The Catastrophe (Anaphylaxis ) Ahmed Yehia, MD, internal medicine, Immunology, rheumatology and allergy, Beni-Suef EAACI Guidelines WAO criteria for anaphylaxis Differential diagnosis of anaphylaxis (Anaphylaxis mimics) Anaphylaxis action plan How to identify anaphylaxis etiology?

1. The Catastrophe
(Anaphylaxis)
Ahmed Yehia, MD, Beni-Suef
(Immunology, allergy & rheumatology)

3. In a retrospective review of
573 adults & children
evaluated in the emergency
department (ED) for
anaphylaxis, only 38 percent
received follow-up
evaluation by an
allergy/immunology
specialist. Of those who did
The diagnosis of anaphylaxis or the
suspected trigger for anaphylaxis was
altered because of the evaluation in 35%.
2% were diagnosed with a mast cell
activation disorder.
6% underwent immunotherapy or
desensitization.

4. In another study, review of medical records from a pediatric ED identified133
cases of anaphylaxis by National Institute of Allergy and Infectious Diseases/Food
Allergy and Anaphylaxis Network criteria
Only 70 children (53%) had been given the diagnosis of
anaphylaxis in the ED, with the remainder described as urticaria,
allergic reaction, or angioedema.
44 (33%) had been discharged from the ED without information
about the probable cause & thus no instructions on how to avoid
future episodes.
Allergy evaluation was subsequently performed in 89% & a cause
was identified in 92% of those evaluated. Food was the culprit in
90% of reactions, although 26% of children were confirmed to be
allergic to a food other than that suspected in the ED.

5. European Academy of Allergy & Clinical Immunology's (EAACI)
guideline: 2021 Update
• This guideline, updated from 2014, provides evidence-
based guidance to help manage it.
• The primary audience is clinical allergists (specialists and
subspecialists), primary care, paediatricians, emergency
physicians, anaesthetists and intensivists, nurses, dieticians,
and other healthcare professionals.

6. European Academy of
Allergy &
Clinical Immunology's
(EAACI) guideline: 2021
Update
•The EAACI TF was drawn from 9
countries & included allergists
(specialist & subspecialists),
paediatricians, primary care,
immunologists, emergency
physicians, anaesthetists,
dieticians, nurses, psychologist,
education & patient organization
representatives. Methodologists
took the lead in undertaking the
SR, while clinical academics took
the lead in formulating
recommendations for clinical
care.

7. Anaphylaxis
Prevent & if it occurs Early detect

8. Which of the
following labs is
essential for
anaphylaxis
diagnosis?
S. histamine level
Urine histamine level
S. tryptase
S. IgE
None

9. Serum
tryptase in
anaphylaxis

10. Tryptase: 20
‫يرحمه‬ ‫هللا‬
.
‫عنده‬ ‫كان‬
anaphylaxis

11. Anaphylaxis pathophysiology
‫الكارثة؟‬ ‫حدثت‬ ‫كيف‬

12. Atopy pathophysiology

13. Anaphylaxis pathophysiology
Immune
•IgE-mediated
•Non-IgE-
mediated
Non-immune

15. Distinction between
the 2 types is not
clinically possible &
acute treatment is
the same for both.

16. Anaphylaxis is a clinical
emergency which all
healthcare professionals
need to be familiar with &
able to recognize &
manage.
Simulation training &
visual prompts for
healthcare professionals
are suggested to improve
the management of
anaphylaxis.

17. EAACI anaphylaxis
guideline
recommendations
The EAACI task force suggests using
clinical criteria, including rapid onset
of multiple symptoms & signs, for
identifying anaphylaxis in an acute
context.
Reason for recommendation: Anaphylaxis is a
clinical emergency, so the diagnosis needs to be
made rapidly. Research suggests that National
Institute of Allergy & Infectious Disease & Food
Allergy & Anaphylaxis Network clinical criteria
has high sensitivity.

