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1.
Mediator-Related Symptoms and Anaphylaxis in Children with Mastocytosis.
Brockow, K, Plata-Nazar, K, Lange, M, Nedoszytko, B, Niedoszytko, M, Valent, P
International journal of molecular sciences. 2021;(5)
Abstract
Mastocytosis is characterized by the pathological accumulation of mast cells (MC) in various organs. In these patients, MC may degranulate and thereby contribute to clinical symptoms, especially when a concomitant allergy is present. However, MC activation can not only be induced by high-affinity receptors for IgE, but also by anaphylatoxins, neuropeptides, IgG immune complexes, complement-components, drugs, products of bacteria or parasites, as well as physical factors such as heat, cold, vibration, stress, sun, or physical effort. Symptoms due to mediators released by activated MC may develop in adults suffering from systemic mastocytosis, but also evolve in children who usually have cutaneous mastocytosis (CM). Clinically, CM is otherwise characterized by typical brown, maculopapular skin lesions or mastocytoma associated with a positive Darier's sign. Pruritus and flushing are common and blistering may also be recorded, especially in diffuse CM (DCM). Pediatric patients with mastocytosis may also have gastrointestinal, respiratory, and neurologic complaints. Although anaphylaxis is not a typical finding, pediatric patients with massive skin involvement and high tryptase levels have a relatively high risk to develop anaphylaxis. This paper reviews MC mediator-related symptoms and anaphylaxis in children with mastocytosis, with special emphasis on risk factors, triggers, and management.
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Biologic excipients: Importance of clinical awareness of inactive ingredients.
Ionova, Y, Wilson, L
PloS one. 2020;(6):e0235076
Abstract
Due to the complexity and fragility of biological drug products, several challenges exist in their formulation development. Excipients are added to increase product stability, maintain tonicity, and facilitate drug delivery. The potential implications of these additive substances merit clinical consideration. We assessed the safety risk of excipients on the basis of their type and variability through an assessment framework, which quantifies excipient complexity in 230 biological formulations, and identifies excipient-related adverse events through published case reports. A biologic on average contained 4.45 excipients, half of that found in oral medications. The frequency distribution was heavily skewed towards the most commonly occurring excipients: water (40.4%), sodium chloride (38.3%), polysorbate 80 (28.7%), sucrose (24.4%), and mannitol (20.9%), with 44.4% of formulations not listing the concentration of the most commonly occurring inactive ingredients. A literature search revealed only 17 case reports of excipient-related adverse events, suggesting the need for more clarity for clinicians on the safety of chemical additives. These cases included injection site reactions, anaphylaxis, hyperglycemia, and acute renal failure. With the expansion of the biopharmaceutical market, it is important to consider the safety data of biologic excipients, so that therapy can be tailored appropriately for a specific patient.
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Anaphylaxis management in Australian schools: Review of guidelines and adrenaline autoinjector use.
Vale, S, Netting, MJ, Ford, LS, Tyquin, B, McWilliam, V, Campbell, DE
Journal of paediatrics and child health. 2019;(2):143-151
Abstract
Food allergy and anaphylaxis is increasing in Australian children, and anaphylaxis is relatively common in Australian schools. This review aims to provide an overview of current policies and practices for anaphylaxis management in Australian schools, including approaches to risk mitigation and anaphylaxis training. We reviewed literature related to anaphylaxis training in the school setting published between 2010 and 2018. Current anaphylaxis policies/guidelines were obtained from Australian education and health departments, and reports of suspected anaphylaxis and adrenaline autoinjector (AAI) use for 2016-2017 were obtained from education departments where available. Our review of policies/guidelines across Australian jurisdictions indicates inconsistent approaches to anaphylaxis management training. Almost half of Australian school anaphylaxis events required a general-use AAI, administered to students not identified as at risk of anaphylaxis. Development of clear, evidence-based, consistent guidelines related to anaphylaxis management and training in the school setting is imperative to minimise risk.
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Management of anaphylaxis and allergies in patients with long QT syndrome: A review of the current evidence.
