Original Study

Elevation of alanine transaminase and gallbladder

wall abnormalities as biomarkers of anaphylaxis in
canine hypersensitivity patients
Jonnie E. Quantz, DVM; Macon S. Miles, DVM, DACVIM; Ann L. Reed, DVM, DACVR and
George A. White, DVM, DACVECC
Abstract
Objective The purpose of the study was to evaluate alanine transaminase (ALT) and gallbladder wall
abnormalities as possible biomarkers for anaphylaxis in dogs presented for acute hypersensitivity reactions.
Design Pilot study.
Setting A private practice, small animal, 24-hour emergency and specialty hospital.
Animals Ninety-six dogs presenting 101 times on an emergency basis for hypersensitivity reactions from
March 2007 through March 2009.
Interventions Veterinarians acquired a history, physical exam, serum chemistry panel, blood pressure, and
ultrasound image of the gallbladder.
Measurements and Main Results Dogs were then divided into 2 groups: dogs fullling the denition for
anaphylaxis (moderate and severe systemic hypersensitivity) and dogs that did not fulll the denition and
were classied as allergic reactions (local hypersensitivity and mild systemic hypersensitivity). Elevated ALT
was signicantly associated with anaphylaxis (Po0.001). Increased gallbladder wall thickness and a striated
wall pattern were signicantly associated with anaphylaxis (Po0.001) and these changes were readily
apparent to rst-responder veterinarians. Decreased body temperature (Po0.001) and hypothermia
(P50.006) were signicantly associated with anaphylaxis. There was no signicant difference between
groups regarding age, heart rate, or presence of respiratory signs. Lower blood pressure was signicantly
associated with anaphylaxis (Po0.001) but hypotension was not signicantly different (P50.09) between
groups. Cutaneous signs were signicantly associated with the allergic reactions group (Po0.001) and, when
seen with anaphylaxis, were subtle.
Conclusions This study showed an elevated ALT and an abnormal gallbladder wall to be biomarkers
signicantly associated with anaphylaxis in dogs with acute hypersensitivity reactions.
(J Vet Emerg Crit Care 2009; 19(6): 536544) doi: 10.1111/j.1476-4431.2009.00474.x
Keywords: allergens, biological markers, dogs, liver, ultrasonography
Introduction
Anaphylactic reactions
1,2
are immunoglobulin E (IgE)-
mediated, Type-I, immediate hypersensitivity reactions.
Initial exposure to an allergen stimulates production
of IgE antibody by macrophages and T cells. This
cytotropic antibody is then bound to the surface of cir-
culating blood basophils and tissue mast cells by high-
afnity receptors (FceRI). Subsequent exposure of
these sensitized cells to the allergen causes cross-linking
of surface IgE and release of preformed mediators as
well as the synthesis of additional mediators.
3,4
Ana-
phylactoid reactions are not distinguishable chemically
or clinically from anaphylactic reactions but are
not mediated by IgE.
5
Anaphylactoid reactions are a
nonimmunologic stimulation and activation of mast
cells. No prior antigenic exposure is necessary.
3,4,69
For
the purpose of this paper, anaphylaxis will be used in-
terchangeably to refer to either an anaphylactic or an
anaphylactoid reaction; treatment is the same for both
conditions.
4,7
Histamine is the primary preformed mediator of ana-
phylaxis. Mast cell degranulation also releases other
preformed mediators including heparin, tryptase,
chymase, and other cytokines. The secondary synthe-
Address correspondence and reprint requests to
Dr. Jonnie E. Quantz, Animal Emergency Referral Center, 3511 Pacic Coast
Highway, Suite A, Torrance, CA 90505.
Email: jqdvm@aol.com
From the Animal Emergency Referral Center, Torrance, CA 90505.
Journal of Veterinary Emergency and Critical Care 19(6) 2009, pp 536544
doi:10.1111/j.1476-4431.2009.00474.x
& Veterinary Emergency and Critical Care Society 2009 536
sized molecules are metabolites of arachidonic acid and
include prostaglandins, leukotrienes, and platelet acti-
vating factor.
35,9,10
Other pathways activated during
anaphylaxis cause an amplication of the inammatory
reaction and include the complement system, the
kallikreinkinin system, the coagulation cascade, and
the brinolytic system.
35,11
Clinical reactions are
species dependent and directly related to the location
of the largest population of mast cells. In the dog, the
gastrointestinal tract and the venous system of the liver
are considered the primary shock organs. In anaphyl-
axis histamine is released from the gastrointestinal
tract into the portal vein resulting in hepatic venous
congestion and portal hypertension.
4,6,10,12
Work toward consensus of denitions in human
medicine includes 2 recent multidisciplinary confer-
ences
8,13
and large retrospective case studies
1,2,14
that
focus on universally accepted denitions for hypersen-
sitivity and anaphylaxis. The working denitions for
hypersensitivity reactions used in this study involved
the concept of a continuum from acute allergic reactions
to life-threatening anaphylaxis.
8
Viewing anaphylaxis
as part of a continuum complicates the problem of
dening the point at which a hypersensitivity reac-
tion transitions from an allergic reaction and becomes
anaphylaxis.
Acute allergic reaction (local hypersensitivity) is dened
as an acute onset of illness and evidence of generalized
mediator release restricted to cutaneous ndings alone,
such as erythema, pruritis, urticaria, or angioedema
without any other systemic signs.
1,14
Systemic (general-
ized) hypersensitivity reactions were classied by the
severity of the systemic reaction based on the grading
system proposed by Brown and colleagues.
