What is meant by the terms allergy and anaphylaxis

Anaphylaxis creates fear and uncertainty throughout the medical profession and general public same. It occurs unexpectedly and may progress rapidly in patients of every ages, often in the young and otherwise healthy. If treated inappropriately, or not treated at every, it may, in rare cases, prove fatal. Rapid diagnosis is essential and dependent on clinical recognition alone. On recognition, immediate injection of intramuscular adrenaline is the treatment of choice, the response to which is often dramatic and potentially life-saving.

The use of adrenaline in the treatment of acute anaphylaxis is well established. However, evidence suggests that adrenaline auto-injectors are under-used in severe reactions, related in part to a reluctance to prescribe them. This has been highlighted in a recent report conducted by The Anaphylaxis Campaign (Uguz et al, 2005). One of the major challenges, with honor to diagnosis and management of anaphylaxis, is the lack of a standard recognised working definition. The purpose of this article is to review anaphylaxis and intramuscular adrenaline istration, particularly for first medical responders.


How does anaphylaxis present?

A clinical presentation of anaphylaxis in its extreme or classical form is easily recognised.

In reality, it is often far more hard to identify, with variable target organ involvement and expression of symptoms. They can be categorised as mild, moderate or severe (Box 1) (Brown, 2004).

Clinical diagnosis of anaphylaxis involves the recognition of one or both of the two severe features of airway compromise (laryngeal oedema and/or asthma) and hypotension (collapse, loss of consciousness, fainting).

What is meant by the terms allergy and anaphylaxis

This is clearly highlighted in the clinical algorithm of the Resuscitation Council’s (UK) guideline (Project Team of the Resuscitation Council, UK, 2005). More finish lists of clinical symptoms are also available (Sampson et al, 2005). Identifying these severe features aids clinical diagnosis. Difficulty arises in the interpretation of the symptoms and signs. For example, urticaria and angio-oedema, in the absence of laryngeal oedema or airway involvement, is not anaphylaxis.


What is anaphylaxis?

In 1902, Charles Richet and Paul Portier first described the phenomenon of anaphylaxis, which literally means ‘against protection’, aboard Prince Albert of Monaco’s yacht in the Mediterranean.

They reported on their attempts to immunise dogs against jellyfish stings (Portuguese Man-of-War), which resulted in the sudden death of a number of the animals. Richet subsequently won the Nobel Prize for physiology or medicine in 1913 for his work on anaphylaxis (Nobel Lectures, 1901–1921).

The European Academy of Allergy and Clinical Immunology defines anaphylaxis as ‘a severe, life-threatening, multiple-organ hypersensitivity, often dominated by severe asthma and hypotension’.

The clinical syndrome of anaphylaxis may involve cutaneous, respiratory, cardiovascular or gastrointestinal symptoms and signs

(Figure 1).

Figure 1. The constellation and complexity of symptoms of anaphylaxis requiring rapid interpretation. These may also be complicated by panic or fainting.


If your kid has symptoms after eating certain foods, he or she may own a food allergy.

A food allergy occurs when the body’s immune system sees a certain food as harmful and reacts by causing symptoms. This is an allergic reaction. Foods that cause allergic reactions are allergens.

Two Categories of Food Allergies

  • Swelling of the lips, tongue or throat
  • Skin rash, itching, hives
  • Immunoglobulin E (IgE) mediated.

    Symptoms result from the body’s immune system making antibodies called Immunoglobulin E (IgE) antibodies. These IgE antibodies react with a certain food.

  • Non-IgE mediated. Other parts of the body’s immune system react to a certain food. This reaction causes symptoms, but does not involve an IgE antibody. Someone can own both IgE mediated and non-IgE mediated food allergies.
  • Stomach pain, vomiting, diarrhea
  • Shortness of breath, trouble breathing, wheezing
  • Feeling love something terrible is about to happen

IgE Mediated Food Allergies

The IgE mediated food allergies most common in infants and children are eggs, milk, peanuts, tree nuts, soy and wheat.

The allergic reaction can involve the skin, mouth, eyes, lungs, heart, gut and brain.

