Retrospective study on the use of epinephrine in patients with drug-induced anaphylactic shock in Chongqing from 2015 to 2022 / 中国药房

OBJECTIVE To evaluate the rationality of epinephrine in the treatment of drug-induced anaphylactic shock， and to provide a reference for further standardizing the treatment measures of anaphylactic shock. METHODS According to the relevant data of the reports of severe adverse drug reaction （ADR） of drug-induced anaphylactic shock provided by Chongqing ADR Monitoring Center from 2015 to 2022， the selection of treatment drugs， and the application of epinephrine in anaphylactic shock were analyzed retrospectively； the clinical outcomes of anaphylactic shock with different epinephrine administration methods were investigated. RESULTS A total of 1 415 cases of severe ADR related to drug-induced anaphylactic shock were reported， with a male-to-female ratio of 1.04∶1； the drugs that caused allergic shock mainly included anti-infective drugs （47.92%）， TCM injections （9.12%）； the patients who suffered from drug-induced anaphylactic shock within 10 min after medication accounted for 43.96%； 97.24% of patients were cured or improved， and 2.76% of patients died or did not been improved. Among 1 415 patients， 63.39% of patients were treated with epinephrine， and the patients who preferred epinephrine treatment accounted for 53.14%； the intramuscular injection， subcutaneous injection， intravenous injection and intravenous drip accounted for 33.78%， 30.32%， 25.75% and 1.23%， respectively. The initial dose range of epinephrine was 0.01-10 mg， and the most frequent single dose was 1 mg （44.70%）. Excessive single doses of intramuscular injection， subcutaneous injection and intravenous injection accounted for 51.03% （148 cases）， 53.13% （136 cases） and 91.47% （193 cases） respectively， and the risk of overdose in intravenous injection was higher （P＜0.05）. The patients receiving initial treatment with epinephrine had a higher improvement rate/cure rate than those who did not use epinephrine （98.14% vs. 96.23%， P＝0.029）； the patients who preferred epinephrine had a higher improvement rate/cure rate than those who did not preferred epinephrine （98.14% vs. 95.17%， P＝0.031）； the improvement rate/cure rate of patients receiving intramuscular injection of epinephrine was higher than those without intramuscular injection （99.01% vs. 96.69%， P＝0.038）. CONCLUSIONS There are some unreasonable phenomena in the treatment of drug-induced anaphylactic shock， such as inappropriate selection of drugs， insufficient use of epinephrine， delay of administration， inappropriate route of administration and excessive single dose.

Indigo Carmine Hemodynamic Studies to Treat Vasoplegia Induced by Compound 48/80 in a Swine Model of Anaphylaxis

Abstract Introduction: There are many reasons to believe that the nitric oxide/guanosine 3'5' - cyclic monophosphate (or NO/cGMP) pathway on vasoplegic states is underestimated. To study indigo carmine (IC) as an alternative to methylene blue was the investigation rationale. Methods: The IC (3mg/kg intravenous infusion) study protocol included five experimental groups; 1) Control group — saline was injected at 0 and 10 minutes; 2) IC group — IC was injected at 0 and saline at 10 minutes; 3) compound 48/80 (C48/80) group — C48/80 was injected at 0 minute and saline at 10 minutes; 4) C48/80 + IC group — C48/80 was injected at 0 minute and IC at 10 minutes; and 5) IC + C48/80 group — IC was injected at 0 minute and C48/80 at 10 minutes. The studies were carried out by registering and measuring hemodynamic and blood gasometric parameters, including continuous cardiac output. Results: 1) The effects of the drugs (IC and C48/80) were more evident in the first 20 minutes of recording; 2) hypotensive responses were more pronounced in the C48/80 groups; 3) IC isolated or applied before C48/80 caused transient pulmonary hypertension; and 4) after the first 20 minutes, the pressure responses showed stability with apparent hypotension more pronounced in the C48/80 groups. Clinical observations showed significant hemodynamic instability and catastrophic anaphylactic reactions (agitation, pulmonary hypertension, severe bronchospasm, urticaria, high-intensity cyanosis, violent gastric hypersecretion, and ascites). Conclusion: A global results analysis showed differences between groups only in the first 20 minutes of the experiments.

