Anaphylaxis to Protamine During a Carotid Endarterectomy.

Protamine sulfate is commonly used to reverse the anticoagulant effects of unfractionated heparin (UFH) during surgical procedures, but its administration can sometimes trigger severe adverse reactions, including life-threatening anaphylaxis. We present the case of a 77-year-old male undergoing carotid endarterectomy who developed profound hypotension and tachycardia following protamine infusion. Anaphylaxis was confirmed by elevated tryptase levels. This case emphasizes the importance of vigilant monitoring during protamine administration, particularly in high-risk patients, and highlights the need to consider alternative reversal strategies to enhance patient safety.

An Observational Study to Evaluate Readability and Reliability of AI-Generated Brochures for Emergency Medical Conditions.

Introduction The study assesses the readability of AI-generated brochures for common emergency medical conditions like heart attack, anaphylaxis, and syncope. Thus, the study aims to compare the AI-generated responses for patient information guides of common emergency medical conditions using ChatGPT and Google Gemini. Methodology Brochures for each condition were created by both AI tools. Readability was assessed using the Flesch-Kincaid Calculator, evaluating word count, sentence count and ease of understanding. Reliability was measured using the Modified DISCERN Score. The similarity between AI outputs was determined using Quillbot. Statistical analysis was performed with R (v4.3.2). Results ChatGPT and Gemini produced brochures with no statistically significant differences in word count (p= 0.2119), sentence count (p=0.1276), readability (p=0.3796), or reliability (p=0.7407). However, ChatGPT provided more detailed content with 32.4% more words (582.80 vs. 440.20) and 51.6% more sentences (67.00 vs. 44.20). In addition, Gemini's brochures were slightly easier to read with a higher ease score (50.62 vs. 41.88). Reliability varied by topic with ChatGPT scoring higher for Heart Attack (4 vs. 3) and Choking (3 vs. 2), while Google Gemini scored higher for Anaphylaxis (4 vs. 3) and Drowning (4 vs. 3), highlighting the need for topic-specific evaluation. Conclusions Although AI-generated brochures from ChatGPT and Gemini are comparable in readability and reliability for patient information on emergency medical conditions, this study highlights that there is no statistically significant difference in the responses generated by the two AI tools.

Timing of onset of intraoperative transfusion anaphylaxis: a literature review.

Clinical diagnosis of intraoperative transfusion anaphylaxis using clinical symptoms is challenging and should be made carefully, as an incorrect clinical diagnosis can exacerbate surgical bleeding secondary to stopping a clinically indicated blood transfusion. The timing of onset of anaphylaxis to start of transfusion may be the key to correctly diagnosing intraoperative transfusion anaphylaxis clinically. However, the reliability of this measure remains unknown. A literature search was conducted using MEDLINE, Embase, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials up to June 29, 2021. No language restriction was applied. Two pairs of review authors independently reviewed intraoperative transfusion anaphylaxis cases and extracted data on the timing of onset of anaphylaxis to start of transfusion. A total of 8,918 articles were reviewed, the full texts of 186 articles were assessed, and 20 intraoperative transfusion anaphylaxis cases were included in this study. The 20 intraoperative transfusion anaphylaxis cases included a precise timing of onset. With nine cases, cardiovascular surgery was the most prevalent, and one case was fatal. Fifteen cases had a timing of onset in minutes, and of those, 14 reported timeframes within 30 minutes of initiation of transfusion (median: 15.5, 5-30 minutes). Almost all cases of intraoperative transfusion anaphylaxis occurred within 30 minutes of the transfusion initiation. This timeframe may be helpful in the clinical diagnosis of intraoperative transfusion anaphylaxis.

Indolent systemic mastocytosis (ISM) without skin lesions as a recurrent anaphylaxis: a case report study.

Introduction and importance: Mastocytosis encompasses a diverse range of disorders characterized by the clonal accumulation of mast cells in various tissues, including the skin, bone marrow, and gastrointestinal tract. Case presentation: This case report describes a 32-year-old male patient who presented with a history of recurrent anaphylactic attacks and elevated serum tryptase levels without apparent skin involvement. The diagnostic process and clinical implications of non-cutaneous mastocytosis are discussed in the context of existing WHO criteria. Clinical discussion: Mastocytosis, although a rare disease, carries the potential for severe complications and can present with atypical symptoms, thereby complicating its diagnosis and management. Consequently, the development of a reliable diagnostic and therapeutic strategy is of paramount importance. Conclusion: There is a pressing need to delve deeper into the investigation of the potential impacts and manifestations of mastocytosis to further our understanding and enhance patient care.

