetuximab)
    • Physiology: tick bite-associated alpha-galactosidase sensitization has been found to be a mechanism of allergic sensitization to cetuximab and read meats (J Allergy Clin Immunol, 2015) [MEDLINE]
  • Intravenous Immunoglobulin (IVIG) (see Intravenous Immunoglobulin)
  • Omalizumab (Xolair) (see Omalizumab): rare etiology of anaphylaxis
  • Rituximab (Rituxan) (see Anti-CD20 Therapy)
• N-Acetylcysteine (Mucomyst, Acetadote, Fluimucil, Parvolex) (see N-Acetylcysteine)
  • Epidemiology: associated with intravenous administration
  • Physiology: histamine release has been implicated
• Non-Dextran Intravenous Iron
  
  • Ferumoxytol (Feraheme) (see Ferumoxytol)
    • Risk of First-Exposure Anaphylaxis (see Anaphylaxis) [MEDLINE]: 24 per 100k patients
  • Iron Gluconate (Ferrous Gluconate, Fergon, Ferralet, Simron) (see Iron Gluconate)
    • Risk of First-Exposure Anaphylaxis (see Anaphylaxis) [MEDLINE]: 24 per 100k patients
  • Iron Sucrose (Venofer) (see Iron Sucrose)
    • Risk of First-Exposure Anaphylaxis (see Anaphylaxis) [MEDLINE]: 24 per 100k patients
    • Cumulative Risk of Anaphylaxis (Over 12 wk Period) [MEDLINE]: iron sucrose has lowest risk of all of the intravenous iron agents
• Nonsteroidal Anti-Inflammatory Drugs (NSAID’s) (see Nonsteroidal Anti-Inflammatory Drug)
  • Epidemiology: NSAID’s rarely cause allergic reactions via this mechanism
• Platins
  • Carboplatin (see Carboplatin
  • Cisplatin (see Cisplatin)
  • Oxaliplatin (Eloxatin, Oxaliplatin Medac) (see Oxaliplatin): anaphylaxis occurs in 1.3% of cases
• Progesterone (see Progesterone)
• Protamine (see Protamine)
• Radiographic Contrast (see Radiographic Contrast)
  • Epidemiology: although contrast-associated IgE-mediated anaphylaxis was once considered rare, contrast-specific IgE antibodies have been demonstrated in some cases (Am J Roentgenol, 2008) [MEDLINE] (Allerg Immunol, 1993; Paris) [MEDLINE]
  • Physiology
    • IgE-Mediated: some cases
    • Non-IgE-Mediated: most cases
      • Activation of Coagulation/Kinin/Complement Cascades
      • Direct Mast Cell Activation
      • Inhibition of Cholinesterase
      • Inhibition of Platelet Aggregation with Increased Serotonin Release
• Sorafenib (Nexavar) (see Sorafenib)
• Streptomycin (see Streptomycin)
• Succinylcholine (see Succinylcholine)
• Sulfobromophthalein
• Taxanes (see Taxanes)
  • Docetaxel (Taxotere) (see Docetaxel)
  • Paclitaxel (Taxol) (see Paclitaxel)
• Vaccines: may be due to either egg or gelatin components of the vaccine
• Vitamin K (see Vitamin K)

Other

• Aeroallergens: rarely involved in angioedema/anaphylaxis
  • Cat Dander
  • Grass Pollen
  • Horse Dander
• Allergen Immunotherapy (see Allergen Immunotherapy)
• Blood Products
  • Packed Red Blood Cells (PRBC) (see Packed Red Blood Cells)
• Fluorescein (see Fluorescein)
• Hemodialysis (see Hemodialysis): due to reaction to dialysis membranes
  • Cellulose Membranes: predominant type of membrane associated with anaphylaxis
    • Membranes are ethylene oxide sterilized
    • Membranes can activate complement
  • Polyacrylonitrile AN69 High Flux Membranes: fewer reported cases of anaphylaxis
• Human Seminal Fluid
  • Epidemiology: rare etiology of anaphylaxis in females
• Intradermal Allergen Skin Testing
• Natural Rubber Latex (see Latex)
• Occupational Allergens
• Vaccines