1,2
Mild sys-
temic hypersensitivity reactions were those involving gen-
eralized skin/mucosal tissue without involvement of
other organs but having some indication of a generalized
component (eg, fever). Acute allergic reactions and mild
systemic hypersensitivity reactions are classied as aller-
gic reactions (AR).
1,2
Moderate systemic hypersensitivity
reactions are allergic reactions involving 2 or more organ
systems, systolic blood pressure 490 mmHg, and with-
out evidence of neurologic compromise. Severe systemic
hypersensitivity reactions are allergic reactions involving
any evidence of neurologic compromise (collapse or syn-
cope) or hypotension o90 mmHg.
1,2,15
Moderate and
severe systemic hypersensitivity reactions are classied
as anaphylaxis (AX).
1,2
The working clinical denition of
anaphylaxis used in this pilot study is that anaphylaxis
is a multiple organ hypersensitivity with any of the
ndings listed for an acute allergic reaction with addi-
tional respiratory, gastrointestinal, or cardiovascular
signs (wheezing, stridor, dyspnea, vomiting, diarrhea,
nausea, abdominal pain, hypotension, or symptoms of
reduced blood pressure [eg, collapse, loss of conscious-
ness], incontinence) or these additional features alone
in the setting of an allergic reaction (eg, patient has
a history of allergic reactions, or a probable allergen
exposure).
1,14
In humans, serum tryptase and urinary N-methyl-
histamine are laboratory tests useful as biomarkers of
anaphylaxis when carried out in close proximity (12 h)
to the inciting trigger.
8,13,16,17
These tests are not readily
available to veterinarians and their value has yet to be
determined for veterinary patients. Given the fulminant
nature of anaphylaxis, these biomarkers are likely to be
of little help in the immediate direction of patient treat-
ment. Anaphylaxis is usually considered a clinical di-
agnosis with laboratory tests being of little value.
18
When there is a lack of historical information, as hap-
pens frequently in veterinary medicine, biomarkers for
anaphylaxis would be valuable. Delay in treatment
leads to an increased chance of poor response with
possible life-threatening consequences.
7,19
The main
purpose of this study was to evaluate hepatobiliary
parameters (alanine transaminase [ALT] and gallblad-
der wall abnormalities) in the canine hypersensi-
tivity patient to identify possible biomarkers of canine
anaphylaxis.
Materials and Methods
Patient selection
Patients in this study were presented to a suburban
veterinary emergency and specialty hospital over a pe-
riod of 25 months from March 2007 through March
2009. Dogs suspected of having a hypersensitivity re-
action were included in the study if they presented with
an acute onset of signs (minutes to hours) having in-
volvement of skin/mucosal tissue (angioedema, urti-
caria, erythema, pruritis), or with gastrointestinal signs
(vomiting, diarrhea, nausea) or hypotonia (collapse/
syncope) associated with known or suspected allergen
exposure. Patients were excluded if another diagnosis
was identied as a cause of their clinical signs. Patients
with known causes of increased gallbladder wall thick-
ness, such as congestive heart failure, cholangiohepa-
titis, pancreatitis, or other causes for blockage of the
lymphatic/venous drainage of the gallbladder were
excluded from the study.
20,21
Patients with known
causes of collapse such as cardiac disease or seizure
disorders were also excluded from the study. Pet own-
ers gave written permission for diagnostic testing per-
formed and inclusion in this study.
Data collection
At presentation a history was taken and physical
examination was performed on all patients. The de-
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 537
Anaphylaxis biomarkers in canine hypersensitivity
tailed history included the possibility of a recent aller-
gen exposure or a past history of a hypersensitivity re-
action. A known allergen exposure was a witnessed
event such as a hymenoptera sting or identication of a
stinger in the patient or recent administration of a
medication or a vaccine. A suspected allergen exposure
included witnessed events such as seeing the patient
playing with a bee, nding a bee near the patient, or
having the patient hold its paw up and cry out on a
walk, but not witnessing the sting or nding a stinger in
the patient. Blood pressure
a
was measured within 30
minutes of presentation. A serum chemistry panel was
evaluated using a point-of-care analyzer.
b
When the
upper limit was exceeded for ALT (1000 U/L), it was
noted as 41000 U/L. The value 1000 U/L was used for
statistical analysis in these cases. Clinicians were asked
to perform a brief abdominal ultrasonographic exam-
ination focusing on the gallbladder.
c,d,e
These veteri-
narians were familiar with general ultrasound
technique and ultrasound trauma protocol,
22
but re-
ceived no specialized training. Patients were shaved
over the area of the gallbladder only if thick fur im-
paired image quality. This procedure took approxi-
mately 3 minutes and was performed concurrently with
other diagnostic testing and treatments. Images were
then reevaluated by a board-certied veterinary radi-
ologist. Gallbladder wall thickness was measured and
the presence of gallbladder wall striation (subserosal
edema) was noted. The radiologist further classied the
gallbladder wall changes as focal or diffuse. Any evi-
dence of striation was considered abnormal.
20,21,23
Statistical analysis
Statistical analysis was performed using standard sta-
tistical software.
f
Fishers exact tests were used to com-
pare the association of categorical data between the AR
and AX groups. Sensitivity, specicity, positive predic-
tive value, and negative predictive value with con-
dence intervals and P-value were reported. Means plus
the 95% condence interval or median with range are
reported for all data. Means were compared between
AR and AX groups using Student 2-group t-test with
Welch correction. Distributions between groups were
compared using the Mann-Whitney test. Statistical sig-
nicance was dened as a Po0.05 on a 2-tailed test.