Time to ACT-UP: Update on precautionary allergen labelling (PAL).

Background: Precautionary Allergen ("may contain") Labelling (PAL) is used by industry to communicate potential risk to food-allergic individuals posed by unintended allergen presence (UAP). In 2014, the World Allergy Organization (WAO) highlighted that PAL use was increasing, but often applied inconsistently and without regulation - which reduces its usefulness to consumers with food allergy and those purchasing food for them. WAO proposed the need for a regulated, international framework to underpin application of PAL. In 2019, the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) of the United Nations convened an expert consultation to address the issue of PAL, the outputs of which are now being considered by the Codex Committee on Food Labelling (CCFL). Objectives: To summarise the latest data to inform the application of PAL in a more systematic way, for implementation into global food standards. Methods: A non-systematic review of issues surrounding precautionary labelling and food allergens in pre-packaged products. Results: Approximately, 100 countries around the world have legislation on the declaration of allergenic ingredients. Just a few have legislation on UAP. Given the risks that UAP entails, non-regulated PAL creates inconvenience in real life due to its unequal, difficult interpretation by patients. The attempts made so far to rationalize PAL present lights and shadows. Conclusions: At a time when CCFL is considering the results of the FAO/WHO Expert Consultation 2020-2023, we summarise the prospects to develop an effective and homogeneous legislation at a global level, and the areas of uncertainty that might hinder international agreement on a regulated framework for PAL of food allergens.

Adrenaline Auto-Injectors for Preventing Fatal Anaphylaxis.

Anaphylaxis affects up to 5% of people during their lifetime. Although anaphylaxis usually resolves without long-term physical consequences, it can result in anxiety and quality of life impairment. Rarely and unpredictably, community anaphylaxis can cause rapid physiological decompensation and death. Adrenaline (epinephrine) is the cornerstone of anaphylaxis treatment, and provision of adrenaline autoinjectors (AAI) has become a standard of care for people at risk of anaphylaxis in the community. In this article, we explore the effectiveness of AAIs for preventing fatal outcomes in anaphylaxis, using information drawn from animal and human in vivo studies and epidemiology. We find that data support the effectiveness of intravenous adrenaline infusions for reversing physiological features of anaphylaxis, typically at doses from 0.05 to 0.5 µg/kg/min for 1-2 h, or ~ 10 µg/kg total dose. Intramuscular injection of doses approximating 10 µg/kg in humans can result in similar peak plasma adrenaline levels to intravenous infusions, at 100-500 pg/mL. However, these levels are typically short-lived following intramuscular adrenaline, and pharmacokinetic and pharmacodynamic outcomes can be unpredictable. Epidemiological data do not support an association between increasing AAI prescriptions and reduced fatal anaphylaxis, although carriage and activation rates remain low. Taken together, these data suggest that current AAIs have little impact on rates of fatal anaphylaxis, perhaps due to a lack of sustained and sufficient plasma adrenaline concentration. Effects of AAI prescription on quality of life may be variable. There is a need to consider alternatives, which can safely deliver a sustained adrenaline infusion via an appropriate route.

Oral food challenge test results of patients with food allergy with specific IgE levels >100 UA/ml.

Specific IgE level (sIgE) is an important factor indicating sensitization status in children with food allergies (FAs). The present study aimed to clarify oral food challenge test (OFC) results in children with FAs with sIgE levels ≥100 UA/ml compared with those in children with sIgE <100. The retrospective study analyzed patients who underwent OFC with egg white, cow milk and wheat at Gifu Prefectural general medical center, Gifu, Japan between July 2017 and March 2023. Clinical history, total IgE (tIgE), sIgE and correlation between sIgE, sIgE/tIgE and eliciting dose as the amount of intake protein were examined. In the <100 group, positive OFC showed significantly higher sIgE for egg white, ovomucoid and casein than negative OFC (P<0.05); however, there was no significant difference between positive and negative OFC in the ≥100 group. In the <100 group, positive OFC showed significantly higher sIgE/tIgE for ovomucoid, milk and casein than negative OFC (P<0.05); however, there was no significant difference in sIgE/tIgE between positive and negative OFC in the ≥100 group. There was a significant negative correlation between eliciting dose and sIgE for egg white and wheat (P<0.05). For milk and wheat, there was no significant difference between ≥100 group and the <100 group with regard to positive rates in the OFC. Therefore, OFC may be safely performed by decreasing total challenge dose for the ≥100 group.