Investigation and management of an anaphylactic shock case after inoculation with COVID-19 vaccine / 上海预防医学

Anaphylactic shock is a serious and rare adverse reaction， which can be life-threatening if not treated in time. COVID-19 vaccine is a newly marketed vaccine， and people pay high attention to its adverse reactions. This report summarized the investigation and management process of a case of anaphylactic shock after inoculation with COVID-19 vaccine， in order to provide reference for standardizing the diagnosis and management of anaphylactic shock after vaccination.

Piperacillin and Its Compound Preparation-induced Anaphylactic Shock ：A Case Report and Literature Analysis / 中国药房

OBJECTIVE：To i nvestigate the clini cal ch aracteristics of anaphylactic shock induced by piperacillin and its compound preparation ，and to provide reference for prevention and treatment of the severe ADR. METHODS ：A case of anaphylactic shock induced by piperacillin and sulbactam were analyzed in our hospital ，meanwhile ADR literatures about piperacillin alone and its compound preparation-induced anaphylactic shock were collected from Medline ，CNKI，Wanfang database and VIP during the inception to Jul. 2020. Gender and age of patients ，allergic history ，primary disease and treatment ，skin test ， administration route and dosage of piperacillin and its compound preparation ，occurrence time and main manifestations of anaphylactic shock ，treatment measure and prognosis were analyzed ，then prevention and treatment suggestions were put forward. RESULTS：The patient in this case was transferred to the ICU after partial hepatectomy. The use of piperacillin and sulbactam to prevent postoperative infection caused anaphylactic shock. A total of 28 literatures about anaphylactic shock induced by piperacillin and its compound preparations were collected from the database （involving 28 patients）. Among totally 29 patients，there were 12 male and 17 female；the majority of patients were 50-59 years old （6 cases，20.69％）. Three patients had allergic history （food， latex gloves ，etc.），and most of the primary diseases were infectious diseases or the drug used in perioperative period. Skin tests were carried out in 22 patients（75.86％）before medication and the results were negative. The possible allergenic drugs of 27 cases which were administered by intravenous route included piperacillin ，piperacillin sulbactam and piperacillin tazobactam. The dosage was different according to the primary disease and severity. 14 patients（55.56％）developed anaphylactic shock within 5 minutes after drug exposure. The main symptoms were systemic allergic reaction ，mainly involving the circulatory system. Except for two death cases ，the other patients ’symptoms were relieved after treatment. CONCLUSIONS ：Allergic history and skin test results may have limitation in predicting anaphylactic shock induced by piperacillin and its compound preparation. Close monitoring needs to be taken in patients during these medications. Rescue therapy should be prepared in advance and countermeasures need to be carried out promptly in case of anaphylactic shock.

Anafilaxia y anafiláctico / Anaphilactic shock and anaphilaxis

Anaphylaxis is a life-threatening clinical condition that results from the activation of mast cells/basophils, inflammatory pathways, or both. It can be specific (allergic), or non-specific (non-allergic). Most anaphylaxis are mediated by IgE, but there are also some mediated by IgM and complement activation. Incidence is about 1:10,000 anesthesia. Recent studies show that the drugs or substances mostly implicated in producing perioperative anaphylaxis are: neuromuscular blockers (60.6%), antibiotics (18.2%), patent blue dye (5.4%) and latex (5.2%). However, all drugs and substances used during anesthesia and surgery, perhaps with the sole exception of inhalation agents and crystalloids, have been reported as potentially causes of anaphylaxis. The clinical presentation is multisystemic, producing signs and symptoms mainly on skin, respiratory, cardiovascular, gastrointestinal and central nervous systems. In its advanced phase, it may evolve to anaphylactic shock, causing tissue hypoperfusion and leading to altered cell integrity and multiple organ failure, associated with high mortality. Diagnosis is based on clinical presentation (history and clinical manifestations), biological evidence (serum tryptase levels, serum histamine levels and search for specific IgE) and allergological evidence (skin tests, provocation test, mediator release tests and tests of activation of basophils). Treatment include 3 stages: general measures, first-line or primary treatment and second-line or secondary treatment. General measures consist of: Trendelenburg position, invasive monitoring (according to the severity of the clinical presentation), 100% oxygen administration, discontinuation of drugs and/or suspected agents and asking for help. The primary treatment is epinephrine in doses proportional to the clinical manifestations, airway support, 100% oxygen and aggressive resuscitation with intravenous fluids. Secondary treatment includesadministration of bronchialodilators, corticosteroids, and antihistamines.