What is meant by the terms allergy and anaphylaxis

Some of the symptoms can include:

  1. Swelling of the lips, tongue or throat
  2. Stomach pain, vomiting, diarrhea
  3. Skin rash, itching, hives
  4. Shortness of breath, trouble breathing, wheezing
  5. Feeling love something terrible is about to happen

Sometimes allergy symptoms are mild. Other times they can be severe. Take every allergic symptoms seriously. Mild and severe symptoms can lead to a serious allergic reaction called anaphylaxis (anna-fih-LACK-sis). This reaction generally involves more than one part of the body and can get worse quick. Anaphylaxis must be treated correct away to provide the best chance for improvement and prevent serious, potentially life-threatening complications.

Treat anaphylaxis with epinephrine.

This medicine is safe and comes in an easy-to-use device called an auto-injector. You can’t rely on antihistamines to treat anaphylaxis. The symptoms of an anaphylactic reaction happen shortly after contact with an allergen. In some individuals, there may be a delay of two to three hours before symptoms first appear.

Cross-Reactivity and Oral Allergy Syndrome

Having an IgE mediated allergy to one food can mean your kid is allergic to similar foods.

For example, if your kid is allergic to shrimp, he or she may be allergic to other types of shellfish, such as crab or crayfish. Or if your kid is allergic to cow’s milk, he or she may also be allergic to goat’s and sheep’s milk. The reaction between diverse foods is called cross-reactivity. This happens when proteins in one food are similar to the proteins in another food.

Cross-reactivity also can happen between latex and certain foods. For example, a kid who has an allergy to latex may also own an allergy to bananas, avocados, kiwis or chestnuts.

Some people who own allergies to pollens, such as ragweed and grasses, may also be allergic to some foods.

Proteins in the pollens are love the proteins in some fruits and vegetables. So, if your kid is allergic to ragweed, he or she may own an allergic reaction to melons and bananas. That’s because the protein in ragweed looks love the proteins in melons and bananas. This condition is oral allergy syndrome.

Symptoms of an oral allergy syndrome include an itchy mouth, throat or tongue. Symptoms can be more severe and may include hives, shortness of breath and vomiting. Reactions generally happen only when someone eats raw food. In rare cases, reactions can be life-threatening and need epinephrine.

Non-IgE Mediated Food Allergies

Most symptoms of non-IgE mediated food allergies involve the digestive tract.

Symptoms may be vomiting and diarrhea. The symptoms can take longer to develop and may final longer than IgE mediated allergy symptoms. Sometimes, a reaction to a food allergen occurs up 3 days after eating the food allergen.

When an allergic reaction occurs with this type of allergy, epinephrine is generally not needed.

What is meant by the terms allergy and anaphylaxis

In general, the best way to treat these allergies is to stay away from the food that causes the reaction. Under are examples of conditions related to non-IgE mediated food allergies.

Not every children who react to a certain food own an allergy. They may own food intolerance. Examples are lactose intolerance, gluten intolerance, sulfite sensitivity or dye sensitivity. Staying away from these foods is the best way to avoid a reaction.

Your child’s doctor may propose other steps to prevent a reaction. If your kid has any food allergy symptoms, see your child’s doctor or allergist. Only a doctor can properly diagnose whether your kid has an IgE- or non-IgE food allergy. Both can be present in some children.

Eosinophilic Esophagitis (EoE)

Eosinophilic (ee-uh-sin-uh-fil-ik) esophagitis is an inflamed esophagus. The esophagus is a tube from the throat to the stomach. An allergy to a food can cause this condition.

With EoE, swallowing food can be hard and painful. Symptoms in infants and toddlers are irritability, problems with eating and poor weight acquire.

Older children may own reflux, vomiting, stomach pain, chest pain and a feeling love food is “stuck” in their throat. The symptoms can happen days or even weeks after eating a food allergen.

EoE is treated by special diets that remove the foods that are causing the condition. Medication may also be used to reduce inflammation.

Food Protein-Induced Enterocolitis Syndrome (FPIES)

FPIES is another type of food allergy. It most often affects young infants. Symptoms generally don’t appear for two or more hours. Symptoms include vomiting, which starts about 2 hours or later after eating the food causing the condition. This condition can also cause diarrhea and failure to acquire weight or height.