Safety signal detected: Anaphylaxis after attenuated dengue vaccine (TAK-003) - Brazil, march 1, 2023-march 11, 2024.

The aim was to describe cases of anaphylaxis following the Attenuated Dengue Vaccine (TAK-003) in Brazil, from March 1, 2023, to March 11, 2024. A descriptive study of anaphylaxis cases following TAK-003 was conducted, as reported in the National System of Surveillance of Adverse Events Following Immunization (AEFI). Percentages and notification rates of AEFI per million doses administered (DA) were calculated. In total, 380,358 doses of TAK-003 were administered, and 626 AEFI were reported. Of these, 85 were cases of immediate hypersensitivity, with 24 (63.1 cases per million) being anaphylaxis, including three anaphylactic shock. For 10 (41.7 %) cases, reactions began within 15 min after vaccination. No deaths related to anaphylaxis were reported. In light of the safety signal identification (increased frequency of anaphylaxis post-dengue vaccination), the Ministry of Health of Brazil published recommendations for intensifying actions for safe vaccination, including healthcare professional training and post-vaccination observation.

A retrospective registry-based study into the proportion of patients admitted to intensive care who have anaphylaxis as a principal diagnosis and their outcomes in Australia and New Zealand.

Objective: To describe the proportion of patients admitted to intensive care who have anaphylaxis as a principal diagnosis and their subsequent outcomes in Australia and New Zealand. Design: Retrospective observational study of ICU admissions for severe anaphylaxis. Setting: ICU admissions recorded in the Australian and New Zealand Intensive Care Society Adult Patient Database between 2012 and 2022. Participants: Adults 16 years or older with severe anaphylaxis admitted to the ICU. Interventions: None. Main outcome measures: Proportion of patients admitted to ICU who have anaphylaxis as a principal diagnosis, mortality rate, ICU and hospital length of stay. Results: 7189 of the 7270 ICU admissions for severe anaphylaxis recorded between 2012 and 2022, were included in the analysis. This represented a proportion from 0.25% in 2012 to 0.43% in 2022. ICU and hospital mortality were 0.4% and 0.8%, respectively. The proportion of ICUs reporting at least one severe anaphylaxis each year increased from 61.7% in 2012 to 83.0% in 2022. Most of the patients were discharged home (92.6%, n = 6660). Increasing age (OR = 1.055; 95%CI: 1.008-1.105) and SOFA scores (OR = 1.616; 95%CI: 1.265-2.065), an immunosuppressive chronic condition (OR = 16.572; 95%CI: 3.006-91.349) and an increasing respiratory rate above 16 breaths/min (OR = 1.116; 95%CI: 1.057-1.178) predicted in-hospital mortality in patients with anaphylaxis, while higher GCS decreased in-hospital mortality (OR = 0.827; 95%CI: 0.705-0.969). Conclusions: The overall proportion of patients admitted to ICU who have anaphylaxis as a principal diagnosis has increased. In-hospital mortality remains low despite the need for vital organ support. Further studies should investigate these identified factors that may predict in-hospital mortality among these patients. Trial registration: Not applicable.

The management of exercise-induced anaphylaxis in a Chinese child with biologics: a case report.