Una anafilaxia es una condición clínica potencialmente mortal que resulta de la activación específica (alérgica), o no específica (no alérgica) de mastocitos/ basófilos, vías inflamatorias o ambos. La mayoría de las anafilaxias son mediadas por IgE, pero también las hay por IgM y activación del complemento. Su incidencia es de 1:10.000 anestesias. En los últimos estudios, los fármacos o sustancias más implicadas en producir anafilaxia perioperatoria son los bloqueadores neuromusculares (60,6%), los antibióticos (18,2%), las tinturas azules (5,4%) y el látex (5,2%), sin embargo, todas las drogas y sustancias usadas durante la anestesia y la cirugía, tal vez con la única excepción de los agentes inhalatorios y los cristaloides, han sido reportadas como potencialmente causantes de anafilaxia. El cuadro clínico es multisistémico, originando signos y síntomas centrados en la piel y los sistemas respiratorio, cardiovascular, gastrointestinal y nervioso central. En su fase avanzada puede evolucionar a anafiláctico, causando hipoperfusión tisular y llevando a alteración en la integridad celular y falla de múltiples órganos, con alta mortalidad asociada. El diagnóstico se basa en evidencias clínicas (historia y manifestaciones clínicas), evidencias biológicas (niveles de triptasa sérica, de histamina sérica y búsqueda de IgE específicas) y evidencias alergológicas (pruebas cutáneas, test de provocación, pruebas de liberación de mediadores y pruebas de activación de basófilos. El tratamiento incluye 3 etapas: medidas generales, tratamiento de primera línea o primario y tratamiento de segunda línea o secundario. Las medidas generales consisten en poner al paciente en posición de Trendelemburg, iniciar monitorización invasiva según la intensidad del cuadro clínico, administración de oxígeno al 100%, discontinuación de drogas y/o agentes posiblemente incriminados y pedir ayuda. El tratamiento primario es la adrenalina, en dosis proporcionales a las manifestaciones clínicas, el soporte de la vía aérea manteniendo el oxígeno ql 100% y la reanimación agresiva con fluidos endovenosos. El tratamiento secundario incluye la administración de broncodilatadores, corticoesteroides y antihistamínicos.

Manejo anestésico de paciente con mastocitosis cutánea / Anaesthetic managemet of cutaneous mastocytosis

Mastocytosis consists of a heterogeneous group of disorders characterized by an abnormal increase of mast cell in one or more organs or tissues. The degranulation of mast cells with subsequent clinical symptoms can be triggered by psychological, chemical or traumatic agents. The main challenge of these patients is to avoid these triggers in order to prevent an anaphylactic shock. We report a case of a patient diagnosed with cutaneous mastocytoses who underwent urgent appendicectomy. Their perioperative management involves a multidisciniplinary approach. We report the anaesthetic management in this disease.

Las mastocitosis son un grupo heterogéneo de enfermedades que se caracterizan por la proliferación de mastocitos y su posterior acumulación. La degranulación de los mastocitos puede desencadenarse por diferentes agentes como la cirugía, el estrés o los fármacos histaminoliberadores. El principal reto que plantea a un anestesiólogo un paciente con mastocitosis es la posibilidad de que se desencadene una reacción anafiláctica. Se describe el manejo anestésico de un paciente con mastocitosis cutánea. El desconocimiento de esta entidad puede suponer un aumento de la morbimortalidad de estos pacientes.