Welzel, T, Ziesenitz, VC, Seitz, S, Donner, B, van den Anker, JN
Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. 2018;(5):545-551
Abstract
OBJECTIVE To develop a treatment algorithm for patients with long QT syndrome (LQTS) in case they need antiallergic medications for allergic reactions, including asthma and anaphylaxis. DATA SOURCES A literature review was performed to assess safety and to develop antiallergic treatment strategies for patients with LQTS. STUDY SELECTIONS LQTS is a heterogeneous group of myocardial repolarization disorders characterized by prolongation of the QT interval that potentially results in life-threatening torsades de pointes tachycardia. Data on pharmacologic treatment in case of anaphylaxis in LQTS are sparse. For this narrative review, all currently available articles on the use of antiallergic drugs for allergic reactions, anaphylaxis, and asthma in patients with LQTS were used. RESULTS Local allergic symptoms can be safely treated primarily with fexofenadine, levocetirizine, desloratadine, or cetirizine and, if needed, a short course of corticosteroids. In case of systemic symptoms, epinephrine should be administered. It may be less effective in patients with LQTS treated with β-blockers, necessitating the use of glucagon as add-on treatment. In case of lower airway obstruction, ipratropium bromide should be used, but if not effective, inhaled β2-adrenergic agents may be used. Continuous cardiac monitoring is indicated with the use of epinephrine and inhaled β2-adrenergic agents. The use of the latter also warrants intense monitoring of serum potassium levels. Clemastine and dimetindene should be avoided in patients with LQTS. CONCLUSION Patients with LQTS have a higher risk of life-threatening complications during the treatment of their allergic reactions because of the underlying disease and concomitant treatment with β-blockers. Treatment algorithms will certainly decrease these complications.
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5.
Incidence of food anaphylaxis in people with food allergy: a systematic review and meta-analysis.
Umasunthar, T, Leonardi-Bee, J, Turner, PJ, Hodes, M, Gore, C, Warner, JO, Boyle, RJ
Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology. 2015;(11):1621-36
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Abstract
BACKGROUND Food allergy is a common cause of anaphylaxis, but the incidence of anaphylaxis in food allergic people is unknown. METHODS We undertook a systematic review and meta-analysis, using the inverse variance method. Two authors selected studies by consensus, independently extracted data and assessed study quality using the Newcastle-Ottawa assessment scale. We searched Medline, Embase, PsychInfo, CINAHL, Web of Science, LILACS and AMED between January 1946 and September 2012 and recent conference abstracts. We included registries, databases or cohort studies which described the number of food anaphylaxis cases in a defined population and time period and applied an assumed population prevalence of food allergy. RESULTS We included data from 34 studies. There was high heterogeneity between study results, possibly due to variation in study populations, anaphylaxis definition and data collection methods. In food allergic people, medically coded food anaphylaxis had an incidence rate of 0.14 per 100 person-years (95% CI 0.05, 0.35; range 0.01, 1.28). In sensitivity analysis using different estimated food allergy prevalence, the incidence varied from 0.11 to 0.21 per 100 person-years. At age 0-19, the incidence rate for anaphylaxis in food allergic people was 0.20 (95% CI 0.09, 0.43; range 0.01, 2.55; sensitivity analysis 0.08, 0.39). At age 0-4, an incidence rate of up to 7.00 per 100 person-years has been reported. In food allergic people, hospital admission due to food anaphylaxis had an incidence rate of 0.09 (95% CI 0.01, 0.67; range 0.02, 0.81) per 1000 person-years; 0.20 (95% CI 0.10, 0.43; range 0.04, 2.25) at age 0-19 and 0.50 (0.26, 0.93; range 0.08, 2.82) at age 0-4. CONCLUSION In food allergic people, the incidence of food allergic reactions which are coded as anaphylaxis by healthcare systems is low at all ages, but appears to be highest in young children.
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Brain injury due to anaphylactic shock: broadening manifestations of Kounis syndrome.
Soufras, GD, Kounis, GN, Kounis, NG
International endodontic journal. 2014;(4):309-13
Abstract
Anaphylactic shock is a real and life threatening medical emergency which is encountered in every field of medicine. The coronary arteries seem to be the primary target of anaphylaxis resulting in the development of Kounis syndrome. Kounis syndrome is a pan-arterial anaphylaxis -associated syndrome affecting patients of any age, involving numerous and continuously increasing causes, with broadening clinical manifestations and covering a wide spectrum of mast cell activation disorders. Recently, Kounis-like syndrome affecting the cerebral arteries was found to be associated with mast cell activation disorders. In anaphylactic shock, the decrease of cerebral blood flow is more than what would be expected from severe arterial hypotension. This is attributed to the early and direct action of anaphylactic mediators on cerebral vessels. While adrenaline is a life saving agent in the treatment of anaphylactic shock, it contains sodium betabisulfite as preservative and should be avoided in sulfite allergic patients. Potential allergens encountered in endodotic practice include formocresol, zinc compounds thiurams, sodium dimethyldithiocarbamade, and mercaptobenzothiazole that might have synergistic action. All these agents together with analgesics, antibiotics, antiseptics, formaldehyde, latex, local anaesthetics and metals used in dental practice, in general, can induce anaphylactic shock. Practitioners should be aware of these consequences. A careful history of previous atopy and reactions is of paramount importance for safe and effective management.