Results
Ninety-six dogs presenting with 101 reactions met the
criteria and were enrolled into the study. Five dogs
presented for repeat hypersensitivity reactions several
months after the initial episode. There were 75 pure-
bred dogs and 21 mixed-breed dogs. Breeds repre-
sented more than once were Labrador Retriever
(n 510), Chihuahua (n 510), Maltese (n 57), Yorkshire
Terrier (n 55), Cocker Spaniel (n54), Boxer (n 53),
Boston Terrier (n 53), Golden Retriever (n 53), Shih
Tzu (n 53), Pug (n53), Dachshund (n 53), French
Bulldog (n 52), English Bulldog (n 52), and West
Highland White Terrier (n 52). The mean age was 2.3
years (range 10 weeks10.5 years), and the mean weight
was 13.8 kg (range 1.5443.2 kg). There were 38 males
and 58 females in the study. There was no signicant
difference between male and female dogs between
groups (P50.09).
After data were collected, hypersensitivity patients
were then divided into 2 groups, either AR or AX. This
separation was based on the continuum concept of hy-
persensitivity reactions and anaphylaxis as dened in
the introduction. The AR group was comprised of 40
dogs each presenting for 1 episode of acute allergic re-
action or mild systemic hypersensitivity reaction
(n 540). The AX group was comprised of 56 dogs pre-
senting for 61 episodes of moderate or severe systemic
hypersensitivity reactions (n 561). In the AR group,
35% (14/40) had a known allergen (10 hymenoptera
stings, 3 vaccines, and 1 medication), 7.5% (3/40) had a
suspected allergen exposure (all hymenoptera stings),
and 57.5% (23/40) had no identiable allergen expo-
sure. In the AX group, the allergen was known in 64%
(39/61) of visits (30 hymenoptera stings, 8 vaccines, and
1 medication), suspected in 21% (13/61) of the visits (all
hymenoptera stings), and unknown in 15% (9/61) of
the visits.
Tables 1 and 2 compare the signalment, clinical signs,
and vital signs on presentation between the 2 groups.
There was no signicant difference between mean val-
ues for age (P50.63) or heart rate (P50.63). The me-
dian body weight was signicantly less in the AX group
than in the AR group (P50.048), but the mean body
weight was not signicantly different between groups
(P50.09). The systolic blood pressure in the AX was
signicantly lower (P50.001) than the AR group and
is shown by scatterplot in Figure 1. However, systolic
blood pressure mean and median in both groups were
490 mmHg. Only 7 patients in the AX group had hypo-
tension (o90mmHg) on presentation. Hypotension was
not signicantly associated with either group (P50.09).
Temperature was signicantly lower (Po0.001) in the
AX group than in the AR group. Hypothermia (o37.51C)
was signicantly associated with the AX group
(P50.006). Cutaneous signs were signicantly more as-
sociated with the AR group (Po0.001). Cutaneous signs,
when seen, were milder and more difcult to identify in
the AX group. Airway compromise was not signicantly
associated with either group (P50.28). Airway compro-
mise was only observed in the AX group and consisted
of 3 patients, 2 with harsh stridorous panting, and 1 with
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 538
J.E. Quantz et al.
a reverse sneezing episode. Ninety-two percent (56/61)
of dogs presenting for AX had acute gastrointestinal
signs (vomiting, diarrhea, nausea, hypersalivation) and
79% (48/61) presented with a history supportive of hy-
potonia (collapse).
Laboratory abnormalities and ultrasound ndings
were compared between the AR group and the AX
group and are shown in Table 3. Elevated ALT was
signicantly associated (Po0.001) with the AX group
when compared with the AR. Comparison of the mean
ALT between the AX group and the AR group is shown
by scatterplot in Figure 2A. Gallbladder wall abnor-
malities (striated gallbladder wall or gallbladder wall
thickness 43 mm) were also signicantly associated
(Po0.001) with the AX group when compared with the
AR group. The gallbladder wall thickness was signi-
cantly greater (Po0.001) for the AX group when com-
pared with the AR group and is demonstrated in Figure
2B. In the AR group, 1 dog had focal gallbladder wall
striation with wall thickness of 2 mm. This gallbladder
wall change was too subtle for the receiving veterinar-
ian to identify and was noted only when the radiologist
reviewed the images. Abnormal gallbladder wall
appearance in anaphylaxis patients was consistently
recognized by receiving veterinarians and the radiolo-
gist. A thickened and diffusely striated gallbladder wall
(halo effect) characteristic of anaphylaxis is shown in
Figure 3.
Discussion
The principal target organ of canine anaphylaxis is the
gastrointestinal tract and the liver
3,4,6,10
and changes
would be expected to be identied within the hepatic
parenchyma and vasculature. A literature search iden-
tied a published case series in which 1 dog was re-
ported as having a known insect sting (low level
exposure) and progressed to severe hepatic compro-
mise.
24
Another published case report reviewed an ep-
isode of fatal anaphylaxis following dexamethasone
administration in which the postmortem revealed sig-
nicant changes in the liver, including portal vein, cen-
tral vein, and sinusoidal congestion. This passive
congestion was considered consistent with Type-I hyper-
sensitivity reactions.
25
Pathophysiologically, histamine is
released from the gastrointestinal tract into the portal
vein during anaphylaxis.