Immunologic Non-IgE-Mediated Mast Cell Activation

• Heparin Contaminated with Oversulfated Chondroitin Sulfate (see Heparin)
  • Physiology: mediated by coagulation system activation
• Dextrans
  • Dextran (see Dextran)
  • Iron Dextran (Dexferrum, INFeD) (see Iron Dextran)
    • Risk of First-Exposure Anaphylaxis [MEDLINE]): 68 per 100k patients
    • Cumulative Risk of Anaphylaxis (Over 12 wk Period) [MEDLINE]: iron dextrose has highest risk of all of the intravenous iron agents
• Idiopathic Histaminergic Angioedema
  • Clinical: recurrent angioedema often associated with chronic spontaneous urticaria or inducible (physical) urticaria
• Infliximab (Remicade) (see Infliximab)
  • Physiology: IgG-mediated
• Packed Red Blood Cells (PRBC) (see Packed Red Blood Cells)
  • Epidemiology: rare cases of patients with very low levels of IgA and anti-IgA Ab’s, may develop anaphylaxis upon receiving blood with IgA present (these patients need IgA-deficient blood products)
• Radiographic Contrast (see Radiographic Contrast)
  • Epidemiology: although contrast-associated IgE-mediated anaphylaxis was once considered rare, contrast-specific IgE antibodies have been demonstrated in some cases (Am J Roentgenol, 2008) [MEDLINE] (Allerg Immunol, 1993; Paris) [MEDLINE]
  • Physiology
    • IgE-Mediated: some cases
    • Non-IgE-Mediated: most cases
      • Activation of Coagulation/Kinin/Complement Cascades
      • Direct Mast Cell Activation
      • Inhibition of Cholinesterase
      • Inhibition of Platelet Aggregation with Increased Serotonin Release

Non-Immunologic Direct Mast Cell/Basophil Activation

• Ethanol (see Ethanol): rarely induces anaphylaxis by itself, but may augment mast cell activation
• Foods: these “pseudoallergens” may cause urticaria (or contact urticaria) via IgE-mediated or via non-immunologic mechanisms, especially in children
  • Strawberries
  • Tomatoes
• Neuromuscular Junction Antagonists (see Neuromuscular Junction Antagonists)
  • Relative Incidence (in Australian Study from 2002-2011): Rocuronium (56% of cases) > Succinylcholine (21% of cases) > Vecuronium (11% of cases) (Br J Anaesth, 2013) [MEDLINE])
    • Cisatracurium Had the Lowest Prevalence of Cross-Reactivity in Patients with Known Anaphylaxis to Either Rocuronium or Vecuronium
  • Atracurium (see Atracurium)
  • Cisatracurium (Nimbex) (see Cisatracurium
  • Curare (see Curare)
  • Rocuronium (Zemuron) (see Rocuronium)
  • Succinylcholine (see Succinylcholine)
  • Vecuronium (see Vecuronium)
• Non-Steroidal Anti-Inflammatory Drugs (NSAID) (see Non-Steroidal Anti-Inflammatory Drug)
• Opiates (see Opiates)
  • Codeine (see Codeine)
  • Dextromethorphan (see Dextromethorphan)
  • Morphine (see Morphine)
• Physical Factors
  • Cold
  • Heat
  • Exercise: usually associated with a co-trigger (such as a food, NSAID, or exposure to cold air or water)
  • Sunlight/Ultraviolet Radiation
• Radiographic Contrast (see Radiographic Contrast)
  • Epidemiology: although contrast-associated IgE-mediated anaphylaxis was once considered rare, contrast-specific IgE antibodies have been demonstrated in some cases (Am J Roentgenol, 2008) [MEDLINE] (Allerg Immunol, 1993; Paris) [MEDLINE]
  • Physiology
    • IgE-Mediated: some cases
    • Non-IgE-Mediated: most cases
      • Activation of Coagulation/Kinin/Complement Cascades
      • Direct Mast Cell Activation
      • Inhibition of Cholinesterase
      • Inhibition of Platelet Aggregation with Increased Serotonin Release
• Stinging Nettle (Urtica Dioica) (see Stinging Nettle): urticaria was named after this weed (which is commonly found in North America, South Americam Europe, and parts of Africa
  • Physiology: histamine (and pain-causing mediators) contained in the plant
• Vancomycin (see Vancomycin)

