Bee Sting Injuries in Thailand's High Apicultural Area: Outcome, Risk and Treatment Patterns.

Objective: This study aims to assess the clinical outcomes and risk factors associated with severe systemic reactions following bee stings, focusing on patients treated at Pa-Sang Community Hospital, located in Lamphun Province, Thailand, which is recognized as one of the country's largest apicultural areas. Methods: A retrospective review was conducted, utilizing electronic medical records with ICD-10 coding, of patients treated for bee sting injuries at the Emergency Department of Pa-Sang Hospital from January 2015 to December 2019. Results: This analysis included a total of 591 bee sting events involving 533 patients. The average incidence of bee sting injuries was 31.3 per 10,000 Emergency Department visits, with 55% being male. A significant majority (86%) of events occurred outside the patients' home area. Notably, the head or extremities (49%) were the most common anatomical sites stung. Systemic reactions were observed in 44% of cases, with 96 visits (16%) diagnosed as anaphylaxis. Epinephrine injection was administered in 77% of these cases, and fortunately, no fatal anaphylactic reactions were recorded. Protective factors for anaphylaxis and severe systemic reactions after bee stings included age less than 15 years old and stings on extremities. Conversely, having more than ten bee stings and seeking Emergency Department treatment within 60 minutes of being stung were identified as significant risk factors. Conclusion: Bee sting injuries were a common presentation at the hospital situated in the high apicultural area, and severe systemic reactions were observed. This study highlights the need for comprehensive interventions to mitigate the increased risk of bee-related accidents in communities with thriving apicultural industries.

A case of paradoxical vocal cord movement misdiagnosed as anaphylaxis.

INTRODUCTION: Anaphylaxis is a severe and life-threatening systemic hypersensitivity reaction. The most frequently encountered causes are foods, drugs, and bee venom, but anaphylaxis may also occur idiopathically. Paradoxical vocal cord movement (PVCM), is a cause of upper airway obstruction due to abnormal adduction of vocal cords during inspiration and, to some degree on expiration. It may be misdiagnosed as asthma or anaphylaxis, and there may be delays in diagnosis. CASE REPORT: We present a 20-year-old male patient with coexistence of urticaria and stridor findings who was evaluated and treated as having idiopathic anaphylaxis but then was diagnosed with PVCM after recurrence of stridor attacks. CONCLUSION: It is useful to bear the diagnosis of PVCM in mind in patients with recurrent and unexplained stridor or in patients with stridor that does not improve despite treatment for another diagnosis such as anaphylaxis. This way, administration of epinephrine, high-dose corticosteroids and interventions such as intubation or tracheostomy can be avoided.

Exploring young adults' experiences with food allergy during their teenage years: A practice research study.

INTRODUCTION: Symptoms of anxiety, eating disorders and social isolation are prevalent among teenagers with food allergy compared to peers without. Treatment of teenagers with food allergy focus on preventing anaphylactic reactions, with little attention to promoting social and emotional well-being. The aim of the study was to explore young adults' perspectives on everyday life with food allergy during their teenage years to improve future clinical practice. METHODS: Critical psychological practice research. During a 2-day camp the perspectives of 10 young adults (18-23 years) were explored through participant observation and informal interviews. Three follow up interviews were conducted. A co-researcher group discussed preliminary results, clinical challenges and ways forward. RESULTS: Being together with peers with food allergy was crucial, fostering belonging and normalisation. The shift in responsibility of managing the risk feels overwhelming and stressful during teen age. Self-understanding was influenced when managing food allergy in social contexts, inducing feelings of burden and isolation. Acceptance and understanding from social relations became important for all participants, and they all underlined desire for being viewed as individuals rather than being defined by their allergy. CONCLUSION: Support from other peers with food allergy is crucial for the participants. Transition to independently managing risks introduces uncertainty and social constraints, affecting self-understanding and interactions. Clinicians should prioritise peer support and empower teenagers in managing the risk and psychosocial challenges.

A retrospective comparison of IgE-mediated cow's milk protein allergy management strategies in pediatric cohorts.