Once the baby stops eating the food causing the allergy, the symptoms go away. Rarely, severe vomiting and diarrhea can happen which can lead to dehydration and even shock. Shock occurs when the body is not getting enough blood flow. Emergency treatment for severe symptoms must happen correct away at a hospital. The foods most likely to cause a reaction are dairy, soy, rice, oat, barley, green beans, peas, sweet potatoes, squash and poultry.

Allergic Proctocolitis

Allergic proctocolitis is an allergy to formula or breast milk. This condition inflames the lower part of the intestine. It affects infants in their first year of life and generally ends by age 1 year.

The symptoms include blood-streaked, watery and mucus-filled stools.

Infants may also develop green stools, diarrhea, vomiting, anemia (low blood count) and fussiness. When properly diagnosed, symptoms resolve once the offending food(s) are removed from the diet.

Medical review December 2014.

Anaphylaxis: Severe Allergic Reactions

IgE Mediated Food Allergies

The IgE mediated food allergies most common in infants and children are eggs, milk, peanuts, tree nuts, soy and wheat. The allergic reaction can involve the skin, mouth, eyes, lungs, heart, gut and brain. Some of the symptoms can include:

  1. Swelling of the lips, tongue or throat
  2. Stomach pain, vomiting, diarrhea
  3. Skin rash, itching, hives
  4. Shortness of breath, trouble breathing, wheezing
  5. Feeling love something terrible is about to happen

Sometimes allergy symptoms are mild.

Other times they can be severe. Take every allergic symptoms seriously. Mild and severe symptoms can lead to a serious allergic reaction called anaphylaxis (anna-fih-LACK-sis). This reaction generally involves more than one part of the body and can get worse quick. Anaphylaxis must be treated correct away to provide the best chance for improvement and prevent serious, potentially life-threatening complications.

Treat anaphylaxis with epinephrine. This medicine is safe and comes in an easy-to-use device called an auto-injector.

You can’t rely on antihistamines to treat anaphylaxis.

What is meant by the terms allergy and anaphylaxis

The symptoms of an anaphylactic reaction happen shortly after contact with an allergen. In some individuals, there may be a delay of two to three hours before symptoms first appear.

Cross-Reactivity and Oral Allergy Syndrome

Having an IgE mediated allergy to one food can mean your kid is allergic to similar foods. For example, if your kid is allergic to shrimp, he or she may be allergic to other types of shellfish, such as crab or crayfish. Or if your kid is allergic to cow’s milk, he or she may also be allergic to goat’s and sheep’s milk.

The reaction between diverse foods is called cross-reactivity. This happens when proteins in one food are similar to the proteins in another food.

Cross-reactivity also can happen between latex and certain foods. For example, a kid who has an allergy to latex may also own an allergy to bananas, avocados, kiwis or chestnuts.

Some people who own allergies to pollens, such as ragweed and grasses, may also be allergic to some foods.

Proteins in the pollens are love the proteins in some fruits and vegetables. So, if your kid is allergic to ragweed, he or she may own an allergic reaction to melons and bananas. That’s because the protein in ragweed looks love the proteins in melons and bananas. This condition is oral allergy syndrome.

Symptoms of an oral allergy syndrome include an itchy mouth, throat or tongue. Symptoms can be more severe and may include hives, shortness of breath and vomiting. Reactions generally happen only when someone eats raw food. In rare cases, reactions can be life-threatening and need epinephrine.

Non-IgE Mediated Food Allergies

Most symptoms of non-IgE mediated food allergies involve the digestive tract.

Symptoms may be vomiting and diarrhea. The symptoms can take longer to develop and may final longer than IgE mediated allergy symptoms. Sometimes, a reaction to a food allergen occurs up 3 days after eating the food allergen.

When an allergic reaction occurs with this type of allergy, epinephrine is generally not needed. In general, the best way to treat these allergies is to stay away from the food that causes the reaction. Under are examples of conditions related to non-IgE mediated food allergies.

Not every children who react to a certain food own an allergy.

They may own food intolerance. Examples are lactose intolerance, gluten intolerance, sulfite sensitivity or dye sensitivity. Staying away from these foods is the best way to avoid a reaction. Your child’s doctor may propose other steps to prevent a reaction. If your kid has any food allergy symptoms, see your child’s doctor or allergist. Only a doctor can properly diagnose whether your kid has an IgE- or non-IgE food allergy. Both can be present in some children.