26
This intraportal infusion of
histamine causes hepatic arterial vasodilation and a con-
Table2: Association of clinical and vital signs at presentation with anaphylaxis or allergic reaction in 96 dogs presenting for 101
episodes of acute hypersensitivity reactions
Anaphylaxis
(n561)
Allergic
reaction
(n540)
Sensitivity
(CI)
Specicity
(CI) PPV (CI) NPV (CI) P-value
Cutaneous signs
n
35 40 0.57 (0.44, 0.70) 0.00 (0.00, 0.09) 0.47 (0.35, 0.59) 0.00 (0.00, 0.13) o0.001
Airway compromise
w
3 0 0.05 (0.01, 0.14) 1.00 (0.91, 1.00) 1.00 (0.29, 1.00) 0.41 (0.31, 0.51) 0.28
Hypotensionz 7 (n 556) 0 (n 530) 0.13 (0.05, 0.24) 1.00 (0.88, 1.00) 1.00 (0.59, 1.00) 0.38 (0.27, 0.50) 0.09
Hypothermia 11 0 (n 539) 0.18 (0.09, 0.30) 1.00 (0.91, 1.00) 1.00 (0.72, 1.00) 0.44 (0.33, 0.55) 0.006
n
Angioedema, urticaria, erythema, or pruritus.
wStridor, dyspnea, or bronchospasm.
zSystolic blood pressure o90 mmHg.
Hypothermia considered o37.51C.
CI, 95% condence interval; PPV, positive predictive value; NPV, negative predictive value.
Table1: Comparison of signalment and vital signs on presentation between anaphylaxis and acute allergic reaction in 96 dogs
presenting for 101 episodes of acute hypersensitivity reactions
Mean (CI) Median (range)
Anaphylaxis
Acute allergic
reaction P-value Anaphylaxis
Acute allergic
reaction P-value
Age (years) 2.3 (1.8, 2.7) 2.5 (1.6, 3.3) 0.63 2.0 (0.28.0) 1.5 (0.210.5) 0.69
Weight (kg) 12.2 (9.5, 15.0) 16.2 (12.7, 19.6) 0.08 8.3 (1.540.0) 14.5 (1.943.2) 0.048
Temperature (
o
C) 38.3 (38.0, 38.5) 39.0 (38.8, 39.1) o0.001 38.3 (36.140.1) 39.0 (37.740.1) o0.001
Heart rate 141 (133, 149) 138 (129, 147) 0.63 140 (80220) 138 (90220) 0.57
Systolic blood pressure (mmHg) 123 (114, 131) 151 (142, 161) o0.001 128 (40177) 145 (103213) o0.001
CI, 95% condence interval.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 539
Anaphylaxis biomarkers in canine hypersensitivity
current increase in arterial hepatic blood ow in about 7
seconds.
26
The intraportal histamine infusion also causes
an effective hepatic outow block, primarily because
histamine constricts hepatic venous sphincters located,
in the dog, near the junction of the hepatic veins and the
inferior vena cava,
2628
increasing the hepatic portal
vascular resistance up to 220% in about 12 seconds.
26
The time course of the effects of intraportal histamine on
the arterial hepatic blood ow eliminates the possibility
that these transhepatic effects are due to systemic recir-
culation of the histamine.
26
Antemortem changes in the
liver and gallbladder would be expected with anaphyl-
axis and were the focus of this study.
Ischemia and hypoxia from the alterations in blood
ow and possible direct effects of the inammatory
mediators of anaphylaxis cause damage to the he-
patocyte.
2629
Alterations of hepatocyte membrane
permeability will result in leakage of cytosolic en-
zymes. ALT is a soluble cytosolic hepatocellular leakage
enzyme that has high activity in the hepatocytes, and
ALT elevation is a very sensitive indicator of hepatic
damage. Leakage can occur with sublethal injury. The
magnitude of the increase in this enzyme does not cor-
relate with the severity of hepatic insufciency. Seventy
percent of the functional hepatocytes must be lost be-
fore there is detectable decreased hepatic function. The
Figure1: Scatterplot of the mean systolic blood pressure with
95% condence interval between the anaphylaxis group (123,
114131 mmHg) (n 556) and the allergic reaction group (151,
142161 mmHg) (n 530) in dogs that presented for acute hyper-
sensitivity reactions. The difference was signicant (Po0.001)
between the groups.
Table3: Association of laboratory abnormalities and ultrasound ndings at presentation with anaphylaxis or allergic reaction in 96
dogs presenting for 101 episodes of acute hypersensitivity reactions
Anaphylaxis
(n561)
Allergic
Reaction
(n540)
Sensitivity
(CI)
Specicity
(CI) PPV (CI) NPV (CI) P-value
Elevated ALT
n
52 1 0.85 (0.74, 0.93) 0.98 (0.87, 1.00) 0.98 (0.90, 1.00) 0.81 (0.67, 0.91) o0.001
Abnormal gallbladder wallw 57 1 0.93 (0.84, 0.98) 0.98 (0.87, 1.00) 0.98 (0.91, 1.00) 0.91 (0.78, 0.97) o0.001
n
Normal ALT 100U/L for dogs 46 months old, 80 U/L for dogs o6 months old.
wGallbladder wall striated (alternating sonolucent and echogenic layers) or gallbladder wall 43 mm thick.
CI, 95% condence interval; PPV, positive predictive value; NPV, negative predictive value.
Figure2: (A) Scatterplot of the mean alanine aminotransferase
with 95% condence interval between the anaphylaxis group
(402, 320484 U/L) (n561) and the allergic reaction group (36,
2744 U/L) (n540). The difference was signicant (Po0.001)
between the groups. (B) Scatterplot of the mean gallbladder wall
thickness with 95% condence interval between the anaphylaxis
group (4.7, 4.25.2 mm) (n 561) and the allergic reaction group
(1.7, 1.51.9 mm) (n540). The difference was signicant
(Po0.001) between the groups.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 540
J.E. Quantz et al.
portal vein supplies the liver with 75% of its blood ow.