BACKGROUND: Complete avoidance of milk is the usual management for IgE-mediated cow's milk protein allergy (CMPA). A baked milk ladder is a method of dietary advancement therapy in IgE-mediated CMPA in Ireland, while in Spain, avoidance of milk awaiting natural tolerance acquisition through an oral food challenge (OFC) is employed. The aim of this study was to evaluate the use of dietary advancement therapy using a milk ladder compared with complete avoidance of milk for managing IgE-mediated CMPA. METHODS: This is a retrospective chart review of 371 pediatric patients from the population who have been treated for IgE-mediated CMPA between 2011 and 2020, with the milk ladder (Ireland) or complete avoidance followed by an OFC (Spain). The main outcome was the introduction of cow's milk. RESULTS: Milk ladder patients were 3.67 times more likely to succeed in comparison with milk avoidance (p < .001). Anaphylaxis during the treatment period occurred in 34 patients in the milk avoidance groups, while three patients in the milk ladder group experienced anaphylaxis due to accidental exposure to milk (p < .001). Failure to complete treatment was associated with a higher skin prick test in the milk avoidance group and a raised specific IgE in the milk ladder group. CONCLUSION: This is the first study that compares outcomes of dietary advancement therapy to complete avoidance for CMPA management, demonstrating that cow's milk can be successfully and safely reintroduced using dietary advancement therapy using a milk ladder.

Legume Allergens Pea, Chickpea, Lentil, Lupine and Beyond.

PURPOSE OF THE REVIEW: In the last decade, an increasing trend towards a supposedly healthier vegan diet could be observed. However, recently, more cases of allergic reactions to plants and plant-based products such as meat-substitution products, which are often prepared with legumes, were reported. Here, we provide the current knowledge on legume allergen sources and the respective single allergens. We answer the question of which legumes beside the well-known food allergen sources peanut and soybean should be considered for diagnostic and therapeutic measures. RECENT FINDINGS: These "non-priority" legumes, including beans, pea, lentils, chickpea, lupine, cowpea, pigeon pea, and fenugreek, are potentially new important allergen sources, causing mild-to-severe allergic reactions. Severe reactions have been described particularly for peas and lupine. An interesting aspect is the connection between anaphylactic reactions and exercise (food-dependent exercise-induced anaphylaxis), which has only recently been highlighted for legumes such as soybean, lentils and chickpea. Most allergic reactions derive from IgE cross-reactions to homologous proteins, for example between peanut and lupine, which is of particular importance for peanut-allergic individuals ignorant to these cross-reactions. From our findings we conclude that there is a need for large-scale studies that are geographically distinctive because most studies are case reports, and geographic differences of allergic diseases towards these legumes have already been discovered for well-known "Big 9" allergen sources such as peanut and soybean. Furthermore, the review illustrates the need for a better molecular diagnostic for these emerging non-priority allergen sources to evaluate IgE cross-reactivities to known allergens and identify true allergic reactions.

Glutenin from the Ancient Wheat Progenitor Is Intrinsically Allergenic as It Can Clinically Sensitize Mice for Systemic Anaphylaxis by Activating Th2 Immune Pathway.

Wheat allergy is a major type of food allergy with the potential for life-threatening anaphylactic reactions. Common wheat, Triticum aestivum (hexaploid, AABBDD genome), was developed using tetraploid wheat (AABB genome) and the ancient diploid wheat progenitor (DD genome)-Aegilops tauschii. The potential allergenicity of gluten from ancient diploid wheat is unknown. In this study, using a novel adjuvant-free gluten allergy mouse model, we tested the hypothesis that the glutenin extract from this ancient wheat progenitor will be intrinsically allergenic in this model. The ancient wheat was grown, and wheat berries were used to extract the glutenin for testing. A plant protein-free colony of Balb/c mice was established and used in this study. The intrinsic allergic sensitization potential of the glutenin was determined by measuring IgE response upon transdermal exposure without the use of an adjuvant. Clinical sensitization for eliciting systemic anaphylaxis (SA) was determined by quantifying the hypothermic shock response (HSR) and the mucosal mast cell response (MMCR) upon intraperitoneal injection. Glutenin extract elicited a robust and specific IgE response. Life-threatening SA associated and a significant MMCR were induced by the glutenin challenge. Furthermore, proteomic analysis of the spleen tissue revealed evidence of in vivo Th2 pathway activation. In addition, using a recently published fold-change analysis method, several immune markers positively and negatively associated with SA were identified. These results demonstrate for the first time that the glutenin from the ancient wheat progenitor is intrinsically allergenic, as it has the capacity to elicit clinical sensitization for anaphylaxis via activation of the Th2 pathway in vivo in mice.