Evaluation of Diagnosis and Management of Anaphylactic shock in Emergency Room

Background: Anaphylaxis is the most severe form of an allergic reaction. The incidence rate of anaphylaxisenhanced during the last decade. Death may happen in fatal anaphylactic shocks within minutes of the reaction.Hence, it is needed to highlight the significance of effective emergency management. Objective: In thisinvestigation, we aimed to discuss the important aspects of anaphylaxis shock diagnosis and management in theemergency room. Method: PubMed database was used for article selection, and the following keywords wereused in the mesh: "anaphylaxis management in emergency room"[Mesh] and “anaphylactic shock managementin emergency room"[Mesh]. A total of 20 papers were reviewed and included in the research. Conclusion: Theessential manifestations of anaphylactic reactions are on the skin, in the gastrointestinal tract, respiratory tract,and cardiovascular system. The symptoms may begin and progress very quickly, in which the condition candeteriorate dramatically into death within a few minutes. Then, a physician should be skilled and prepared forsuch cases. The most noteworthy drug in the acute remedy of anaphylaxis is adrenaline as it is a lifesaving drugin cases of anaphylaxis.

Systematic Retrospective and Review of Anaphylactic Shock Induced by Cefazolin Sodium with Negative Skin Test / 中国药学杂志

OBJECTIVE: To systematicly review and analyse the clinical characteristics of anaphylactic shock induced by cefazolin sodium with negative skin test, and provide a basis for the safe and reasonable application of cefazolin sodium. METHODS: Databases of PUBMED, EMBASE, CBM, CNKI, VIP and WANFANG data(from built to October 2017)were conducted for case reports published in English or Chinese involving anaphylactic shock induced by cefazolin sodium. Literatures were screened, extracted and statistic analysed by two authors independently. RESULTS: A total of 1 358 literatures were searched out and 18 were included involving 20 patients, the median age was 39.0 years, 60.0% of the patients had no history of penicillin or drug allergy, and 30.0% of the patients had used penicillin or cephalosporin antibiotics, and intravenous infusion was the main route of administration. Anaphylactic shock occurred within 30 min accouted for 47.6%, and the longest time occurred on the 7th day of medication. The clinical manifestations were mainly circulatory system damage, and the rescue measures included discontinuation of medicine immediately, prostration, establishment of intravenous channels, oxygen uptake, administration of vasoactive drugs and glucocorticoids, etc., all of which were eventually successfully rescued.The correlation evaluation of ADR was definite and probable in 1 and 19 cases, respectively. CONCLUSION: High attention should be put on anaphylactic shock induced by cefazolin sodium with negative skin test. The proportion of young people and immediate anaphylactic shock were high.The cefazolin sodium skin test is of little value in predicting anaphylaxis. History of medication and allergies of patients should be taken in detail before medication, and the whole-process of medication, especially within 30 min should be closely monitored. Emergency rescue measures of anaphylactic shock should be prepared in advance.

Anaphylactic shock after sugammadex administration, induced by formation of a sugammadex-rocuronium complex: a case report / 대한마취과학회지

BACKGROUND: Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers and widely used worldwide on account of its rapid and effective reversal from neuromuscular blockade, despite its advantages, multiple cases of sugammadex-induced anaphylactic shock have been reported. CASE: A 42-year-old man developed anaphylactic shock in the postanesthesia care unit. Initially, sugammadex was suspected as the causative agent, but an intradermal skin test revealed negative results. A further skin test was performed with sugammadex-rocuronium complex that yielded positive results. CONCLUSIONS: Anesthesiologists and healthcare providers should be aware of the possibility of anaphylaxis from the sugammadex-rocuronium complex, as well as from sugammadex or rocuronium alone.