18. Case 1
A 4-year-old boy presented with an acute
onset of these diffuse lesions & swelling 1
hour ago after penicillin injection.
Examination is normal apart from skin
manifestations. His vital signs, heart, chest &
abdominal examination are unremarkable.
Is this drug- induced anaphylaxis?
How to manage?

19. Acute urticaria
& angioedema
• He received Avil
(Pheniramine) ampoule
with poor response, so the
physician gave him a second
Avil ampoule.

20. Search for a cause &
remove.
Antihistamines H1
blockers
•2nd generation
•Up to 4-fold
Acute urticaria & angioedema

21. Guideline for
Primary Care
management of
Paediatric Urticaria

22. Acute and Chronic Urticaria: Evaluation and
Treatment
It is important to rule out
underlying anaphylaxis in
patients presenting with
urticaria.
Evidence rating: C Evaluate vital signs and
symptoms involving other
organ systems such as
pulmonary,
cardiovascular,
neurologic, or
gastrointestinal.

23. Case 2
• A 4-year-old boy presented with
an acute onset of dyspnoea &
wheezes associated with these
diffuse lesions & swelling 1 hour
ago.
• No history of allergen exposure.
• Examination:
• BP: 100/70
• SaO2: 88%
• These skin lesions &
swellings.
• Diffuse chest wheezes.
• Is this anaphylaxis?
• How to manage?

24. NIAID/FAAN criteria Clinical criteria for diagnosing
anaphylaxis

25. Case 3
A 5-year-old girl presented with crampy
abdominal pain & vomiting after eating a peanut
cake.
BP: 70/50.
No respiratory, skin or mucosal manifestations.
Is this anaphylaxis?

26. NIAID/FAAN criteria Clinical criteria for
diagnosing anaphylaxis

27. Case 4
A 12-year-old boy presented with hypotonia & collapse
30 minutes ago after cow milk ingestion for which he is
known to be allergic to.
No skin, respiratory or GIT manifestations.
BP: 70/50.
He is drowsy.
Is this anaphylaxis?

28. NIAID/FAAN criteria Clinical criteria for diagnosing
anaphylaxis

29. Case 5
A 33-year-old hypertensive man presented with syncope
30 minutes ago after fish ingestion for which he is known
to be allergic to. His BP was 170/90 2 days ago.
No skin, respiratory or GIT manifestations.
BP: 110/62.
He is drowsy.
Is this anaphylaxis?

30. NIAID/FAAN criteria Clinical criteria for diagnosing
anaphylaxis

31. NIAID/FAAN criteria Clinical criteria for diagnosing
anaphylaxis
• The WAO Anaphylaxis Committee has proposed to amend the current NIAID/FAAN criteria. The
aim is to simplify the existing criteria, by combining the first 2 criteria & modifying the third.

35. 1. Typical skin symptoms
AND significant symptoms
from at least 1 other
organ system; OR
2. Exposure to a known or
probable allergen for that
patient, with respiratory
and/or cardiovascular
compromise.

36. •70 mmHg + (2x
age in years)
Age-specific
hypotension
in infants &
children <
10 years =

37. Anaphylaxis may
occur in the absence
of skin involvement
or cardiovascular
shock; such a
presentation is
common in fatal
anaphylaxis.
Skin signs are absent
in 10–20% of
anaphylaxis reactions,
and this may result in
delays in the
recognition of
anaphylaxis.
In one study, only 55% of health care professionals recognized
anaphylaxis without cutaneous involvement.

38. Therefore, the
WAO
Anaphylaxis
Committee has
proposed the
following
definition for
anaphylaxis.
• “Anaphylaxis is a serious systemic
hypersensitivity reaction that is usually rapid
in onset & may cause death.
• Severe anaphylaxis is characterized by
potentially life-threatening compromise in
airway, breathing and/or the circulation, and
may occur without typical skin features or
circulatory shock being present.”

39. Case 6
•An 8-year-old boy presented to the ER by severe
wheezes & dyspnea after being in a picnic. He gives no
history of allergy or any chronic disease.
•Examination shows diffuse wheezes & tachypnoea.
• Skin shows red area in an exposed area in his arm!!!!
• Parents admit that it may be a bee sting.

