The most explosive, immediate, and obvious reactions are mediated by
basophil and mast cell degranulation. Anaphylaxis is a whole-body emergency
involving multiple systems. The triggers are food proteins, drugs that attach to
proteins inside the body, bee or wasp stings and occasionally other allergens.
Histamine is the first mediator released by mast cells, often in massive
amounts. The largest concentrations of mast cells are in the skin, lungs, and
the gastrointestinal tract.
Lieberman' estimated the incidence of anaphylaxis
in the United States, based on episodes of food, drug, latex, and stinging
insect hypersensitivity. He suggested that between 1.24% and 16.8% of the US
population is at risk of anaphylaxis. Approximately 0.002% of these are at risk
for a fatal reaction. The foods most commonly associated
with anaphylaxis are cow's milk, eggs, wheat, shrimp, fish, peanuts and other
The drugs that trigger anaphylaxis include penicillin, aspirin,
anti-arthritic drugs, morphine, radio contrast dyes, and anesthetics. Insect
bites especially wasp and bee stings do cause fatal anaphylaxis. A physician
died, for example, on the golf course 20 minutes after a wasp bit him on the
nose. He had an old epipen injector (adrenalin) in his golf bag, but the
injection did not save him. The risk of life-threatening anaphylactic reactions
to insect stings increases with age. Adrenalin supplies should be fresh and a
second dose is often required.
An anaphylactic attack may begin with hives,
shortness of breath, wheezing and a feeling of impending doom. The major
features are bronchoconstriction, edema, with increased capillary permeability
and rapid movement of water from blood to tissue spaces leading to hypovolemic
shock. Symptoms include angioedema, asthma, urticaria, flushing, pruritus,
rhinorrhea, tachycardia, hypotension, vomiting, diarrhea and abdominal pain. A
woman in her late 20's described the following anaphylactic reaction: "My teeth
started tingling and the inside of my throat was itchy...my palms got red and
swollen. I felt light-headed and agitated. My heart started to race...by the
time I got to the emergency my entire body had broken out in a rash and my feet
were so swollen my boots wouldn't come off. But things got worse as soon as I
walked in...I couldn't breathe and I began to panic. I felt I was going to die.
The doctor in charge was very short with me. He told me to get a hold of myself,
that I was just making things worse, but I was out of control. I was terrified
and wanted to pass out but couldn't."
By-standers and even physicians may not
appreciate the gravity of the allergic crisis. Immediate treatment with injected
adrenalin, antihistamine, steroids and life support may be necessary to rescue
the anaphylaxis victim. The second, late phase of anaphylaxis can develop into a
prolonged illness if left untreated. The initial immune response recruits other
immune responses. Anaphylaxis is unpredictable and is probably not caused by a
single mechanism. Lethal events include:
1. tongue and
throat swelling, obstructing the upper airway
asthma and/or lung swelling with failure of respiration
shock – water moves from blood into tissue spaces
rhythm abnormalities and cardiac arrest
Sudden death occurs rarely and
randomly as a tragic consequence of eating a reactive food, often in a
restaurant. The actual trigger for anaphylaxis is seldom known with any
certainty, although often a single agent such as traces of peanut oil in a salad
or dessert may be blamed, usually with no proof. Previous occurrences of severe
asthma attacks, whole-body hives, local swelling reactions of the tongue,
throat, and face; general swelling of the extremities and sudden onset of
breathing difficulty suggest increased risk of life-threatening anaphylaxis.
Sampson et al reported on 13 children and adolescents with fatal and near-fatal
food anaphylaxis. All 13 had asthma with previous serious reactions to food -
peanuts (4), nuts (6), cow’s milk (2), and egg (1). The six patients who died
had itching or tingling in the mouth, tightness of the throat, irritability,
abdominal pain or vomiting within 3 to 30 minutes of eating the food. None of
the fatalities had self-injected epinephrine. All of the survivors received
epinephrine within 30 minutes of the onset of symptoms. Anaphylaxis was rapidly
progressive and uniphasic in 7 patients and biphasic in 3 who had early oral and
abdominal symptoms followed by a 1-2 hour remission, followed by increasing
respiratory symptoms, hypotension, and death. Three children who survived had a
protracted course requiring ventilatory support and treatment with vasopressors
for 3 to 21 days after the onset. This report emphasizes the potential severity
of food reactions and the importance of prompt administration of epinephrine.
Anaphylaxis can be triggered by exertion after eating certain foods and may
be responsible for sudden deaths in healthy athletes as well as people with
known asthma and food allergy who exercise with unaccustomed vigor. Allergy
patients are cautioned to exercise in gradually graded increments, watch food
intake before athletic events, and avoid sudden, unaccustomed exertion. In one
patient wheat was the sensitizing food, and anaphylaxis began with exertion 40
minutes following ingestion. The patient, a 42 year-old man, developed
generalized urticaria and loss of consciousness playing tennis following a meal
of wheat bread and tea. His symptoms were reproduced and studied. His reactive
pattern began with itching during exertion, followed by hand swelling, and
generalized redness, and then hives broke out. He experienced drowsiness and
shortness of breath. Within minutes he would lose consciousness. Studies of this
pattern of reactivity showed elevated blood levels of histamine and an increase
in blood acidity. The oral intake of sodium bicarbonate (3.0 grams) taken before
exertion was successful in blocking this severe reactivity. Another case-report
described wheat allergy as a trigger for exercise-induce anaphylaxis in an 18
year old girl; one hour after lunch she exercised and developed urticaria,
abdominal pain, diarrhea and dyspnea. Two further episodes occasioned a
challenged study which confirmed the wheat reactivity and showed that sodium
cromoglycate blocked the reaction.
Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an
investigation into its epidemiology. Arch Intern Med. 001;161:15-21)
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