Eosinophilic Esophagitis (EoE)

Eosinophilic (ee-uh-sin-uh-fil-ik) esophagitis is an inflamed esophagus. The esophagus is a tube from the throat to the stomach.

An allergy to a food can cause this condition.

With EoE, swallowing food can be hard and painful. Symptoms in infants and toddlers are irritability, problems with eating and poor weight acquire. Older children may own reflux, vomiting, stomach pain, chest pain and a feeling love food is “stuck” in their throat. The symptoms can happen days or even weeks after eating a food allergen.

EoE is treated by special diets that remove the foods that are causing the condition.

Medication may also be used to reduce inflammation.

Food Protein-Induced Enterocolitis Syndrome (FPIES)

FPIES is another type of food allergy. It most often affects young infants. Symptoms generally don’t appear for two or more hours. Symptoms include vomiting, which starts about 2 hours or later after eating the food causing the condition. This condition can also cause diarrhea and failure to acquire weight or height. Once the baby stops eating the food causing the allergy, the symptoms go away. Rarely, severe vomiting and diarrhea can happen which can lead to dehydration and even shock. Shock occurs when the body is not getting enough blood flow.

Emergency treatment for severe symptoms must happen correct away at a hospital.

What is meant by the terms allergy and anaphylaxis

The foods most likely to cause a reaction are dairy, soy, rice, oat, barley, green beans, peas, sweet potatoes, squash and poultry.

Allergic Proctocolitis

Allergic proctocolitis is an allergy to formula or breast milk. This condition inflames the lower part of the intestine. It affects infants in their first year of life and generally ends by age 1 year.

The symptoms include blood-streaked, watery and mucus-filled stools. Infants may also develop green stools, diarrhea, vomiting, anemia (low blood count) and fussiness. When properly diagnosed, symptoms resolve once the offending food(s) are removed from the diet.

Medical review December 2014.

Anaphylaxis: Severe Allergic Reactions


Nearly one in 50 Americans are at risk for anaphylaxis

Some children are allergic to certain foods, medicines, insects and latex.

When they come into contact with these things they develop symptoms, such as hives and shortness of breath. This is known as an allergic reaction. Things that cause an allergic reaction are called allergens. Take every allergic symptoms seriously because both mild and severe symptoms can lead to a serious allergic reaction called anaphylaxis (anna-fih-LACK-sis).

Be Prepared for Anaphylaxis

Keep an Emergency Plan with You

You, your kid, and others who supervise or care for your kid need to recognize the signs and symptoms of anaphylaxis and how to treat it. Your child’s doctor will give you a written step-by-step plan on what to do in an emergency.

The plan is called an allergy emergency care plan or anaphylaxis emergency action plan. To be prepared, you, your kid, and others who care for your kid need to own copies of this plan.

About Epinephrine

Epinephrine is the medicine used to treat anaphylaxis. The emergency action plan tells you when and how to give epinephrine. You cannot rely on antihistamines to treat anaphylaxis.

Know How to Use Epinephrine

Learn how to give your kid epinephrine.

Epinephrine is safe and comes in an easy-to-use device called an auto-injector. When you press it against your child’s outer thigh, it injects a single dose of medicine. Your child’s health care team will show you how to use it. You, in turn, can teach people who spend time with your kid how to use it.

Always own two epinephrine auto-injectors near your kid. Do not store epinephrine in your car or other places where it will get too boiling or too freezing. Discard if the liquid is not clear, and replace it when it expires.

After Anaphylaxis

  1. Sometimes, a reaction is followed by a second, more severe, reaction known as a biphasic reaction.

    This second reaction can happen within 4 to 8 hours of the first reaction or even later. That’s why people should be watched in the emergency room for several hours after anaphylaxis.

  2. Make a follow up appointment or an appointment with an allergy specialist to further diagnose and treat the allergy.

Be Aware of Symptoms of Anaphylaxis

The symptoms of anaphylaxis may happen shortly after having contact with an allergen and can get worse quickly.