With anaphylaxis the portal blood supply and the ve-
nous return from the liver to the systemic circulation
are severely compromised.
2628,30,31
The half life of ALT
in the dog is about 60 hours. After an insult to the
canine liver of the magnitude seen with anaphylaxis,
ALT should rapidly elevate (o12 h), peak in 2448
hours, and return to normal over a period of 23
weeks.
30
ALT elevations are not specic markers for
anaphylaxis, but should be consistently elevated with
dogs with moderate to severe systemic hypersensitivity
(anaphylaxis) in the dog.
Within this group of dogs with hypersensitivity re-
actions, ALT proved to be a signicant marker of ana-
phylaxis when compared with the AR group. On-site
laboratory testing is common in the modern veterinary
practice. The point-of-care chemistry analyzer used in
this study can deliver results within 10 minutes, but
blood draw and preparation increased time to results to
1520 minutes. This makes the cytosolic enzyme, ALT, a
valuable biomarker to help support the diagnosis of
anaphylaxis in the clinical setting, but less valuable in
the immediate treatment period when time is critical.
The gallbladder wall is poorly visualized via ultra-
sonography in the healthy dog as a thin, echogenic line
separating the bile from the hepatic parenchyma and
sometimes is not visualized at all.
25,32
One study re-
corded the normal canine gallbladder wall as measur-
ing between 2 and 3 mm in thickness.
20
Thickening of
the gallbladder wall is considered a nonspecic nding.
Multiple striations (alternating sonolucent and echo-
genic layers) in the gallbladder wall, the halo or double
rim effect, is indicative of wall edema or inammation,
and can be associated with causes unrelated to gall-
bladder disease including primary liver disease, portal
hypertension, and blockage of the lymphatic/venous
drainage of the gallbladder.
21,23,3234
The portal venous
system returns the blood from the gallbladder to the
systemic circulation. With hepatic venous congestion
and portal hypertension due to hepatic arterial vasodi-
lation and venous outow obstruction identied in
canine anaphylaxis,
4,10,2628
venous drainage of the
gallbladder would be impaired and similar changes
(striation and thickening) of the gallbladder wall would
be expected.
Signicant thickening of the gallbladder wall and a
distinctive striated pattern were seen on presentation
with the anaphylaxis group when compared with the
AR group. The same hepatic venous outow block that
occurs in 12 seconds
26
and is suspected to be the cause
of delayed elevation of the ALT by several hours in
some patients, is speculated to be responsible for the
gallbladder wall changes being almost immediate. In
the 9 dogs in the AX group with normal ALT on pre-
sentation, gallbladder wall changes were seen immedi-
ately in 8 of them. The radiologist identied 1 abnormal
gallbladder wall change in the AR group (focal area of
striation with wall thickness at 2 mm), but this change
was too subtle for the receiving veterinarian to identify.
All rst-responder veterinarians were able to identify
abnormal gallbladder walls in the anaphylaxis group,
making this a valuable tool for rapid assessment of
suspected dogs with canine anaphylaxis. The docu-
mentation of gallbladder wall abnormalities proved to
be a valuable biomarker in the identication of emer-
gent canine anaphylaxis, sometimes occurring even be-
fore ALT elevation.
Cutaneous manifestations in humans may be delayed
or absent in rapidly progressive anaphylaxis, with up to
20% not having identied cutaneous components.
8,13
Cutaneous symptoms may occur in every case of ana-
phylaxis, but these symptoms are often subtle and
transient.
1,18
Veterinary patients, because of their fur
and pigmentation, present an even greater challenge to
identify these cutaneous manifestations. This study
supports that cutaneous manifestations were milder
and more difcult to discern in patients with anaphyl-
axis with only 57% having recognizable cutaneous
manifestations.
Respiratory signs were not signicantly associated
with either AX or AR in this study of canine hyper-
sensitivity. One owner reported a reverse sneezing ep-
isode and 2 dogs with harsh, stridorous panting were
observed (Cocker Spaniel and English Bulldog) on pre-
sentation. No cases involved laryngeal edema, broncho-
spasm, or dyspnea as is frequently found in humans
where the predominant shock organ is the respiratory
tract.
5,10
Although these signs have been reported in the
veterinary literature,
4,35
they were not identied in this
Figure3: Ultrasound image of the gallbladder in a patient di-
agnosed with anaphylaxis after a single hymenoptera sting.
Gallbladder wall is thickened (0.5 cm) and striated (alternating
echogenic and sonolucent layers).
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 541
Anaphylaxis biomarkers in canine hypersensitivity
study. In dogs, the target organ for anaphylaxis is not
the respiratory system, and this could explain the lack
of airway compromise in dogs. Another possible ex-
planation could be that patients with severe respiratory
signs did not survive to reach the emergency room, as
death from anaphylaxis is frequently reported to occur
in o1 hour.
3,4,9,12,35,36
The measurement of blood pressure was not initially
required to be taken in this study. Consequently mea-
surements were not taken in some early patients. Mea-
surement of blood pressure was taken in 92% (56/61) of
anaphylaxis events and 75% (30/40) of allergic reac-
tions. Hypotension was not signicantly associated
with either the AX group or the AR group. When the
blood pressure values were compared between groups
they were signicantly lower in the AX group, but
the mean and median were still in a clinically accept-
able range. Hypotension (systolic blood pressure
o90 mmHg)
19
in the anaphylaxis group was noted in
11% (7/61) of measured AX events and was never
identied in the 30 dogs with allergic reaction in which
blood pressure was measured. In the 10 dogs with AR
where blood pressure was not measured, all patients
were identied with a bright, alert, and responsive
mentation and were not suspected to be hypotensive.