40. The GP gave the child IV Avil &
Dexamethasone & discharged him home.
The boy condition worsened & he was
brought to the ER again.
What is the treatment of choice?
Is the GP action true?

41. The first line
treatment of
anaphylaxis is
IV methylprednisolone
IV hydrocortisone
IV antihistaminics
Adrenaline injection
Dependent on the presenting symptoms of
anaphylaxis

42. What is the adrenaline
route of administration?
•Oral
•Intramuscular
•Intravenous
•Subcutaneous
•Rectal

43. Where to inject IM adrenaline?
Glutal muscle (buttock)
Arm
Vastus lateralis of the quadriceps (antero-lateral thigh)
Vastus medialis of the quadriceps (antero-medial thigh)

44. According to his weight.
What is the adrenaline dose in
this boy?

45. 0.01 mg/kg of body weight, to a maximum total dose of 0.5 mg (equivalent to 0.5
mL of 1 mg/mL (1:1000) epinephrine)

46. Is there any other lines of management?
Remove exposure to the
trigger if possible (eg,
discontinue administration
of drugs/therapeutic agents)
Assess
ABC: airways, breathing,
circulation
mental status
Skin
Simultaneously call
emergency services

47. How to position the patient
during anaphylaxis?
• Most patients should be placed supine.
• If respiratory distressed, sitting position may
optimize respiratory effort;
• If pregnant, position semirecumbent on the
left side
• If unconscious, place in the recovery position.
• The benefit of elevation of the lower
extremities (Trendelenburg position) is
controversial.

48. •Despite intramuscular epinephrine
(adrenaline) being the first-line drug
recommended to treat anaphylaxis,
its use remains suboptimal.

51. His parents are worried about
repeating epinephrine.
Epinephrine administered by the intramuscular
route is generally well-tolerated.
This is in contrast to the intravenous route,
where potentially fatal arrhythmias can occur
as a result of bolus administration of
epinephrine.

52. Do other drugs have role in anaphylaxis?
Only after epinephrine
administration should
adjunct medications be
considered
These include histamine
H1 and H2 antagonists,
corticosteroids,
beta2 agonists, and
glucagon.

54. Search for the Etiology
To decrease acute exposure.
To avoid further attacks.

55. Search for the Etiology
History..History..History
• History is enough.
• I will perform SPT immediately.
• I will perform SPT after 4-6 weeks post-anaphylaxis
Would you perform skin prick test? When?

56. Anaphylaxis triggers
(WAO)
Known
Immunologic
IgE
dependent
IgE
independent
Non-
immunologic
Unknown
Idiopathic

57. Anaphylaxis triggers (WAO)
Known
•IgE
independent
•Non-
immunologic
•Immunologic
•IgE
dependent
Unknown
Idiopathic

58. Anaphylaxis
triggers
(WAO)

59. Anaphylaxis triggers (WAO)

60. Anaphylaxis triggers (WAO)

61. Anaphylaxis triggers (WAO)

62. Etiology (EAACI)
Food, drug, and Hymenoptera
venom are the most common
elicitors of anaphylactic reactions.
The prevalence of the various
causes of anaphylaxis are age-
dependent and vary in different
geographical regions.
In Europe, typical causes of food-induced
anaphylaxis in children are peanut, hazelnut,
milk & egg & in adults, wheat, celery &
shellfish; fruits such as peach are also typical
causes of food-induced anaphylaxis in adults in
some European countries such as Spain & Italy.
Venom-induced anaphylaxis is
typically caused by wasp and bee
venom.
Drug-induced anaphylaxis is
typically caused by antibiotics and
NSAIDs.
Among antibiotics, beta-lactam antibiotics are
the leading eliciting allergens.
At times, there is an occupational
cause.
Co-factors may be aggravating
factors in anaphylaxis, examples
are exercise, stress, infection,
NSAIDs & alcohol.
In some cases, the cause is not obvious
(idiopathic anaphylaxis) & investigations for
rarer allergens or differential diagnoses should
be considered.