Is Component-Specific Antibody Testing Sufficient to Replace the Oral Food Challenge in the Diagnostics of Peanut-Sensitized Children? A Proof-of-Concept Study.

(1) Peanut allergy is associated with high risk of anaphylaxis which could be prevented by oral immunotherapy. Patients eligible for immunotherapy are selected on the basis of a food challenge, although currently the assessment of antibodies against main peanut molecules (Ara h 1, 2, 3 and 6) is thought to be another option. (2) The current study assessed the relationship between the mentioned antibodies, challenge outcomes, skin tests and some other parameters in peanut-sensitized children. It involved 74 children, divided into two groups, based on their response to a food challenge. (3) Both groups differed in results of skin tests, levels of component-specific antibodies and peanut exposure history. The antibody levels were then used to calculate thresholds for prediction of challenge results or symptom severity. While the antibody-based challenge prediction revealed statistical significance, it failed in cases of severe symptoms. Furthermore, no significant correlation was observed between antibody levels, symptom-eliciting doses and the risk of severe anaphylaxis. Although in some patients it could result from interference with IgG4, the latter would not be a universal explanation of this phenomenon. (4) Despite some limitations, antibody-based screening may be an alternative to the food challenge, although its clinical relevance still requires further studies.

Prevalence of food allergy increased 1.7 times in the past 10 years among Japanese patients below 6 years of age.

BACKGROUND: While food allergy (FA) has been increasingly recognized as a growing public health burden worldwide, epidemiological studies on FA in Japan are limited. METHODS: This was a noninterventional, observational study using the administrative claims data from 2010 to 2019 (10 years). Patients with physician-diagnosed FA in Japan (prevalent cohort) were divided into high-risk or low-risk cohorts using adrenaline prescription. The high-risk cohort was further divided into anaphylaxis or nonanaphylaxis cohort based on the occurrence of anaphylaxis or a serious allergic reaction (SAR) during 1 year after adrenaline prescription. The primary objective was to examine yearly prevalence of FA. The secondary objectives were to describe demographics/clinical characteristics and healthcare resource utilization (HCRU), to evaluate the number of occurrences of anaphylaxis/SAR in the high-risk cohort, and the impact of anaphylaxis/SAR on HCRU. RESULTS: The overall standardized prevalence rate was 0.325% (95% confidence interval [CI], 0.311-0.339) in 2010 and 0.797% (95% CI, 0.790-0.804) in 2019 and predominant in patients age <6 years (preschool; 3.377% [95% CI, 3.229-3.525] in 2010 and 5.726% [95% CI, 5.663-5.789] in 2019). Majority of FA patients (>80%) were children/adolescent throughout the 10 years. While high-risk cohort was a relatively minor population (8.5% in the prevalent cohort in 2019), the occurrence of anaphylaxis/SAR in the high-risk cohort was 227,690/100,000 patient-years. Multivariate analysis showed a significant increase in HCRU variables in the anaphylaxis versus nonanaphylaxis cohort (e.g., 2.08 [95% CI, 2.05-2.11] times more FA-related outpatient visits). CONCLUSIONS: Prevalence of FA increased in a statistically significant way from 2010 to 2019; 1.7-fold increase was observed in patients <6 years old. Patients in the high-risk cohort appear to have suffered from frequent anaphylaxis/SAR, highlighting an unmet medical need for FA patients at "high-risk," considering the unavailability of approved medications to prevent anaphylaxis/SAR.

Quality of Life in the Management of Anaphylaxis in Food-Allergic Adults.