Exercise-induced anaphylaxis (EIA) is a rare and potentially life-threatening disorder. In difficult to control and refractory cases of EIA, biologics such as omalizumab and dupilumab have shown promise, with documented successful outcomes. Here, we present a case of EIA with lipid transfer protein (LTP) sensitization successfully treated with omalizumab with long-term follow-up. A 12-year-old girl presented to our allergy department because of recurrent episodes of EIA, with no specific food ingestion before exercise. Allergen testing revealed sensitization to weed pollens, particularly mugwort (76.1 kUA/L) and Alternaria alternata (10.8 kUA/L). Allergen component testing indicated sensitization to LTP components from mugwort Art v 3 (49.9 kUA/L), wheat Tri a 14 (2.03 kUA/L), and peach Pru p 3 (11.5 kUA/L), with a negative result for omega-5 gliadin. Despite initial prophylactic treatment with budesonide-formoterol (80/4.5 µg) and cetirizine (10 mg) before exercise, the patient still experienced EIA; she was then recommended for dupilumab therapy (an initial dose of 600 mg, followed by 300 mg every 2 weeks for six doses). However, even while undergoing dupilumab therapy, she suffered two anaphylactic episodes after running 800-1,000 m. With the patient's consent, a trial of omalizumab was initiated (injections of 300 mg every 4 weeks). After 2 months of omalizumab therapy, the patient showed significant improvement. She had been engaging in physical exercise three times a week and experienced a mild episode of urticaria. There were no further episodes of anaphylaxis or emergency room visits. By the fourth month of omalizumab treatment, she was able to consume food normally even just before exercising and had returned to her full activity level without any restrictions. This case presents the first successful off-label use of omalizumab in the prevention of EIA in the Chinese population. It is concluded that omalizumab may be helpful in resolving EIA symptoms, as evidenced by this case of successful long-term use.

Carboxymethylcellulose: A hidden culprit in immediate hypersensitivity reactions after triamcinolone injections.

We aim to bring awareness of allergies to excipients such as carboxymethylcellulose as "hidden dangers" that can be easily missed in diagnosis, leading to severe effects on patient health, and falsely limit the drug treatments that a patient can receive.

Severe Anaphylaxis From Remimazolam in a Mastocytosis Cancer Patient: A Case Report.

Remimazolam besylate is a novel, rapid-onset, ultra-short-acting benzodiazepine with an advantageous cardio-respiratory safety profile. To date, there have been few published reports of remimazolam-induced anaphylaxis, none of which are documented in patients with mast cell disease. We describe the case of a 77-year-old male with oncologic mastocytosis who developed anaphylaxis following remimazolam administration. Symptoms included shortness of breath, hypoxia, loss of consciousness, tachycardia, and hypotension. Resolution of symptoms was attained after the administration of flumazenil, dexamethasone, diphenhydramine, famotidine, and phenylephrine. Suspicion of an anaphylactic reaction was confirmed by elevated serum tryptase levels. This case report helps establish how to diagnose anaphylaxis in a mastocytosis patient.

The first case of erythritol-induced anaphylaxis in Europe diagnosed with skin tests and basophil activation tests.

The use of erythritol as a food sweetener has spread significantly from Japan throughout the world. We describe a case of severe anaphylaxis due to immediate-type allergy to erythritol that was diagnosed with in vitro basophil activation tests and in vivo skin tests.

Safety of COVID-19 Vaccines among People with History of Allergy: A European Active Surveillance Study.

Background: Conventional vaccines rarely cause severe allergic reactions. However, the rapid development and approval of COVID-19 vaccines left limited initial data on their adverse reactions, particularly in individuals with a history of allergy. The aim of this study was to assess and compare the safety profile of different doses and brands of COVID-19 vaccines in subjects with a history of allergy vs. those without a history of allergy. Methods: From February 2021 to February 2023, a web-based prospective study gathered vaccinee-reported outcomes using electronic questionnaires across eleven European countries. Baseline and up to six follow-up questionnaires captured data on vaccinee demographics, as well as both solicited and unsolicited adverse reactions. Results: Overall, 3476 vaccinees with a history of allergy were matched with 13,872 vaccinees from the general population at the first vaccination cycle and were included in the analysis. A total of 825 vaccinees with a history of allergy who had received a booster dose, matched to 3297 vaccinees from the general population, were included in the analysis. Higher rates of ADRs occurred after the first vaccination cycle compared to after the booster dose (64-91% vs. 56-79%). However, most reported ADRs were solicited and not serious, and no case of anaphylaxis was reported. Women and vaccinees with a history of allergy reported ADRs more frequently than men and the matched controls, respectively. Compared to other COVID-19 vaccines, a higher proportion of vaccinees experiencing at least one ADR following their first vaccination cycle was observed with Comirnaty and Vaxzevria. Statistically significant differences were observed among the study cohorts for median TTO after the second dose, and for median TTR following the first vaccination cycle and booster dose (p < 0.001). Conclusions: Typically, any drug or vaccine use carries a risk of severe allergic reactions, yet the benefits of vaccination generally outweigh these potential risks, as shown with the COVID-19 vaccines.