Other

• Clonal Mast Cell Disorder
• Systemic Mastocytosis (see Systemic Mastocytosis)
• Previously Unrecognized Allergen

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Physiology

Molecular Mechanism of Anaphylaxis

• Mast Cell/Basophil Activation with Release of Multiple Mediators
  • Histamine
  • IL-4
  • IL-13
  • Leukotrienes
  • Platelet Activating Factor
  • Prostaglandin D2 (PGD2)
  • TNFα
  • Tryptase

Distributive Shock (Similar to Sepsis) (see Hypotension)

• Variable Cardiac Output (CO)
  • Early (Before Volume Resuscitation): hypovolemia predominates -> decreased preload -> normal or decreased CO
  • Later (After Volume Resuscitation): high CO with low SVR state
  • Myocardial depression (decreased ejection fraction observed on echocardiogram) is frequent, despite increased CO
• Venous and Arterial Vasodilation
• Capillary Leak: due to endothelial cell dysfunction
  • Interstitial edema
• Tachycardia: due to hypotension-induced reflexive increase in heart rate
• Hypovolemia (early in course): due to capillary leak and venous/arterial vasodilation

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Diagnosis

Mast Cell Serum Tryptase Level (see Serum Tryptase)

• Draw within hours of event to diagnose anaphylaxis
• May not be elevated in some cases

RAST Testing

• Useful for Allergy Testing: detects allergen-specific IgE

Chest X-Ray (CXR) (see Chest X-Ray)

• Normal CXR: most common pattern
• Hyperinflation: may indicate the presence of bronchospasm
• Pulmonary Edema: may occur in severe cases

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Diagnostic Criteria (One of Three Following Criteria) (J Allergy Clin Immunol, 2006) [MEDLINE]

Acute Onset of Illness (Within Min-Several Hours) with Skin/Mucosal Tissue Involvement (Flushing/Generalized Erythema, Hives, Pruritus, Swollen Lips/Tongue/Uvula) and At Least One of the Following

• Respiratory Compromise
  • Bronchospasm (see Obstructive Lung Disease)
  • Dyspnea (see Dyspnea)
  • Hypoxemia (see Hypoxemia)
  • Stridor (see Stridor)
• Hypotension or Associated End-Organ Dysfunction
  • Hypotonia
  • Incontinence (see Urinary Incontinence
  • Syncope (see Syncope)

Two or More of the Following Occurring Rapidly After Exposure to a Likely Antigen

• Involvement of Skin/Mucosal Tissue
  • Flushing/Generalized Erythema (see Flushing and Erythroderma)
  • Pruritus (see Pruritus)
  • Swollen Lips/Tongue/Uvula (see Lingual Edema)
  • Urticaria (Hives) (see Urticaria)
• Respiratory Compromise
  • Bronchospasm (see Obstructive Lung Disease)
  • Dyspnea (see Dyspnea)
  • Hypoxemia (see Hypoxemia)
  • Stridor (see Stridor)
• Hypotension or Associated End-Organ Dysfunction
  • Hypotonia
  • Incontinence (see Urinary Incontinence)
  • Syncope (see Syncope)
• Persistent Gastrointestinal Symptoms
  • Crampy Abdominal Pain (see Abdominal Pain)
  • Nausea/Vomiting (see Nausea and Vomiting)

Hypotension After Exposure to a Known Allergen for a Specific Patient Within Min-Several Hours (see Hypotension)

• Adult: systolic blood pressure 90 mm Hg or >30% in systolic blood pressure from patient’s baseline
• Infant/Children: age-specific hypotension or >30% decrease in systolic blood pressure

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Clinical Manifestations

General Comments

• Onset: within min-4 hrs
• Biphasic Reaction: symptoms can recur 10 hrs later -> due to this clinical characteristic, prolonged observation may be required (and corticosteroids are often useful to blunt the development of the second phase)

Cardiovascular Manifestations

• General Comments
  • Cardiovascular Manifestations Occur in 45% of Cases
• Sinus Bradycardia (see Sinus Bradycardia): may occur in some cases
• Hypotension/Cardiovascular Collapse (see Hypotension): common
• Palpitations (see Palpitations)
• Sinus Tachycardia (see Sinus Tachycardia): common
• Syncope (see Syncope)