Background: Anaphylaxis is a life-threatening allergic reaction that can significantly affect the quality of life of those affected. Factors including undiagnosed allergies, lack of allergen information, and insufficient emergency training can impact the quality of life for food-allergic individuals. Well-informed patients are less likely to experience severe allergic responses, ensuring their safety and quality of life. Aim: This study aims to evaluate the effectiveness of following preventive behavior, focusing on routine counseling and training provided by healthcare professionals in preventing anaphylaxis and assessing the impact of strict adherence to an allergen avoidance regimen against anaphylaxis. Methods: This study was a descriptive, cross-sectional survey conducted in the Makkah region of Saudi Arabia. It involved adults aged 18 and above who had food allergies. A structured online questionnaire of seven items was developed and distributed to achieve the study's goals from October 2023 to January 2024. The data collected was automatically exported to Excel and then analyzed using the Statistical Package for the Social Sciences. Results: The study involved 93 participants, 65.6% female and 34.4% male. Among those with food allergies, 34.4% had experienced anaphylaxis, with 50% allergic to eggs and seafood. The study found no significant association between specific food allergens and a history of anaphylaxis, but strict allergen avoidance was linked to lower anaphylaxis rates. Counseling or training for managing food allergy reactions also showed potential benefits. The research indicated that males were less likely to have anaphylaxis than females, and age increased the severity of anaphylaxis reactions regardless of gender. Conclusion: The study emphasizes the importance of preventive behaviors and healthcare professional support in reducing the risk of anaphylactic reactions for food-allergic adults. Future research could focus on improving their quality of life through education programs, policy development, and better access to emergency medications and psychosocial support strategies.

[A CASE OF FOOD-DEPENDENT EXERCISE-INDUCED ANAPHYLAXIS DUE TO POLISHED RICE].

A 14-year-old girl presented to our hospital with food-dependent exercise-induced anaphylaxis (FDEIA), possibly caused by rice. Despite experiencing four previous episodes of suspected FDEIA, she did not seek medical attention at her own discretion. On the fifth occurrence of symptoms, the general practitioner suspected FDEIA and referred the patient to our hospital. The only common factor in all five episodes was the consumption of rice, leading to the examination of the patient under suspicion of FDEIA caused by rice. Skin prick test results were positive for bran and polished rice, and exercise after consumption of polished rice resulted in anaphylaxis. Therefore, we diagnosed FDEIA caused by polished rice. Immunoblotting confirmed the presence of immunoglobulin E reacting with 14-16kDa rice bran protein in the patient's serum. The immunoblot inhibition test suggested that the rice bran protein to which the patient's serum reacted was also present in polished rice and no wash rice. As the patient may experience FDEIA after ingestion of no wash rice or rice flour, she was advised to eliminate these from her diet, treating them similarly to brown rice or polished rice.

A Case of Anaphylactic Shock Suspected to Be Caused by Bovine Serum Albumin Tissue Adhesive (BioGlue) During Thoracoabdominal Aortic Replacement.

Bovine serum albumin (BSA) tissue adhesive (BioGlue, Cryolife Inc., Kennesaw, GA, USA) is often used as a hemostatic adjunct in adult patients undergoing open surgical repair of large vessels, such as the aorta, femoral, and carotid arteries. We present a case of intraoperative anaphylaxis attributed to the use of BioGlue during thoracoabdominal aortic replacement. The patient suddenly developed hypotension, hypoxemia, and airway edema after the BioGlue application. BioGlue is composed of purified BSA and glutaraldehyde. Despite the BSA component being an allergen that can cause anaphylaxis in some patients, reported occurrences of anaphylaxis are extremely rare. We need to recognize BSA tissue adhesive as a potential allergen. In the event of an intraoperative shock, prompt recognition and investigation of the underlying cause are necessary.

Buckwheat Allergy in Asia.

PURPOSE OF REVIEW: Buckwheat (BW) allergy is a significant issue in Asia. This review delves into three types of BW allergy: immediate food allergy; food-dependent, exercise-induced anaphylaxis (FDEIA) as a subset of immediate food allergy; and food protein-induced enterocolitis syndrome (FPIES); by comparing data from Asian and non-Asian countries. RECENT FINDINGS: Most studies on BW have been published in Japan and Korea, and only a few studies on the topic have been done outside Asia. To date, seven components of common BW (Fagopyrum esculentum) and four components of Tartary BW (Fagopyrum tartaricum) have been implicated in BW allergy. Although BW-sIgE has limited utility for evaluating immediate BW allergy, Fag e 3-specific IgE, one of the components of common BW, and the skin prick test are diagnostically useful. The present review aims to shed light on the current state of knowledge, highlight research gaps, and suggest future directions in the management and understanding of BW allergy.