63. Anaphylaxis is classified as idiopathic when no trigger can be
identified and currently represents between 6.5 and 35% of cases,
depending on the studies. In such cases, mast cell disorders
should be ruled out. Excluding urticaria pigmentosa does not
exclude mastocytosis, neither does a normal baseline tryptase.
Detecting KIT mutation in peripheral blood or in bone marrow
may be necessary. Also, the role of allergens previously
unrecognized (such as alpha-Gal) or less straightforward to
identify (omega-5-gliadin, oleosins) has to be considered.

64. Should we go
home now as he
is stable?
•Patients should be monitored for a
biphasic reaction (i.e., recurrence of
anaphylaxis without re-exposure to
the allergen) for four to 12 hours,
depending on risk factors for severe
anaphylaxis.

65. Case continued
The boy with the previous peanut-induced
anaphylaxis (confirmed by investigations) had
an accidental exposure to peanut. His
parents brought him to the ER for fear of
anaphylaxis.
Examination is completely free.
What is the next step?

66. Early suspicion of anaphylaxis,
either by patients or health-
professionals, based on the
development of symptoms
suggestive of allergy usually
affecting several organ systems
more or less simultaneously,
should prompt immediate
management.
Anaphylaxis is a medical
emergency that requires rapid
identification & immediate
treatment.

67. Anaphylaxis
management can
be divided into
two steps
The first step is based on the primary
role of IM epinephrine (adrenaline), &
provision of injectable epinephrine for
self-injection, as part of a patient's self-
management using an emergency
protocol.
The second step includes additional
interventions that start upon transfer to
the care of healthcare professionals.

68. Case 7
A 14-year-old female presented with acute
dyspnoea & cough after sharing in an exercise.
She was diagnosed to be asthmatic 2 years ago
with poor response to inhalers, montelukast &
sometimes systemic steroid short courses.
Examination revealed wheezes & tachypnoea.
She was suspected to have exercise-induced
asthma or anaphylaxis.

69. PFTs later revealed
the following

71. Laryngoscope revealed abnormal VC adduction in
inspiration.

72. VCD has been reported in
50% of patients with chronic cough (Ryan et al. 2008)
3-5% of patients with severe asthma (Kenn et al. 1997 AJRCCM)
Up to 30% of patients with difficult asthma (Radhakrishna et al. 2016)
5-22% of patients requiring emergency care for dyspnea (Jain 1997)
15% of US recruits assessed for asthma (Morris et al. 2002)
5% of US Olympians (Rundell et al. 2003)

73. So, consider
anaphylaxis mimics.

74. Differential diagnosis of anaphylaxis (WAO)

75. D.D. of
shock

79. Complete an Anaphylaxis Action
Plan & keep on file at work, school,
camp or other places where others
may need to recognize your
symptoms and provide treatment.

80. Why is an anaphylaxis action plan important?
1.Wood RA, Camargo CA, Lieberman P, et al. Anaphylaxis in America: the prevalence and characteristics of anaphylaxis in the United States. J
Allergy Clin Immunol. 2014;133(2):461-467.
2.Rudders SA, Banerji A, Clark S, et al. Age-related differences in the clinical presentation of food-induced anaphylaxis. J
Pediatr. 2011;158(2):326-328.
only

81. • Because anaphylaxis is a potentially fatal medical emergency,
even if the diagnosis is uncertain, the patient should be
equipped to self-treat a potential recurrence & if another
episode occurs, the clinician should plan to re-evaluate the
patient and ascertain if exposure is common to both the
episodes can be detected.

82. Role of serum
tryptase levels
• Clinicians can obtain
serum tryptase levels,
reflecting mast cell
degranulation, when the
clinical diagnosis of
anaphylaxis is not clear.

83. Challenges
life-threatening
The symptoms of
anaphylaxis are
highly variable.

84. THANK YOU