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NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population.
Burks, AW, Jones, SM, Boyce, JA, Sicherer, SH, Wood, RA, Assa'ad, A, Sampson, HA
Pediatrics. 2011;(5):955-65
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Abstract
Data from many studies have suggested a rise in the prevalence of food allergies during the past 10 to 20 years. Currently, no curative treatments for food allergy exist, and there are no effective means of preventing the disease. Management of food allergy involves strict avoidance of the allergen in the patient's diet and treatment of symptoms as they arise. Because diagnosis and management of the disease can vary between clinical practice settings, the National Institute of Allergy and Infectious Diseases (NIAID) sponsored development of clinical guidelines for the diagnosis and management of food allergy. The guidelines establish consensus and consistency in definitions, diagnostic criteria, and management practices. They also provide concise recommendations on how to diagnose and manage food allergy and treat acute food allergy reactions. The original guidelines encompass practices relevant to patients of all ages, but food allergy presents unique and specific concerns for infants, children, and teenagers. To focus on those concerns, we describe here the guidelines most pertinent to the pediatric population.
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Food-induced anaphylaxis.
Järvinen, KM
Current opinion in allergy and clinical immunology. 2011;(3):255-61
Abstract
PURPOSE OF REVIEW Food-induced anaphylaxis is the leading single cause of anaphylaxis treated in emergency departments and increasing in prevalence. RECENT FINDINGS Food allergy is an increasing problem in westernized countries around the world, with a cumulative prevalence of 3-6%. Peanut, tree nuts, and shellfish are the most commonly implicated foods in anaphylaxis, although milk is a common trigger in children. Asthmatics, adolescents, and those with a prior reaction are at increased risk for more severe reactions. Most first reactions and reactions in children most commonly occur at home, whereas most subsequent reactions and reactions in adults occur outside home. Studies on schools have identified inadequate management plans and symptom recognition whereas those on restaurants report lack of prior notification by allergic individuals and lack in staff education. Epinephrine, although underutilized is the drug of choice with multiple doses needed in up to one-fifth of reactions. Diagnosis is currently based on convincing history and allergy testing supported by elevated serum tryptase, if available. Long-term management includes strict avoidance and emergency action plan. SUMMARY With a growing population of food-allergic children and adults, markers to predict which individuals are at increased risk for anaphylaxis as well as new therapies are vigorously sought.
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Allergic reactions to local anesthetic formulations.
Speca, SJ, Boynes, SG, Cuddy, MA
Dental clinics of North America. 2010;(4):655-64
Abstract
True allergic reactions to local anesthetics are rare adverse reactions. At the most, they represent less than 1% of all adverse local anesthetic reactions. When true allergic reactions have been confirmed, the reactions are most commonly the type I anaphylactic and type IV delayed hypersensitivity responses. The type I immediate hypersensitivity reactions are the most severe and may be life-threatening. In the event a potential allergic reaction occurs in a dental office, the dentist needs to properly evaluate the events leading up to the reaction and provide a differential diagnosis. A referral should be given to any patient when an allergic reaction cannot be ruled out as an intravascular injection, toxic overdose, psychogenic reaction, or an idiosyncratic event.
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Pre-lethal anaphylaxis to carboxymethylcellulose confirmed by identification of specific IgE--review of the literature.
Dumond, P, Franck, P, Morisset, M, Sainte Laudy, J, Kanny, G, Moneret-Vautrin, DA
European annals of allergy and clinical immunology. 2009;(6):171-6
Abstract
BACKGROUND Carboxymethylcellulose (CMC) is used extensively in the pharmaceutical and food industries on account of its various properties. Anaphylactic reactions are rare. It has been reported principally after intra-articular infiltration of sustained-release corticosteroids containing CMC and, very rarely, after barium enema. METHODS A case of pre-lethal anaphylactic shock after barium enema was studied by prick-test, intra-dermal reaction (IDR), leukocyte histamine release test (LHRT), basophil activation test (BAT), cystein-leukotriene release test (CAST) and dot-blot analysis. RESULTS IDR to CMC was positive at a concentration of 10 microg/ml. BAT and CAST were positive. Specific IgE were identified using dot-blot analysis. DISCUSSION This is the third report of CMC-specific IgE and the second of anaphylaxis to CMC associated with a barium suspension in contact with GI tract mucosa. CMC as an excipient in medicinal products may therefore be a risk factor for severe anaphylaxis after injection or following contact with GI tract mucosa. Sensitization and allergic reactions by CMC in food additives have to be considered.