Hypotension and shock in anaphylaxis result from loss
of effective circulating volume caused by peripheral
vasodilation, increased vascular permeability, and di-
rect myocardial dysfunction.
10,18,19
This activates the
renin-angiotensin-aldosterone system and causes cat-
echolamine release. Clinical signs in humans with
anaphylaxis that are associated with neurologic com-
promise have the highest correlation with hypoten-
sion
1,8,13,14
and were identied in dogs in this study by
a history of collapse (hypotonia).
3739
A history of hy-
potonia was associated with anaphylaxis in this study
79% (48/61) of the time. Gastrointestinal features have
also been demonstrated to have a signicant association
with hypotensive anaphylaxis in humans.
1,14
Gastroin-
testinal signs occurred in 56 of 61 (92%) dogs with
anaphylaxis in this study. Further studies would be
necessary to compare whether hypotonia and gastroin-
testinal signs have signicant correlation with hypo-
tension in the dog.
Decreased body temperature was expected in ana-
phylaxis due to vasodilation, hypoperfusion, and hypo-
tension. Although a statistically signicant decrease in
body temperature was found, it would be hard to use
this parameter in the differentiation of AR from AX in
the clinical setting due to the clinically insignicant
difference. However, when hypothermia
40
was present,
it was signicantly associated with anaphylaxis. Lower
median body weight was signicantly associated with
AX in this study. Smaller patients could be expected to
have a more profound response due to a proportionally
greater allergen exposure per body weight. However, in
dogs it is unknown whether the amount of histamine
released is proportional to the allergen dose.
Although not a part of the original study, the effect of
anaphylaxis on the liver was followed in most dogs
with AX. Five of the 9 AX patients that had normal ALT
on presentation developed an elevated ALT on recheck
over the following 24 hours. The data are insufcient to
draw concrete conclusions, but we theorize that the
ALTcould have been normal in some AX patients if the
closure of the posthepatic venous sphincters prevented
release of ALT into the circulation. Over the ensuing
hours, the ALT in the peripheral blood would elevate as
the sphincters relaxed. Additional studies would be
necessary to determine more about this observation.
When ALTwas rechecked in hospitalized AX patients it
remained elevated in most patients for more than 24
hours, making ALT useful in retrospective diagnosis.
Only 3 AR patients had their ALT followed and none
developed elevations. ALT was followed in several AX
patients after release from the hospital and all of the
ALT values returned to normal over the following 24
weeks. Two patients in the AX group (3%) had pro-
longed fasting and 2-hour postprandial bile acids sup-
porting a diagnosis of hepatic insufciency.
30
Bile acid
values returned to normal in both patients within 11
days. Both of these dogs with compromised hepatic
function had a known single hymenoptera sting, were
gravely ill, and required extended hospitalization and
supportive care. Reactions to a single hymenoptera
sting are considered hypersensitivity reactions
12
and
not the direct toxic effects on the liver seen with mas-
sive envenomation.
24,41
Elevation of the ALT associated
with anaphylaxis should not be assumed to be benign.
Anaphylaxis is a medical emergency that requires
immediate treatment to prevent a possible catastrophic
outcome. Treatment for anaphylaxis outlined in veter-
inary literature includes epinephrine, aggressive uid
therapy, oxygen, positive inotropic support, pressors,
bronchodilators, glucocorticoids, and antihistamines.
3,4
The rst line treatment and medication of choice for
anaphylaxis in all species is epinephrine. National
guidelines for humans recommend all patients with
anaphylaxis be treated with epinephrine and the World
Health Organization classies epinephrine as an essen-
tial drug.
8
Epinephrine blocks the effects of the medi-
ators produced during anaphylaxis, increases cardiac
output through positive inotropic and chronotropic
effects, and promotes bronchodilation.
3,4,8,42
A recent
study found that only continuous rate infusion of
epinephrine provided sustained hemodynamic recov-
ery in dogs; bolus administration by subcutaneous, in-
tramuscular, or intravenous routes was not effective.
43
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 542
J.E. Quantz et al.
Subcutaneous bolus administration in dogs did not in-
crease plasma epinephrine over endogenous levels and
is not recommended.
42,43
A failure to diagnose and a propensity to undertreat
anaphylaxis are well recognized in the human emer-
gency department.
5,7,10,16,18,44
There is consistent failure
to appreciate the variable presentations of anaphylaxis
and disagreement among physicians in what is severe
enough to be considered anaphylaxis rather than an al-
lergic reaction.
8
The authors suspect a similar quandary
exists with veterinarians treating the canine hypersen-
sitivity patient. Consequently, appropriate treatment is
often not instituted. Early and accurate diagnosis of
canine anaphylaxis is supported by utilization of the
biomarkers found to be associated with anaphylaxis in
this study: elevated ALTand an abnormal (thickened or
striated) gallbladder wall.
This study was limited by several factors. Blood
pressure should have been required in patients in both
groups at the start of the study. Hypotension could
have been present in some of the 10 dogs in the AR
group in which the blood pressure was not taken. The
study should have specically included the presence of
airway compromise as one of the inclusion criteria. Re-
spiratory signs were extrapolated from the medical re-
cord. Many owners with pets exhibiting only an acute
allergic reaction declined participation in the study,
making the AR group smaller than would have been
expected. This study is further limited by the small
number of visits meeting inclusion criteria (n 5101).