Dermatologic Manifestations

• General Comments
  • Dermatologic Manifestations Occur in 80-90% of Cases
• Angioedema (see Angioedema)
• Erythematous Rash/Flushing (see Erythroderma or Flushing)
• Pruritus (see Pruritus)
• Rash
• Urticaria (see Urticaria)

Gastrointestinal Manifestations

• General Comments
  • Gastrointestinal Manifestations Occur in 45% of Cases
• Crampy Abdominal Pain (see Abdominal Pain)
• Diarrhea (see Diarrhea)
• Nausea/Vomiting (see Nausea and Vomiting)

Neurologic Manifestations

• Dizziness (see Dizziness)
• Lightheadedness
• Sense of Impending Doom

Otolaryngologic Manifestations

• Conjunctival Injection
• Lacrimation
• Metallic Taste
• Nasal Congestion
• Ocular Pruritus
• Oropharyngeal Edema/Upper Airway Obstruction (see Obstructive Lung Disease)
  • Clinical
    • Drooling
    • Dysphagia
    • Dysphonia
    • Hoarseness (see Hoarseness)
    • Inability to Speak
    • Lingual Edema (see Lingual Edema)
    • Stridor (see Stridor)
• Peri-Orbital Edema
• Rhinorrhea (see Rhinorrhea)
• Sneezing

Pulmonary Manifestations

• General Comments
  • Pulmonary Manifestations Occur in 70% of Cases
• Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome): may occur in severe cases
• Acute Respiratory Failure (see Respiratory Failure)
  • Physiology: high-grade upper airway obstruction or bronchospasm with excessive work of breathing
  • Clinical
    • Cyanosis (see Cyanosis)
• Bronchospasm (see Obstructive Lung Disease)
  • Clinical
    • Dry Cough (see Cough)
    • Dyspnea (see Dyspnea)
    • Wheezing (see Wheezing)
    • Tachypnea (see Tachypnea)

Other Manifestations

• Uterine Contractions: in females

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Anaphylactoid Reactions to Contrast Medium

Cutaneous and Mucosal

• Angioedema
• Edema
• Flushing
• Laryngeal Edema
• Pruritus

Smooth Muscle

• Arrhythmia
• Bronchospasm
• Cardiovascular
• GI Spasm
• Uterine Contraction
• Vasodilation/Hypotension/Anaphylactic Shock

Types of Contrast Reactions

Minor

• Flushing
• Nausea
• Pruritus
• Rash
• Urticaria

Major

• Cough
• Dyspnea
• Seizures
• Shock
• Stridor
• Syncope
• Wheezing

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Treatment

General Treatment

• Airway Management (see Airway Management)
  • Mechanical Ventilation (see Mechanical Ventilation-General): as required
• Intravenous Fluid Management: as required
• Eliminate Source/Eliminate Contact with Antigen (If Known): crucial

Epinephrine (see Epinephrine)

• Indications
  • Systemic Symptoms (Hypotension, etc)
• Pharmacology
  • Bronchodilation
  • Vasoconstriction
• Adverse Effects
  • Palpitations (see Palpitations)
  • Sinus Tachycardia (see Sinus Tachycardia)
• Dose: 0.3 mg IM (1:1000) for adults
  • Repeat Dosing: may repeat q5-10 min
  • Max Single Dose: 1 mg
  • Max Total Dose: none
• Preferred Route of Administration
  • Non-Code Blue Situation: IM into thigh is preferred over SQ route
  • Code Blue Situation: IV route (with 1:10,000 solution) is preferred

Preloaded Epinephrine Injectable Devices

• Advantages
  • Patient Can Keep Nearby at Home for Emergency Use: do not store in warm/hot places (such as a car), due to drug stability
    • Shelf-Life: 1 year (when stored properly)
• Adult Dose: 0.3 mg IM (1:1000) for adults
• Brands
  • Epipen
    • Hold like a pen, not like a knife (to avoid inadvertent injection into the thumb)
    • Remove blue safety cap -> firmly push orange tip against lateral thigh (don’t need to remove clothes to use), until it clicks -> hold in place for 5-10 sec
  • Auvi-Q: provides verbal instructions
  • Adrenaclick: pen-like device

Corticosteroids (see Corticosteroids)

