MEDICINE 2
Risk Factors
F.24B ANAPHYLAXIS, HYPERSENSITIVITY AND ADVERSE DRUG
REACTIONS (Part 2)
Dr. Tolentino | May 7, 2019
I. OUTLINE
I. OUTLINE
II. Definition
III. Predisposing factors and etiology
IV. Manifestations
V. Diagnosis
VI. Treatment and Prevention
II. Defintion
• Is a serious, severe allergic reaction that is rapid in onset affecting
many body systems and may cause death. As I said it can occur
seconds to minutes upon contract to your allergen.
• The life-threatening anaphylactic response to a sensitized (prior
exposure to the allergen) human appears within minutes after
administration of specific antigen and is often manifested by
respiratory distress often followed by vascular collapse or by
shock without antecedent respiratory difficulty
Etiology
• Anaphylaxis can occur in response to almost any foreign substance
Common triggers include:
MC trigger in children and young adults Food
MC trigger in older adults Medications, insect bites/sting
• Venom from insect bites or stings
o Venom from stinging or biting insects such as Hymenoptera
(ants, bees, and wasps) or Triatominae (kissing bugs) may
cause anaphylaxis in susceptible people
• Food
o Many food can trigger anaphylaxis; this may occur upon the first
known ingestion, kung food usually pwedeng first time
o Common triggering food vary around the world
o In western cultures, ingestion of or exposure to peanuts,
wheat, nuts, certain types of seafood like shellfish, milk
and eggs are the most frequent causes
o Severe causes are usually caused by ingesting the allergen, but
some people experience a severe reaction upon contact
o Children can outgrow their allergies
o By age 16, 80% of children with anaphylaxis to milk or eggs and
20% who experience isolated anaphylaxis to peanuts can
tolerate them
• Medication
o Any medication may potentially trigger anaphylaxis
o The most common are B-Lactam antibiotics (such as
penicillin) followed by aspirin and NSAIDs
o Other antibiotics are implicated less frequently
o Other relatively common causes include chemotherapy,
vaccines, protamine and herbal preparation
o Some medication (vancomycin, morphine, xray contrast among
others) cause anaphylaxis by directly triggering mast cell
degranulation
Others:
• Physical factors such as exercise (known as exercise-induced
anaphylaxis) or temperature (either hot or cold) may also act as
triggers through their direct effects on mast cells.
Less common causes include:
• Physicial factors
• Biologic agents such as semen, latex, hormonal changes
• Food additives such as (tartrazine)monosodium glutamate and food
colors, and
• Topical medications- most common are antibiotics (beta lactams,
penicillin followed by aspirin or NSAIDS)
• Vaccines, Chemotherapy, herbal preparations
• Some medications like vancomycin, morphine
• Even contrast media when you do contrast studies like CT scan, MRI
Transcribers: DE VERA E, BONIFACIO, GERVERO
• People with atopic diseases such as asthma, eczema, or
allergic rhinitis are at high risk of anaphylaxis from food,
latex (rubbers, gloves) and radiocontrast agents but not from
injectable medications or stings (stinging insects).
• One study in children found that 60% had a history of previous
atopic diseases, and of children who die from anaphylaxis,
more than 90% have asthma
• Those with mastocytosis or of a higher socioeconomic status
are at increased risk, mga mayayaman at high risk kasi di sila
naexpose sa mga allergens or yung mga elderly ng mayayaman mas
madaming sakit DM, hypertension, they have more drug intake kasi
may pambili sila.
• The longer the time since the last exposure to the agent in question,
the lower the risk
Pathophysiology
• It is due to the release of inflammatory mediators and
cytokines from mast cells and basophils, typically due to an
immunologic reaction but sometimes non-immunologic mechanism
1. Immunologic
• Immunglobulin E, (IgE) binds to the antigen (the foreign material
that provokes the allergic reaction)
• Antigen-bound IgE then activates FceRI receptors on mast cells
and basophils
• What’s the difference between receptor I and II? Bakit FceRI?
Because receptor I have higher affinity to mast cells than
receptor II.
• This leads to the release of inflammatory mediators such as histamine
2. Non-immunologic
• Involves substances that directly cause the degranulation of mast
cells and basophils
• These include agents such as contrast medium, opioids, temperature
(hot or cold), and vibration
III. Manifestations
• The hallmark of anaphylactic reaction is the onset of some
manifestation within seconds or minutes after introduction
of the antigen, generally by injection or ingestion that is why
kaagad-agad kapag nakita mo na magbibigay ka na ng epinephrine
• With an average onset of 5-30 minutes if exposure is
intravenous and 2 hours if from eating food. I know one
medical student who went with us in kalinga medical mission, kumain
siya ng itlog ng ants, 30 minutes after that nagkarashes, binigyan
naming ng antihistamine. 1 hour after that di na makahinga, ayun
tinakbo na sa hospital.
• The most common areas affected include (with usually 2 or more
being involved)
o Skin (80-90%)
o Respiratory (70%)
o GI (30-45%)
o Heart and vasculature (10-45%)
o CNS (10-15%)
1. Skin
• Symptoms typically include generalized hives, itchiness,
flushing, or swelling (angioedema) of the afflicted tissues
• Those with angioedema may describe a burning sensation of the skin
rather than itchiness. Mainit ito kaya yung iba naglalagay ng ice para
matanggal yung kati.
• Swelling of the tongue of throat occurs in up to about 20% of the
cases. This is very important because when you have involvement of
your larynx your patient will go into dyspnea
• Other features may include a runny nose and swelling of the
conjuctiva
• The skin may also be blue tinged because of lack of oxygen
2. Respiratory
• Shortness of breath, wheezes, or stridor
• So you have bronchospasm
• The wheezing is typically caused by spasms of the bronchial muscles