What is meant by the terms allergy and anaphylaxis

You can’t predict how your kid will react to a certain allergen from one time to the next. Both the types of symptoms and how serious they are can change. So, it’s significant for you to be prepared for every allergic reactions, especially anaphylaxis. Anaphylaxis must be treated correct away to provide the best chance for improvement and prevent serious, potentially life-threatening complications.

Symptoms of anaphylaxis generally involve more than one part of the body such as the skin, mouth, eyes, lungs, heart, gut, and brain. Some symptoms include:

  1. Shortness of breath, trouble breathing, wheezing (whistling sound during breathing)
  2. Follow the steps in your child’s emergency care plan to give your kid epinephrine correct away.

    This can save your child’s life.

  3. Skin rashes and itching and hives
  4. Swelling of the lips, tongue or throat
  5. Dizziness and/or fainting
  6. After giving epinephrine, always call 911 or a local ambulance service. Tell them that your kid is having a serious allergic reaction and may need more epinephrine.
  7. Feeling love something terrible is about to happen
  8. Stomach pain, vomiting or diarrhea
  9. Your kid needs to be taken to a hospital by ambulance. Medical staff will watch your kid closely for further reactions and treat him or her if needed.

Your child’s doctor will give you a finish list of symptoms.

Common Causes of Anaphylaxis

Foods. The most common food allergies are eggs, milk, peanuts, tree nuts, soy, wheat, fish and shellfish. The most common food allergies in infants and children are eggs, milk, peanuts, tree nuts, soy and wheat.

Insect stings from bees, wasps, yellow jackets and fire ants.

Latex found in things such as balloons, rubber bands, hospital gloves.

Medicines, especially penicillin, sulfa drugs, insulin and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen.

Take Steps to Avoid Anaphylaxis

The best way to avoid anaphylaxis is for your kid to stay away from allergens.

Teach your kid about his or her allergy in an age-appropriate way. Teach your kid to tell an adult about a reaction, how to avoid allergens and how and when to use an epinephrine auto-injector. Here are some first steps you can take for each type of allergy:

Food. Learn how to read food labels and avoid cross-contact. Read the label every time you purchase a product, even if you’ve used it before. Ingredients in any given product may change.

Insect allergies. Wear closed-toe shoes and insect repellent when outdoors. Avoid loose-fitting clothing that can trap an insect between the clothing and the skin.

Medicine allergies.

Tell your doctor about medicines your kid is allergic to. Know both the generic and brand names of the medicines.

Latex allergies. Tell your doctors, dentists and other health care providers about your child’s latex allergy. Enquire them to put a note in your child’s medical chart about your child’s allergy. Also remind them of the allergy before any medical procedure or test.

For every allergies:  Educate family, friends, the school and others who will be with your kid about your child’s allergies.

They can assist your kid avoid allergens and help if anaphylaxis occurs.

Reviewed by medical advisors June 2014.

Know How to Treat Anaphylaxis

  • Follow the steps in your child’s emergency care plan to give your kid epinephrine correct away. This can save your child’s life.
  • After giving epinephrine, always call 911 or a local ambulance service. Tell them that your kid is having a serious allergic reaction and may need more epinephrine.
  • Your kid needs to be taken to a hospital by ambulance. Medical staff will watch your kid closely for further reactions and treat him or her if needed.

Adrenaline use in anaphylaxis: friend or foe?

Dr Andrew Bentley

Consultant in Respiratory and Critical Care MedicineSouth Manchester University Hospital Believe Wythenshawe Hospital Manchester, M23 9LT, UK

Dr Dermot Ryan

GPIAG Clinical Research Fellow

Department of Primary Care, University of Aberdeen

General Practitioner, Woodbrook Medical Centre, Loughborough,

LE11 1NH,

UK

Dr David Luyt

Consultant in Paediatric Medicine,

Leicester Royal Infirmary,

Leicester,

LE1 5WW,

UK

Adrenaline use in anaphylaxis: friend or foe?

Dr Andrew Bentley

Consultant in Respiratory and Critical Care MedicineSouth Manchester University Hospital Believe Wythenshawe Hospital Manchester, M23 9LT, UK

Dr Dermot Ryan

GPIAG Clinical Research Fellow

Department of Primary Care, University of Aberdeen

General Practitioner, Woodbrook Medical Centre, Loughborough,

LE11 1NH,

UK

Dr David Luyt

Consultant in Paediatric Medicine,

Leicester Royal Infirmary,

Leicester,

LE1 5WW,

UK


The aetiology of anaphylaxis

From an immunological perspective, anaphylaxis can be defined as an immediate systemic reaction caused by the rapid release of potent mediators from tissue mast cells and peripheral basophils (AAAI, 1998).