Attempting to extrapolate data from a small, nonstan-
dard patient population to a large scale has inherent
limitations.
Conclusion
Anaphylaxis in the human and veterinary emergency
room is difcult to diagnose and often undertreated.
Improved management of anaphylaxis rests on rst-
responder veterinarians making the correct diagnosis
despite a confusing presentation. In this study, elevation
of ALT and an abnormal gallbladder wall (increased
thickness or striation) were signicantly associated with
moderate to severe systemic hypersensitivity reactions
and were valuable biomarkers in supporting the diag-
nosis of canine anaphylaxis. Gallbladder wall abnormal-
ities were identiable immediately in some dogs before
the elevation of ALT. The ALT levels remained elevated
(424 h) with canine anaphylaxis making ALT useful
retrospectively in reviewing the patients diagnosis and
ongoing treatment. Emergency veterinarians were able
to identify these abnormal biomarkers quickly and con-
sistently, providing the veterinarian with results that
could be used in the emergent treatment of anaphylaxis.
Acknowledgements
The authors would like to thank Dr. Philip H. Kass,
Professor, Department of Population Health and Re-
production, UCD, College of Veterinary Medicine for
his assistance in statistical methodology, and Dr. Car-
olyn Briggs with the Department of Internal Medicine
at Animal Emergency Referral Center for her advice
and guidance.
Footnotes
a
Cardell Plus, CAS Medical Systems Inc, Branford, CT.
b
VetTest 8008, IDEXX, Portland, ME.
c
Just Vision Ultrasound, Toshiba, Tochigi-ken, Japan.
d
Logiq 5 Ultrasound, GE Medical Systems, Milwaukee, WI.
e
Logiq 7 Ultrasound, GE Medical Systems.
f
GraphPad Prism version 5.00 for Windows, GraphPad Software, San
Diego, CA.
References
1. Brown SG. Clinical features and severity grading of anaphylaxis.
J Allergy Clin Immunol 2004; 114(2):371376.
2. Clark S, Long AA, Gaeta TJ, et al. Multicenter study of emergency
department visits for insect sting allergies. J Allergy Clin Immunol
2005; 116(3):643649.
3. Cohen RD. Systemic Anaphylaxis, In: Bonagura JD, Kirk RW. eds.
Kirks Current Veterinary Therapy XII Small Animal Practice.
Philadelphia: WB Saunders Co; 1995, pp. 150152.
4. Waddell L. Systemic anaphylaxis, In: Ettinger SJ, Feldman EC. eds.
Textbook of Veterinary Internal Medicine, 6th ed. Philadelphia:
WB Saunders Co; 2005, pp. 458460.
5. Johnson RF, Peebles RS. Anaphylactic shock: pathophysiology,
recognition, and treatment. Semin Respir Crit Care Med 2004;
25(6):695703.
6. Boothe DM. Adverse reactions to therapeutic drugs in the CCU
patient, In: Wingeld WE, Raffe MR. eds. The Veterinary ICU
Book. Jackson Hole, WY: Teton NewMedia; 2002, pp. 10491056.
7. Rusznak C, Peebles RS. Anaphylaxis and anaphylactoid reactions:
a guide to prevention, recognition, and emergent treatment. Post-
graduate Med Online 2002; 111(5):12.
8. Sampson HA, Munoz-Furlong A, Bock SA, et al. Symposium on
the denition and management of anaphylaxis: summary report.
J Allergy Clin Immunol 2005; 115(3):584591.
9. Mealie CA, Multz AS, Wisgerhof MV, et al. Wasp stings. emed-
icine4Critical Care January 30, 2007. Available at: http://
www.eMedicine.com. Accessed October 30, 2007.
10. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mech-
anisms. J Allergy Clin Immunol 2002; 110:341348.
11. Ross J, Murtaugh J, Moore K. Shock II: clinical presentation and
treatment, In: Murtaugh RJ. ed. Quick Look Series in Veterinary
Medicine Critical Care. Jackson, WY: Teton NewMedia; 2002, pp.
6263.
12. Cowell AK, Cowell RL. Management of bee and other hymen-
optera stings, In: Bonagura JD, Kirk RW. eds. Kirks Current Vet-
erinary Therapy XII Small Animal Practice. Philadelphia: WB
Saunders Co; 1995, pp. 226228.
13. Sampson HA, Munoz-Furlong A, Campbell RL, et al. Second
symposium on the denition and management of anaphylaxis:
summary report Second National Institute of Allergy and Infec-
tious Disease/Food Allergy and Anaphylaxis Network sympo-
sium. J Allergy Clin Immunol 2006; 117(2):391397.
14. Brown AF, McKinnon D, Chu K. Emergency department anaphyl-
axis: a review of 142 patients in a single year. J Allergy Clin
Immunol 2001; 108(5):861866.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 543
Anaphylaxis biomarkers in canine hypersensitivity
15. Simmons JP, Wohl JS. Hypotension, In: Silverstein DC, Hopper K.
eds. Small Animal Critical Care Medicine. St Louis, MO: Saunders
Elsevier; 2009, pp. 2730.
16. Golden DBK. What is anaphylaxis? Curr Opin Allergy Clin
Immunol 2007; 7(4):331336.
17. Galli SJ. Pathogenesis and management of anaphylaxis: current
status and future challenges. J Allergy Clin Immunol 2005;
115(3):571574.
18. Beltrani VS. Urticaria, angioedema, and anaphylaxis: anaphylaxis,
In: Dale DC, Federman DD. eds. Immunology/Allergy XIII.
ACP Medicine Online. New York: WebMD Inc; 2003. pp. 911.