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• Stridor is related to upper airway obstruction secondary to swelling
• Hoarseness, pain with swallowing, or a cough may occur
3. Cardiovascular
• While a fast heart rate caused by low blood pressure is more
common, a Bezold-Jarisch reflex has been described in 10% of
people, where a slow heart rate is associated with low blood
pressure. Dapat normally pag bumaba BP mo increase dapat heart
rate.
• A drop in blood pressure or shock (either distributive or cardiogenic)
may cause the feeling of lightheadedness or loss of consciousness
• Rarely, very low blood pressure may be the only sign of anaphylaxis
• Coronary artery spasm may occur with subsequent myocardial
infarction, dysrhythmia, or cardiac arrest
• Those with underlying coronary disease are at greate risk of cardiac
effects from anaphylaxis
• The coronary spasm is related to the presence of histamine-releasing
cells in the heart
4. Others
• GI symptoms may include crampy abdominal pain, diarrhea and
vomiting
• There may be confusion, a loss of bladder control or pelvic pain
similar to that of uterine cramps
• Dilation of blood vessels around the brain may cause headaches
• A feeling of anxiety or of “impending doom” has also been
described
IV. Diagnosis
• Immunoassays, skin testing, serum tryptase
• Anaphylaxis is diagnosed on the basis of a person’s signs and
symptoms. History and PE is very important
• When any one of the following three occurs within minutes or
hours of exposure to an allergen there is a high likelihood of
anaphylaxis
Clinical Criteria:
1. Involvement of the skin or mucosal tissue plus either
respiratory difficulty or a low blood pressure causing
symptoms
• Skin involvement may include: hives, itchiness or a
swollen tongue among others.
• Respiratory difficulties may include: shortness of breath,
stridor, or low oxygen levels among others
• Low blood pressure is defined as a greater than 30%
decrease from a person’s usual blood pressure. In adults, a
systolic blood pressure of less than 90mmHg is often
used
2. 2 or more of the following symptoms: involvement of the
skin/mucosa, respiratory difficulty, GI symptoms
3. Low blood pressure after exposure to a known allergen
• During an attack blood tests for tryptase or histamine (released
from mast cells) might be useful in dignosis anaphylaxis due to insect
stings or medications
o However, these tests are of limited use if the cause is food or
if the person has a normal blood pressure, and they are not
specific for the diagnosis
Classifications
• Anaphylactic shock is associated with systemic vasodilation that
causes low blood pressure, which is by definition 30% lower than the
person’s baseline or below standard values
• Biphasic anaphylaxis is the recurrence of symptoms within 1-72
hours with no further exposure to the allergen
o Kapag naexpose ka ngayon tapos naganaphylaxis ka you have
to watchout kasi the patient may go into anaphylactic shock
with no further exposure
o Reports of incidence vary, with some studies claiming as many
as 20% of cases
o The recurrence typically occurs within 8 hours
o It is managed in the same manner as anaphylaxis
Transcribers: DE VERA E, BONIFACIO, GERVERO
• Pseudoanaphylaxis or anaphylactoid reactions are a type of
anaphylaxis that does not involve an allergic reaction, but is due to
direct mast cell degranulation
• Non-immune anaphylaxis is the current term used by the World
Allergy Organization with some recommending that the old
terminology no longer used
Skin Allergy Testing
• Is done 1 month after anaphylaxis if trigger is unknown
• Or skin test is done on individuals who are at risk because of the
atopy
• There should be no antihistamine 1 week before skin testing
V. Treatment and Prevention
1. Avoidance of triggers
2. Desensitization
• In ADRs, only if there is no substitute
• Aka: immunotherapy – in allergic rhinitis, bronchial asthma, insect
sting hypersensitivity
Management
• Anaphylaxis is a medical emergency that may require resuscitation
measures such as:
o Airway management
o Supplemental oxygen
o Large volumes of IV fluids
o Close monitoring
• Administration of epinephrine (0.5 ml IM anterior thigh repeat
for 5-15 minutes for max of 3 doses) is the treatment of choice,
with the use of antihistamines and steroids (i.e. Dexamethasone)
often used as adjuncts
Epinephrine
• Adrenaline, is the primary treatment for anaphylaxis with no
absolute contraindications to its use
• It is recommended that an epinephrine solution be given
intramuscularly into the mid anterolateral thigh as soon as the
diagnosis is suspected. The IM route is preferred over
subcutaneous administration because the latter may have
delayed absorption
• The injection may be repeated every 5-15 minutes if there is no
insufficient response
• A second dose is needed in 16-35% of episodes with more than 2
doses rarely required
• A period of in-hospital observation for between 2-24 hours is
recommended for people once they have returned to normal due to
concerns of biphasic anaphylaxis kaya lahat yan dapat iobserve mo
sa hospital
Preparedness
• People prone to anaphylaxis are advised to have an allergy action
plan
• Parents are advised to inform schools of their children’s allergies and
what to do in case of an anaphylactic emergency
• The action plan usually includes use of epinephrine
autoinjectors, the recommendation to wear a medical alert
bracelet, and counseling on avoidance of triggers
• Immunotherapy is available for certain triggers to prevent future
episodes of anaphylaxis
• A multi-year course of subcutaneous desensitization has been
found effective against stinging insects, while oral desensitization is
effective for many types of food
• Avoid triggers kaya if food is your trigger do not eat, if inhalant is
your trigger do not inhale
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VI. Checkpoint MEDICINE NOTE TAKERS THROUGH THE YEARS