Anaphylaxis as an Unusual Cause of Shock in the Trauma Setting: A Case Report.

Anaphylactic shock is the most severe form of an acute systemic allergic reaction and can be potentially lethal if left untreated. Here, we present the case of a 51-year-old male with no significant medical history, who arrived at our hospital's emergency trauma bay following a motor vehicle accident caused by a sudden onset of malaise while driving. Upon arrival, the patient's airway was patent, but he reported a sensation of a foreign body in his larynx. He also had an oxygen saturation of 88%, although no abnormal breath sounds were auscultated. The patient was also hypotensive and tachycardic, with no favorable response after crystalloid administration. He had no neurological alterations but was diaphoretic, with hives spreading across his trunk and all four extremities. Upon further interrogation, we identified that he had consumed diclofenac, a non-steroidal anti-inflammatory drug (NSAID), 45 minutes before the driving incident. Prompt recognition and management of the anaphylactic shock were initiated alongside the assessment and treatment of the traumatic injuries. This case highlights the importance of considering unusual causes of shock in trauma patients. It underscores the need for a comprehensive approach to patient care in trauma settings, where multiple etiologies of shock should be considered and managed simultaneously.

Uneventful vaginal delivery using epidural anesthesia in patient with exercise induced anaphylaxis: a case report and literature review.

Exercise induced anaphylaxis (EIA) is a rare and potentially life-threatening syndrome characterized by anaphylaxis provoked by exercise. Although vaginal delivery with labor pain is a physical strain for women and a possible trigger for EIA, no consensus exists on the management strategy of delivery in patients with EIA. A 28-year-old primigravida was referred to our hospital because of history of EIA, associated with pruritus, urticaria, and respiratory distress, exacerbated during physical activity. To avoid physical stress, we chose scheduled labor induction with epidural anesthesia, and administered prophylactic intravenous hydrocortisone. She delivered vaginally with no symptoms suggestive of EIA during labor. Since it is quite possible for patients with EIA to develop anaphylaxis during vaginal delivery with labor pain, epidural anesthesia and prophylactic steroid administration may be the most rational approaches for delivery in pregnant women with EIA.

Incidence of and risk factors for paediatric perioperative anaphylaxis in the USA.

BACKGROUND: Perioperative anaphylaxis is a serious and often life-threatening immediate hypersensitivity reaction. There are few published data on paediatric perioperative anaphylaxis (pPOA). We evaluated the incidence of and risk factors involved in the occurrence of pPOA within a large US national database. METHODS: Deidentified data from the US Nationwide Inpatient Sample from 2005 to 2014 were used to identify pPOA cases and to conduct a retrospective multivariate analysis of preselected independent variables. RESULTS: Among 3,601,180 surgeries and procedures in children aged 0-18 yr, 297 pPOA cases were identified for an incidence of one in 12,125 surgeries and procedures. Compared with controls, pPOA cases had an increased median length of stay (6 vs 2 days; P<0.001) and median hospital cost ($54 719 vs $5109; P<0.0001). The age groups between 6 and 12 yr (odds ratio [OR] 7.1; 95% confidence interval [CI] 3.9-12.9; P<0.001) and 13 and 17 yr (OR 8.5; 95% CI 4.7-15.2; P<0.001) were associated with increased odds of pPOA. Transplant (OR 46.3; 95% CI 20.8-102.9; P<0.001), cardiac (OR 16.4; 95% CI 7.5-35.9; P<0.001), and vascular (OR 15.2; 95% CI 7.5-30.7; P<0.001) procedures posed the highest risk for pPOA. Chronic pulmonary disease, coagulopathy, and fluid and electrolyte disorders were also associated with pPOA (OR 2.2; 95% CI 1.5-3.3; P<0.001). CONCLUSIONS: The incidence of pPOA was one in 12,125 cases. Risk factors included age, procedure type, and comorbidities.