Anafilaxia em serviços de emergência: constante desafio para clínicos e equipe de saúde / Anaphylaxis in emergency services: a constant challenge for clinicians and health staff

Introdução: a anafilaxia é uma reação alérgica sistêmica grave, de início rápido e potencialmente fatal. A despeito da gravidade e da intensidade das reações anafiláticas, os sinais e sintomas desta síndrome são subestimados e não são reconhecidos por pacientes e por médicos. Objetivo: revisar os aspectos principais da epidemiologia, diagnóstico e tratamento da anafilaxia em sala de emergências. Metodologia: foi realizada busca de estudos publicados na língua inglesa, nas bases de dados PUBMED/ MEDLINE que discorressem sobre o tema anafilaxia. Os estudos foram selecionados após a definição dos DeCS e MeSH: alergia, hipersensibilidade, choque anafilático, emergência e morte. Estes termos foram cruzados por meio do chaveador boleano (AND). Os dados foram coletados no período de maio de 2017 a agosto de 2017. Conclusão: a anafilaxia caracteriza-se por ser uma síndrome sistêmica, multiorgânica, potencialmente fatal porem ainda de difícil diagnóstico. Epinefrina constitui-se o tratamento de escolha na emergência.

Introduction: anaphylaxis is a serious, early-onset and potentially fatal systemic allergic reaction. Despite the severity and intensity of anaphylactic reactions, the signs and symptoms of this syndrome are underestimated and are not recognized by patients and physicians. Objective: to review the main aspects of epidemiology, diagnosis and treatment of anaphylaxis in an emergency room. Methodology: a search was made for studies published in the English language, in PUBMED / MEDLINE databases that discuss the topic of anaphylaxis. The studies were selected after the definition of DeCS and MeSH: allergy, hypersensitivity, anaphylactic shock, emergency and death. These terms were crossed by the boolean switch (AND). The data were collected from May 2017 to August 2017. Conclusion: anaphylaxis is characterized by a systemic, multiorganic syndrome, potentially fatal but difficult to diagnose. Epinephrine is the treatment of choice in the emergency room.

β₂-Adrenoceptor Blockade Deteriorates Systemic Anaphylaxis by Enhancing Hyperpermeability in Anesthetized Mice

PURPOSE: Patients treated with propranolol, a nonselective β-adrenoceptor antagonist, develop severe anaphylaxis, but the mechanism remains unknown. We determined effects of β₁- and β₂-adrenoceptor antagonists on the anaphylaxis-induced increase in vascular permeability in mice. METHODS: In anesthetized ovalbumin-sensitized C57BL mice, mean arterial blood pressure (MBP) was measured, and Evans blue dye extravasation and hematocrit (Hct) were assessed at 20 minutes after antigen injection. The following pretreatment groups (n=7/group) were studied: (1) sensitized control (non-pretreatment), (2) propranolol, (3) the selective β₂-adrenoceptor antagonist ICI 118,551, (4) the selective β₁-adrenoceptor antagonist atenolol, (5) adrenalectomy, (6) the selective β₂-adrenoceptor agonist terbutaline, and (7) non-sensitized groups. RESULTS: The antigen injection decreased MBP, and increased Hct and vascular permeability in the kidney, lung, mesentery, and intestine, but not in the liver or spleen. Pretreatment with ICI 118,551, propranolol and adrenalectomy, but not atenolol, reduced the survival rate and augmented the increases in Hct and vascular permeability in the kidney, intestine, and lung as compared with the sensitized control group. Pretreatment with terbutaline abolished the antigen-induced alterations. Plasma epinephrine levels were increased significantly in the sensitize control mice. CONCLUSIONS: Blockade of β₂-adrenoceptor can deteriorate systemic anaphylaxis by augmenting hyperpermeability-induced increase in plasma extravasation by inhibiting beneficial effects of epinephrine released from the adrenal glands in anesthetized mice.