Immediate allergies to chlorhexidine: A series of pediatric cases from the French pharmacovigilance database: Immediate allergies to chlorhexidine: series of pediatric cases from the French pharmacovigilance database.

BACKGROUND: Immediate allergic reactions to chlorhexidine have been clearly identified in numerous countries, generating governmental warnings worldwide. OBJECTIVES: The aim of our study was to characterize (i) these allergies, which are less reported in pediatric populations, and (ii) the patient-at-risk profile so as to suggest preventive measures. METHODS: In association with the allergy department and the regional pharmacovigilance center in Rennes University Hospital, France, a multicenter retrospective, descriptive, and observational study was conducted using data from the national pharmacovigilance database for the period of January 1, 2010 to June 30, 2020. Immediate allergies to chlorhexidine cases based on a clinical history compatible with an immunoglobulin E (IgE)-mediated reaction, along with positive allergic testing, were analyzed. RESULTS: Of the 478 cases identified, 17 pediatric cases of immediate allergic reaction to chlorhexidine (13 cases of grades II-IV anaphylaxis) were retained for the analysis. For 58.8 % of these cases, a history of a previous more moderate reaction to the substance was identified. The reactions occurred most frequently in cases of domestic misuse (88.2 %, n = 15/17) of chlorhexidine to dress a wound. Recurrence was reported for two cases, later leading to severe reactions at each new exposure to the allergen, suggesting an aggravation mechanism. CONCLUSION: The number of pediatric cases of immediate allergies to chlorhexidine has possibly been underestimated on account of insufficient knowledge of the allergy and in view of its common usage. Information on the method of caring for wounds among children and on the risk of allergic sensitization as well as exploring any unusual reaction to chlorhexidine application could reduce the number of allergic reactions.

Cardiac Arrest Due to Perioperative Anaphylactic Shock Induced by Re-Exposure to Propofol: A Case Report.

Anaphylaxis is a potentially life-threatening systemic allergic reaction that can result in fatal outcomes if not promptly and appropriately treated. The diagnosis of the cause of anaphylaxis during anesthesia can be challenging due to the complexity of the perioperative environment. Propofol-induced perioperative anaphylaxis is uncommon, occurring in perioperative anaphylactic shock cases. We present a case of perioperative anaphylactic shock in a patient with no known allergies who had been exposed to the same anesthetic agents, propofol, rocuronium, and remifentanil, three times previously without incident. Cardiac arrest occurred 50 min after induction, which showed pulseless electrical activity with decreasing saturation without bronchial spasm and skin erythema or edema. After prompt and appropriate management including cardiopulmonary resuscitation, the patient recovered without complications. The diagnosis was confirmed as propofol-induced anaphylactic shock by an elevated serum tryptase level, measured in a timely manner, and by skin tests (skin prick test and intradermal test), which revealed strong hypersensitivity to propofol. This case is notable for the cardiovascular collapse that occurred without respiratory symptoms or skin manifestations, as well as the delayed onset of anaphylaxis (>50 min). This case underscores the importance of vigilance for anaphylaxis, even with repeated exposure to previously well-tolerated drugs, as sensitization can lead to more severe reactions. It also highlights the potential for anaphylaxis to occur outside the acute phase and without typical clinical features.

IgE-Mediated Legume Allergy: A Pediatric Perspective.

Legumes are an inexpensive and essential protein source worldwide. The most consumed legumes include peanuts, soybeans, lentils, lupines, peas, common bean and chickpeas. In addition, the food industry is growing interested in expanding the use of legumes to partially replace or substitute cereals. Legumes were described to cause IgE-mediated allergies, and their growing use may also increase the incidence of allergy. The epidemiology of legume allergy varies by region; peanuts and soybeans are the legumes most involved in food allergies in Western countries, whereas lentils, peas, and chickpeas are reported as culprit allergens mainly in the Mediterranean area and India. This review, edited by the Italian Society of Pediatric Allergology and Immunology, summarizes the scientific literature on legume allergy in children and proposes a diagnostic workup and therapeutic approach.