Commonly Associated with Anaphylaxis Due to Concomitant Ingestion of a Specific Food Trigger
Celery
Omega-5 Gliadin
Shellfish
Wheat
Less Commonly Associated with Anaphylaxis Due to Concomitant Ingestion of Ethanol or NSAID Drug: these enhance intestinal permeability and allergen absorption
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
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]
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
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)
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
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
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
Hyperinflation: may indicate the presence of bronchospasm
Pulmonary Edema: may occur in severe cases
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
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
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
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
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]
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]