A pediatric case of anaphylactic shock induced by tipepidine hibenzate (Asverin)

Tipepidine hibenzate (Asverin) is commonly used as an antitussive drug for acute and chronic cough in various age groups and is generally safe and well-tolerated. However, we experienced a case of tipepidine hibenzate-induced anaphylactic shock in a 1-year-old boy. After ingesting cold medication including tipepidine hibenzate, the patient presented with generalized erythema and urticaria, swollen face, coughing, wheezing and vomiting, together with hypotension and a decreased level of consciousness. To identify the culprit drug, we performed skin prick tests (SPTs) and oral drug provocation tests (DPTs). SPTs revealed a negative reaction for all drugs, but DPTs caused a positive reaction only for a full therapeutic dose of tipepidine hibenzate. Physicians need to consider tipepidine hibezate as a culprit drug when anaphylaxis occurs after taking anticough or common cold medication.

Retrospective Study on 53 Cases of Anaphylactic Shock Induced by Paclitaxel / 中国药房

OBJECTIVE:To provide reference for safe drug use of paclitaxel in clinic. METHODS:The literatures about anaphylactic shock induced by paclitaxel were retrieved from China Hospital Knowledge Database during 2006-2016. After screening literatures which met inclusion criteria,the literatures were analyzed statistically in respects of the distribution of patient's gender and age,primary disease,distribution of occurrence time of anaphylactic shock,prophylactic drug use,route of administration and dosage,combined with chemotherapy drugs,prodromal clinical manifestations,first-aid measures and prognosis,etc. RESULTS:A total of 53 cases of anaphylactic shock induced by paclitaxel were included,among which there were 16 male and 37 female,aged 17-72 years;female patients over 40 year-old took up the highest proportion(30 cases,56.60%). The major primary diseases were lung cancer(15 cases,28.30%),breast cancer(12 cases,22.64%)and ovarian cancer(11 cases,20.75%). Anaphylactic shock mainly occurred within 5 min after intravenous dripping(34 cases,64.15%). 45 cases (84.90%)received antiallergic prophylactic program before using paclitaxel;53 patients were given intravenous dripping with single dose of 30-300 mg. Among 53 patients,25 patients were given paclitaxel alone,and other patients were given paclitaxel combined with chemotherapy drugs. The prodromal clinical symptoms of anaphylactic shock mainly involved cardiovascular system (123 case time,36.07%),skin and mucous membrane system(73 case time,21.41%)and respiratory system(67 case time, 19.64%). 2 patients(3.77%)died after rescue treatment. CONCLUSIONS:More attention must be paid to the occurrence of anaphylactic shock induced by paclitaxel.

Epinephrine combined with acupuncture therapy can treat anaphylactic shock mice through nuclear factor-κB signaling pathway: a rat experimental result / 中华危重病急救医学

Objective To explore the therapeutic effect of epinephrine combined with acupuncture on anaphylactic shock and its mechanism. Methods Sixty male Kunming mice were randomly divided into normal saline (NS) group, anaphylactic shock model group, and integrated traditional Chinese and Western medicine treatment group with 20 mice in each group. The anaphylactic shock model was reproduced by egg albumin infusion: intraperitoneal injection of 0.25 mL egg albumin (0.01 mmol/L), repeated injection 1 week later, and intravenous injection of 0.5 mL egg albumin through caudal vein on the 3rd week to induce anaphylactic shock. The mice in the NS group were injected with NS. The mice in the treatment group were immediately subcutaneously injected with 0.2 μg of 0.1% epinephrine, and intraperitoneally injected with aminophylline 0.2 mg, combined with acupuncture at Shuigou, Neiguan and Hegu points. Number of died mice in each group were observed at 1, 6, and 12 hours after model reproduction. The mice were sacrificed at 12 hours, the blood was harvested, and the serum tryptase, immunoglobulin E (IgE), tumor necrosis factor-α (TNF-α), interleukins (IL-1 and IL-6) were determined by enzyme linked immunosorbent assay (ELISA). The lung tissues were harvested, and the protein expressions of p65, phosphorylation of p65 (p-p65), and phosphorylation of nuclear factor-κB inhibitor α (p-IκBα) were determined by Western Blot. Results No mice died in the NS control group at 12 hours. In the treatment group, the mortality at 12 hours was significantly lower than that in the model group (10% vs. 80%, P < 0.01). The levels of tryptase and IgE in the model group were significantly higher than those in the NS control group [tryptase (μg/L): 1.53±0.28 vs. 0.91±0.23, IgE (μg/L): 33.3±3.1 vs. 21.3±1.9, both P < 0.01], both levels in the treatment group were significantly lower than those in the model group [tryptase (μg/L): 1.31±0.26 vs. 1.53±0.28, IgE (μg/L): 25.6±2.2 vs. 33.3±3.1, both P < 0.05]. The levels of TNF-α, IL-1 and IL-6 in the model group were significantly higher than those in the NS control group [TNF-α (ng/L): 35.3±4.7 vs. 16.4±3.5, IL-1 (ng/L): 13.8±3.3 vs. 4.2±1.8, IL-6 (ng/L): 15.3±4.8 vs. 5.5±2.1, all P < 0.01]. The serum inflammatory factors of the treatment group were significantly higher than those of the model group [TNF-α (ng/L): 26.1±4.3 vs. 35.3±4.7, IL-1 (ng/L): 7.2±2.7 vs. 13.8±3.3, IL-6 (ng/L): 8.8±3.8 vs. 15.3±4.8, all P < 0.05]. It was shown by Western Blot results that there was no significant difference in p65 protein expression of the lung tissue among the three groups. In the NS control group, the expression of p-p65 protein in the nucleus of the lung tissue was extremely low but was significantly increased in the model group, and p-p65 protein in the treatment group was significantly decreased as compared with that in the model group. The expression tendency of p-IκBα protein was consistent with that of p-p65. Conclusion Epinephrine combined with acupuncture plays a therapeutic role in mice with anaphylactic shock by inhibiting the activation of NF-κB signaling pathway.