1. Most common cause of allergy in children and young adults.

a. Food
b. Insect bites
c. Medication
d. Temperature
2. What is the most common area involved in anaphylactic
reaction?
a. Respiratory
b. GI
c. Skin
d. CNS
3. A type of anpahylaxis that does not involve an allergic reaction,
but is due to direct mast cell degranulation How do we even start?
a. Biphasic anaphylaxis Margins… Column width… Header and Foot adjustments… Font sizes…
b. Pseudoanaphylaxis From 10/9/8 pages to 6 pages, the “Maximum of 6 pages rule” was born
c. Anaphylactoid reaction But if we really can’t limit it to 6, 8 pages is ok.
d. B and C We have summary tables naman, yey!
4. The first line treatment for anaphylaxis?
a. Isotonic saline solution
b. Antihistamine A roster of doctors we need to listen to
c. Epinephrine Sit in the classroom a couple of hours coz we have to
d. Glucocorticoids Loads of concepts we must remember
5. Prevention of Anaphylaxis includes: Good thing we have each other
a. Desensitization
b. Avoidance of trigger Bulky coverage for all quizzes
c. Immunotherapy Not enough time to finish the transes
d. All of the above POMRs, PBLs and Procedures,
ACDCD Four OSCEs we need to endure

Patient encounters we have conquered

Incomplete history and PE, consultants were triggered
Most of the time, it's come what may,
Fret not, for what we've learned is always here to stay

Indeed, we have come a long way

We are now who we are today (JI’s)
Now we have reached the end
Wishing you success and luck, our friend

God bless you on your clerkship!

Good luck on your future endeavors!
See you around, Future Doctors!

Transcribers: DE VERA E, BONIFACIO, GERVERO Page 3 of 3