Allergen-driven cross-linking of receptor-bound IgE activates mast cells and basophils, to release their mediators (Figure 2) (Galli et al, 2005).

Figure 2. Activation of mast cells in response to allergens (Galli et al, 2005).

Anaphylaxis can be provoked by numerous agents, or allergens, most usefully categorised into drug or non-drug causes (Table 1).

Table 1.

The causes of anaphylaxis

Non-drug causes Drug causes
Foods –any, but notably nuts, milk, egg, seafood, fish Antibiotics – especially penicillin/ cephalosporins

Insect stings – wasps, bees

Anaesthetic agents – neuromuscular blocking drugs reported most commonly

Latex rubber – health care workers, spina bifida patients (multiple medical procedures)

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs)

Exercise induced – often with concomitant food (e.g., wheat) reaction (in up to 50% of cases)

Intravenous contrast media, blood products and intravenous fluids (colloidal starch)
Idiopathic – up to 20% of cases (in adults; rare in children), but this is a diagnosis of exclusion Opioid analgesics
ACE inhibitors

For anaphylaxis to happen, a patient has generally been previously sensitised to the allergen.

The initial sensitisation is a complicated process, involving multiple cell types and mediators, and is also affected by environmental and genetic factors.

The immunobiology and pathophysiology of anaphylaxis are basically the same, irrespective of the initial trigger, although there may be subtle differences in the responses.

The term ‘anaphylactoid’ has been used to represent the identical clinical pictures seen as a result of the degranulation of mast cells and basophils, but which are not mediated through IgE. The treatment for both of the mechanisms is identical, and the misinterpretation of anaphylactoid reactions has resulted in fatal re-exposure of the patient to the allergen concerned (Fischer, 1995).

The release of cell mediators during anaphylaxis leads to end-organ responses in the skin, respiratory, cardiovascular, gastrointestinal, and central nervous systems. The combined physiological effects of these mediators contribute to a multi-organ ‘hypovolaemic-distributiveÓshock,whichinvolves:

¤ Smooth muscle contraction, leading to bronchoconstriction and abdominal cramps

¤ Vasodilatation, leading to flushing, urticaria, hypotension and a reduced level of consciousness

¤ Increased capillary permeability, leading to angio-oedema and laryngeal oedema

¤ Activation of vagal pathways, leading to bradycardia and neurocardiogenic syncope.

The rapidity of onset of the severe symptoms and their presentation differ, depending on the causal agent.

In a study of fatal anaphylaxis, the median time to cardiac or respiratory arrest was 30 minutes for food allergens, 15 minutes for insect venom and 5 minutes for medications or radiological contrast reagents (Pumphrey, 2000). Allergens such as intravenous drugs or insect stings more commonly result in circulatory collapse and shock. Ingested allergens in food-related anaphylaxis are more likely to produce symptoms of upper airway obstruction, or respiratory compromise and shock is less common, unless the patient stands up.

What is meant by the terms allergy and anaphylaxis

In keeping with this view, an adjunct to the treatment of acute anaphylaxis, presenting with features of circulatory collapse, is to ensure the patient is lying below with their feet elevated, thereby aiding venous return and maintaining cardiac filling pressures (Brown, 2005).

An anaphylactic reaction is not necessarily a discrete event. Biphasic reactions are well described, as are delayed onset, protracted or persistent reactions (Starks and Sullivan, 1986; Lieberman, 2005).

These factors should be taken into consideration in the observation period, following resolution of the initial event. They can happen with sufficient frequency as to recommend an overnight or 24-hour waiting period before discharge (Project Team of the Resuscitation Council, UK revised anaphylaxis guideline May 2005). Furthermore, fatal reactions are more likely to happen in individuals with concomitant asthma, and this should be recognised in both food-related anaphylaxis and in reactions to insect stings (Sampson et al, 1992; Settipane et al, 1980; Bock et al, 2001; Lee and Greenes, 2000).


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