Anaphylaxis following intralesional triamcinolone acetonide (Kenacort) injection

Intralesional triamcinolone acetonide injection is indicated for multiple skin conditions such as keloid scars, alopecia areata, and hypertrophic lichen planus. Immediate hypersensitivity reaction remains uncommon. We report on a 24-year-old woman who had received multiple intralesional injections with triamcinolone acetonide (Kenacort) plus lidocaine for keloid scar treatment without any reaction for the previous 10 years. The immediate reaction occurred 15 minutes after injection, with numbness on her face and 5 minutes later with urticaria on her chest wall and upper extremities, together with hypotension (blood pressure of 90/60 mmHg). Allergology workup revealed positive skin prick test for triamcinolone acetonide (Kenacort). Skin tests for other corticosteroids (hydrocortisone, methylprednisolone, and dexamethasone), excipients (carboxymethylcellulose, benzyl alcohol, and polysorbate 80) and lidocaine were negative, including subcutaneous challenge for lidocaine and oral challenge for carboxymethylcellulose. IgE-mediated hypersensitivity reaction must be considered in cases of multiple applications of triamcinolone acetonide injection.

Advancement on the diagnosis of anaphylactic shock in forensic medicine / 中国法医学杂志

It is still an important and hard work to diagnose anaphylactic shock in forensic practice. However, no breakthrough progresses in the diagnosis of anaphylactic shock and relevant research have been made so far due to the problems we used to meet in actual postmortem examination ,which are short of specific pathological changes in autopsy, the condition progress of patients who occur anaphylactic shock and history of allergy. Furthermore, patients suffer from diseases such as coronary heart disease, pneumonia, asthma, skin irritation, etc, and blood serum allergy biomarkers degrade after hemolysis on account of a long time from death to autopsy ,which are also the difficulties we have to cope with. The aim of this review is to focus on present situation and diagnostic index of anaphylactic shock including the pathological changes and some experimental methods such as special stain, immunohistochemical and serological test to provide reference for diagnosis and study of anaphylactic shock.