Prior Bariatric Surgery Predicts Lower Life-Threatening Morbidity in Patients Admitted for Acute Allergic Reaction and Anaphylaxis: a Propensity Score-Matched Analysis of the U.S. Nationwide Inpatient Sample, 2005-2018.

PURPOSE: Acute allergic reactions may occur in susceptible individuals following exposure to various allergens. Obesity is linked to allergic reactions, and weight loss from bariatric surgery may attenuate the severity of certain conditions such as airway hyperresponsiveness in asthma. This retrospective observational study investigates associations between prior bariatric surgery and lower risk for life-threatening conditions in patients hospitalized with acute allergic reactions and anaphylaxis. MATERIALS AND METHODS: Adults ≥ 18 years old diagnosed with morbid obesity and admitted to US hospitals with acute allergic reactions/anaphylaxis were included. All data were extracted from the US Nationwide Inpatient Sample (NIS) database 2005-2018. Patients without information on in-hospital mortality, discharge destination, hospital costs, and length of stay (LOS) were excluded. Patients were divided into two groups based on prior bariatric surgery or not. All diagnoses were verified through ICD-9 and ICD-10 codes. Between-group differences and associations between variables were evaluated using logistic regression analysis. RESULTS: After matching, patients with prior bariatric surgery had significantly lower proportions of any life-threatening morbidity (37.2% vs. 47.4%), respiratory distress or failure (11.2% vs. 17.0%), pneumonia or severe infection (7.4% vs. 10.2%), sepsis/septic shock (15.2% vs. 20.9%), intubation and mechanical ventilation (11.2% vs. 14.6%), prolonged LOS (10.3% vs. 20.6%) and unfavorable discharge (6.9% vs. 12.5%) than those without prior bariatric surgery. CONCLUSION: Prior bariatric surgery predicts a lower risk of life-threatening morbidity and prolonged LOS among adults hospitalized for acute allergic reaction and anaphylaxis. Future prospective studies are warranted to confirm the present findings and reveal underlying mechanisms.

Epidemiology and Triggers of Severe Perioperative Anaphylaxis: An 8-Year Single-Center Study.

OBJECTIVE: To determine the features, rescue measures, outcomes, re-allergic reactions, and independent risk factors associated with severe anaphylaxis during surgery. DESIGN: Instances of severe perioperative anaphylaxis were identified through perioperative electronic records, adverse event reporting records, and surveys of anesthesiologists. Confirmed cases were randomly matched 4:1 with control cases on the same operation day. Patient risk factors, surgery type, anesthetic technique, and perioperative medications, fluids, and blood transfusions were given in instances of severe perioperative anaphylaxis were compared with control cases. SETTING: A tertiary hospital in China. PATIENTS: All patients undergoing surgery and anesthesia in the operating room from January 2014 to February 2022. MEASUREMENTS: Incidence and the independent risk factors for severe perioperative anaphylaxis. MAIN RESULTS: Ninety-seven patients experienced severe perioperative allergic responses during the 266,033 surgeries performed, with an incidence rate of 3.6 per 10,000. Three of 97 anaphylaxis patients experienced a severe allergic reaction again during the second surgery. The nested case-control study revealed that the independent triggers during surgery were allergy history (odds ratio 5.23; 95% confidence interval [CI], 2.35-11.68; p < 0.001), cisatracurium use (odds ratio 5.03; 95% CI, 1.22-20.70; p < 0.001), hydroxyethyl starch 130/0.4 use (odds ratio 5.36; 95% CI, 2.99-9.60; p =0.025), and allogeneic plasma (odds ratio 11.02; 95% CI, 3.78-35.95; p < 0.001). CONCLUSIONS: Perioperative severe anaphylaxis is a rare but life-threatening complication. Previous allergic history, cisatracurium, hydroxyethyl starch 130/0.4, and allogeneic plasma may be the independent triggers. Early diagnosis of anaphylaxis and the timely administration of epinephrine are critical to allergic treatment. Avoiding exposure to allergens is effective for preventing severe allergic responses and the efficacy of glucocorticoids and antihistamines is controversial.