Available at: http://www.medscape.com. Accessed October 26,
2007.
19. Yong PFK, Birns J, Ibrahim MAA. Anaphylactic shock: the great
mimic. South Med J 2007; 100(3):295297.
20. Spaulding KA. Ultrasound corner gallbladder wall thickness. Vet
Rad Ultrasound 1993; 34(4):270272.
21. Teefey SA, Baron RL, Bigler SA. Sonography of the gallbladder:
signicance of striated (layered) thickening of the gallbladder
wall. Am J Roentgenol 1991; 156:945947.
22. Boysen SR, Rozanski EA, Tidwell AS, et al. Evaluation of a focused
assessment with sonography for trauma protocol to detect free
abdominal uid in dogs involved in motor vehicle accidents. J Am
Vet Med Assoc 2004; 225(8):11981204.
23. Nyland TG, Mattoon JS, Herrgesell EJ, et al. Liver, In: Nyland TG,
Mattoon JS. eds. Small Animal Diagnostic Ultrasound, 2nd ed.
Philadelphia: WB Saunders Co; 2002, pp. 93127.
24. Cowell AK, Cowell RL, Tyler RD, et al. Severe systemic reactions
to Hymenoptera stings in three dogs. J Am Vet Med Assoc 1991;
198(6):10141016.
25. Schaer M, Ginn PE, Hanel RA. A case of fatal anaphylaxis in a dog
associated with a dexamethasone suppression test. J Vet Emerg
Crit Care 2005; 15(3):213216.
26. Richardson PDI, Withrington PG. Responses of the simulta-
neously-perfused hepatic arterial and portal venous vascular beds
of the dog to histamine and 5-hydroxytryptamine. Br J Pharmac
1978; 64:581588.
27. Greenway CV, Oshiro G. Effects of histamine on hepatic volume
(outow block) in anaesthetized dogs. Br J Pharmac 1973; 47:282
290.
28. Lautt WW, Legare DJ. Effect of histamine, norepinephrine, and
nerves on vascular pressures in dog liver. Am J Physiol 1987;
252(4, Part 1):G472G478.
29. Kurihara H, Fukami H, Asami S, et al. Inuence of histamine in a
liver injury model induced by Propionibacterium acnes and lipo-
polysaccharide. Biol Pharm Bull 2003; 26(10):13931397.
30. Bain PJ. Liver, In: Latimer KS, Mahaffey EA, Prasse KW. eds.
Duncan & Prasses Veterinary Laboratory Medicine, 4th ed. Ames,
IA: Blackwell Publishing; 2003, pp. 193214.
31. Khan AN, Macdonald S, Ali M, et al. Portal hypertension. emed-
icine Specialties4Radiology4Gastrointestinal 18 April 2007.
Available at: http://www.eMedicine.com. Accessed October 30,
2007.
32. Konde LJ, Green PA, Pugh CR. Ultrasonography of the diges-
tive system, In: Tams TR. ed. Handbook of Small Animal
Gastroenterology, 2nd ed. St Louis, MO: Saunders; 2003, pp.
7486.
33. Boland GW, Slater G, Lu DS, et al. Prevalence and signicance of
gallbladder abnormalities seen on sonography in intensive care
unit patients. Am J Roentgenol 2000; 174:973977.
34. Van Breda Vriesman AC, Engelbrecht MR, Smithuis RH, et al.
Diffuse gallbladder wall thickening: differential diagnosis. Am J
Roentgenol 2007; 188:495501.
35. Fitzgerald KT, Flood AA. Hymenoptera stings. Clin Tech Small
Animal Practice 2006; 21(4):194204.
36. Campbell TW. Bites and stings, In: Wingeld WE, Raffe MR. eds.
The Veterinary ICU Book. Jackson Hole, WY: Teton NewMedia;
2002, pp. 10171019.
37. Minors SL. Syncope, In: Ettinger SJ, Feldman EC. eds. Textbook of
Veterinary Internal Medicine, 6th ed. Philadelphia: WB Saunders
Co; 2005, pp. 2427.
38. Schulman RL. Weakness, In: Ettinger SJ, Feldman EC. eds. Text-
book of Veterinary Internal Medicine, 6th ed. Philadelphia: WB
Saunders Co; 2005, pp. 2830.
39. Waddell LS. Hypotension, In: Ettinger SJ, Feldman EC. eds. Text-
book of Veterinary Internal Medicine, 6th ed. Philadelphia: WB
Saunders Co; 2005, pp. 480483.
40. Todd J, Powell LL. Hypothermia, In: Silverstein DC, Hopper K.
eds. Small Animal Critical Care Medicine. St Louis, MO: Saunders
Elsevier; 2009, pp. 720722.
41. Waddell LS, Drobatz KJ. Massive envenomation by Vespula spp. in
two dogs. J Vet Emerg Crit Care 1999; 9(2):6771.
42. Bautista E, Simons FER, Simons KJ, et al. Epinephrine fails to
hasten hemodynamic recovery in fully developed canine anaphy-
lactic shock. Int Arch Allergy Immunol 2002; 128(2):151164.
43. Mink SN, Simons FER, Simons KJ, et al. Constant infusion of epi-
nephrine, but not bolus treatment, improves haemodynamic re-
covery in anaphylactic shock in dogs. Clin Exp Allergy 2004;
34(11):17761783.
44. Clark S, Camargo CA. Emergency treatment and prevention of
insect-sting anaphylaxis. Curr Opin Allergy Clin Immunol 2006;
6(4):279283.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00474.x 544
J.E. Quantz et al.