The value of multiple immunological indexes in the identification of anaphylactic death by penicillin / 中国法医学杂志

Objective To investigate the expression level of tryptase, chymase, IL-4 and IL-10 in guinea pigs died from anaphylactic death caused by penicillin allergy within 48 hours. Methods Guinea pigs were sensitized and elicited by penicilloyl-protein, the blood and tissues were extracted within 48 hours after the death. The expression of tryptase and chymase in tracheas and lungs were detected by the ways of immunohistochemistry, IL-4 and IL-10 levels in serum, tracheas and lungs were detected by ELISA. Results Compared with the control group, the expression of tryptase and chymase has enhanced in lungs and tracheas, the level of IL-4 and IL-10 increased in serum, lungs and tracheas in experimental groups(P<0.05). Conclusion Tryptase, chymase, IL-4 and IL-10 have significant value in the identification of the deaths caused by penicillin allergy.

Identification of IgE and IgG1 specific antigens in Echinococcus granulosus cyst fluid

Cystic echinococcosis (CE) is an anthropozoonotic disease with worldwide distribution and is caused by the cestode Echinococcus granulosus. Anaphylactic shock induced by CE rupture is a serious complication especially in patients with hydatid infections, as the resulting leakage of fluid contains highly toxic endogenous antigen. We aimed to isolate and identify the antigens of specific IgE and IgG1 (sIgE and sIgG1) in E. granulosus cyst fluid (EgCF). Crude antigen for EgCF was prepared from E. granulosus-infected sheep liver. Antigens were separated and identified by one-dimensional sodium dodecyl sulfate-polyacrylamide gel electrophoresis (1D SDS-PAGE), two-dimensional gel electrophoresis (2-DE), and immunoblotting. Results of 1D SDS-PAGE and immunoblotting showed that 40.5 kDa protein was the major antigen of sIgE, and 35.5 kDa protein was the major antigen of sIgG1 in EgCF. Results of 2-DE and immunoblotting showed that main antigens of sIgE in EgCF were four proteins with pI values ranging from 6.5 to 9.0 and a molecular weight of 40.5 kDa. Main antigens of sIgG1 in EgCF were five proteins with pI values ranging from 6.5 to 9.0 and a molecular weight of 35.5 kDa. The antigens identified for sIgE and sIgG1 can provide critical insights into cellular and molecular mechanisms underlying anaphylactic shock induced by CE.

Cardiac arrest caused by nafamostat mesilate

A 65-year-old man was transferred from the Department of Vascular Surgery to Nephrology because of cardiac arrest during hemodialysis. He underwent incision and drainage for treatment of a buttock abscess. Nafamostat mesilate was used as an anticoagulant for hemodialysis to address bleeding from the incision and drainage site. Sudden cardiac arrest occurred after 15 minutes of dialysis. The patient was treated in the intensive care unit for 5 days. Continuous veno-venous hemodiafiltration was started without any anticoagulant in the intensive care unit. Conventional hemodialysis was reinitiated, and nafamostat mesilate was used again because of a small amount of continued bleeding. Ten minutes after hemodialysis, the patient complained of anaphylactic signs and symptoms such as dyspnea, hypotension, and facial swelling. Epinephrine, dexamethasone, and pheniramin were injected under the suspicion of anaphylactic shock, and the patient recovered. Total immunoglobulin E titer was high, and skin prick test revealed weak positivity for nafamostat mesilate. We first report a case of anaphylactic shock caused by nafamostat mesilate in Korea.

Combined etiology of anaphylactic cardiogenic shock: Amiodarone, epinephrine, cardioverter defibrillator, left ventricular assist devices and the Kounis syndrome.

Anaphylactic shock is a life‑threatening condition which needs detailed and mediculous clinical assessment and thoughtful treatment. Several causes can join forces in order to degranulate mast cells. Amiodarone which is an iodine‑containing highly lipophilic benzofuran can induce allergic reactions and anaphylactic shock in sensitized patients. Epinephrine is a life saving drug, but in sulfite allergic patients it should be given with caution due its metabisulfite preservative. Metals covering cardiac defibrillators and pacemakers can act as antigens attached to serum proteins and induce allergic reactions. In anaphylactic shock, myocardial involvement due to vasospasm‑induced coronary blood flow reduction manifesting as Kounis syndrome should be always considered. Clinically, combined treatment targeting the primary cause of anaphylaxis together with protection of cardiac tissue seems to be of paramount importance.