• Pharmacology
• Administration
  • PO: Prednisone (see Prednisone)
    • Dose: 40-50 mg qday PO with taper
  • IV: Methylprednisolone (Solumedrol) (see Methylprednisolone)
    • Dose: 125 mg IV x1, then 60 mg IV q6hrs with taper

H1-Histamine Receptor Antagonists (see (see H1-Histamine Receptor Antagonists)

• Indications
  • Skin Symptoms
• Pharmacology: H1-Histamine Receptor Antagonist
• Agents
  • Diphenhydramine (Benadryl) (see Diphenhydramine): 25-50 mg IV PRN

H2-Histamine Receptor Antagonists (see H2-Histamine Receptor Antagonists)

• Pharmacology: H2-Histamine Receptor Antagonist
• Agents
  • Cimetidine (Tagamet) (see Cimetidine)
  • Famotidine (Pepcid) (see Famotidine)
    • Administration: 20 mg IV q12hrs
  • Ranitidine (Zantac) (see Ranitidine)

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References

• Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66:1072-1080 [MEDLINE]
• Hemodynamic changes in human anaphylaxis. Am J Med 1984; 77:341-344 [MEDLINE]
• Profound reversible myocardial depression after anaphylaxis. Lancet 1988; 1:386-388 [MEDLINE]
• Anaphylactic shock induced by paracetamol. Eur J Clin Pharmacol. 1990;38(4):389 [MEDLINE]
• Anaphylaxis-induced myocardial depression treated with amrinone. Lancet 1991; 337:682-683 [MEDLINE]
• Anaphylaxis. N Engl J Med 1991; 324:1785-1786 [MEDLINE]
• Histamine decreases left ventricular contractility in normal human subjects. J Appl Physiol 1992; 73:2530-2537 [MEDLINE]
• Paracetamol anaphylaxis. Clin Exp Allergy. 1992;22(9):831 [MEDLINE]
• Case report: recurrent anaphylactic shock to radiographic contrast media. Evidence supporting an exceptional IgE-mediated reaction. Allerg Immunol (Paris). 1993;25(10):425 [MEDLINE]
• Anaphylaxis induced by horsefly bites: identification of a 69 kd IgE-binding salivary gland protein from Chrysops spp. (Diptera, Tabanidae) by western blot analysis. J Allergy Clin Immunol. 1998;101(1 Pt 1):134. [MEDLINE]
• Second symposium on the definition and management of anaphylaxis: summary report–Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006 Feb;117(2):391-7 [MEDLINE]
• Anaphylaxis to iodinated contrast material: nonallergic hypersensitivity or IgE-mediated allergy? AJR Am J Roentgenol. 2008;190(3):666 [MEDLINE]
• Anaphylaxis. J Allergy Clin Immunol. 2010;125(2 Suppl 2):S161 [MEDLINE]
• World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011 Feb;4(2):13-37. doi: 10.1097/WOX.0b013e318211496c [MEDLINE]
• The relevance of tick bites to the production of IgE antibodies to the mammalian oligosaccharide galactose-α-1,3-galactose. J Allergy Clin Immunol. 2011;127(5):1286. Epub 2011 Mar 31 [MEDLINE]
• Anaphylaxis to neuromuscular blocking drugs: incidence and cross-reactivity in Western Australia from 2002 to 2011. Br J Anaesth. 2013 Jun;110(6):981-7. doi: 10.1093/bja/aes506. Epub 2013 Jan 18 [MEDLINE]
• Tick bites and red meat allergy. Curr Opin Allergy Clin Immunol. 2013 Aug;13(4):354-9. doi: 10.1097/ACI.0b013e3283624560 [MEDLINE]
• International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014; 7(1): 9 [MEDLINE]
• The alpha-gal story: lessons learned from connecting the dots. J Allergy Clin Immunol. 2015;135(3):58 [MEDLINE]
• Comparative Risk of Anaphylactic Reactions Associated With Intravenous Iron Products. JAMA. 2015 Nov 17;314(19):2062-2068. doi: 10.1001/jama.2015.15572 [MEDLINE]
• Red meat allergy induced by tick bites: A Norwegian case report. Eur Ann Allergy Clin Immunol. 2017 Jul;49(4):186-188 [MEDLINE]