AAAAI 2014 San Diego WAF Symposium “Anaphylaxis: From Mechanisms to Novel Therapies” “Causes of Anaphylaxis” Motohiro Ebisawa, MD, Ph D, FAAAAI Sagamihara National Hospital Clinical Research Center for Allergy and Rheumatology Department of Allergy
WAO POSITION PAPER WAO Guidelines for the Assessment & Management of Anaphylaxis WAO Journal 2011; 4:13–37)
WAO POSITION PAPER WAO Guidelines for the Assessment & Management of Anaphylaxis WAO Journal 2011; 4:13–37)
Overview of Anaphylactic Triggers 35 35 30 25 20 20 20 20 % of Cases 15 10 5 3 5 0 Food Drug/Bio Insect Idiopathic Exercise Allergen Sting Vaccines Golden. Anaphylaxis , 2004 、 AAAAI education slide
Triggers of Anaphylaxis: Food • Milk • Eggs • Seafood • Peanuts • Tree nuts • Wheat • Other Modified from AAAAI education slide
Case1: Food-induced anaphylaxis (A case of wheat OFC) 4 years old boy developed skin flush with wheezing and dyspnea.
Causes of food-induced anaphylaxis among children Caused by Cases Publication food-induced anaphylaxis Study Country Ref. year (n) 1st 2nd 3rd J Allergy Clin USA 2008 Peanuts Cow’s milk Nuts 95 Järvinen KM et al. Immunol. J Allergy Clin USA 2010 Peanuts Cow’s milk Nuts 846 Rudders SA et al. Immunol. Pediatr Emerg USA 2010 Peanuts shellfish Cow’s milk 124 Russell S et al. Care. Australia 2006 Dairy Egg Peanuts 57 Arch Dis Child. Braganza SC et al. Australia 2008 Peanuts cashew nut Cow milk 104 Allergy de Silva IL et al. Crustacean Singapore 1999 Bird's nest Egg and milk 124 Allergy D. L. M. Goh et al. seafood Asian Pac J Thailand 2008 Prawn Allergy Piromrat K et al. Immunol. Japan* 2004 Hen's egg Cow’s milk Wheat 408 Arerugi Imai T *: infant only
Causes of food-induced anaphylaxis among adults Caused by Cases Publication food-induced anaphylaxis Study Country Ref. year (n) 1st 2nd 3rd J Allergy Clin USA 2009 Cow’s milk Nuts Shellfish 104 Greenhawt MJ et al. Immunol. Int Arch Allergy Italy 2009 Peach Shrimp Nuts 58 Asero R et al. Immunol. Ann Fish or milk or fruit- Moneret-Vautrin DA France 1995 Hen’s egg 794 Gastroenterol et al. crustaceans latex group Hepatol Fish and Mango or J Allergy Clin Australia 2001 Nuts 22 Brown AF et al. Immunol. Seafood Lemon drink Japan 2004 Fish Buckwheat Meat 130 Arerugi Imai T
Causes of food-induced anaphylaxis from childhood to adulthood Caused by Cases Publication food-induced anaphylaxis Study Country Age Ref. year (n) 1st 2nd 3rd J Allergy Clin USA 2008 2-66y Seafood nuts 23 Ross MP et al. Immunol. Ann Allergy Korea 2008 5–76y Wheat flour Buckwheat Seafood 29 Asthma Min-Suk Yang et al. Immunol. Pediatr Imamura T et al. Japan 2008 0-93y Milk Eggs Wheat 319 Allergy Immunol Ann Allergy Italy 2001 ? Seafood 113 Asthma Cianferoni A et al. Immunol.
Worldwide cases of fatal food-induced anaphylaxis UK 1999-2006 48 cases Peanut 9 Nuts 9 Milk 6 Fish 1 Shellfish 1 Snail 1 Sesame 1 Egg 1 USA Tomato 1 Japan 1994-1999 (uncertain 18) 1999-2004 32 cases* JACI 2007,119:1018-9 4 cases Peanut 20 Shrimp 1 Tree nuts 10 Buckwheat1 Milk 1 Fish 1 Fish 1 Chocolate 1 *Including a case of antigen suspected USA Nihon Kyukyu to cause Igakukai 2001-2006 JACI 2001,107:191- Zasshi2005,16 ： 564-6 31 cases 3 Australia Peanut 17 1997-2005 Tree nuts 8 7 cases Milk 4 Peanut 3 Shrimp 1 Fish 1 JACI (no information 2007,119:1016-8 1) (undetermined 2) JACI 2009,123:434- 42
Anaphylaxis from ingestion of mites: Pancake anaphylaxis J Allergy Clin Immunol 2013;131:31-5 J Allergy Clin Immunol 2013;131:31-5
Gelatin sensitization Positive test Percent Clinical group No. tested results positive Red meat 30 40 75 Gelatin colloid 2 2 100 Venom allergy 1 * 242 * 0.4 Idiopathic anaphylaxis 4 172 2.3 Drug allergy 4 368 1.1 Nonmeat food allergy 0 222 0 Miscellaneous 0 290 0 Totals 40 * 1335 2.9 One thousand three hundred twenty-five patients underwent IDTs with gelatin colloid between 1997 and 2011. *One patient returned with red meat–induced anaphylaxis 5 years after investigation for insect venom allergy and was reclassified into the red meat allergy group. J Allergy Clin Immunol 2012;129:1334-42.
Clinical features of subjects presenting with anaphylaxis to CMF with scGOS Patient Atopy Age at No. of Milk eliciting Volume eliciting Sex Time (min) Reaction no. phenotype reaction episodes reaction reaction (mL) 1 F AR, AS, 5 y, 6 mo 3 Gain IQ (1) 100 10 RS, Resp AD, AC Step3 (2) 120* (CMF2) (3) 40 2 F AR, AD 6 y, 6 mo 1 Mamil 250 30 AE, RS Gold Resp Step4 (CMF1) 3 M AR 38 y 1 Mamil 180 10 AE, RS Gold Resp Step3 (CMF1) 4 F AR 6 y 1 Mamil 250 15 AE, GU, GI Gold RS, Resp Step4 (CMF1) 5 M AD, AR, 8 y 1 Gain IQ 180 5 AE, GU, RS AS Step3 Resp (CMF2) CMF1 and CMF2 denote the respective CMF brands, as listed above. These abbreviations are also referred to as such in the main text. AC, Allergic conjunctivitis; AD, atopic dermatitis; AE, angioedema; AH, antihistamines; AR, allergic rhinitis; AS, asthma; F, female; GI, vomiting; GU, generalized urticaria; LU, localized urticaria; M, male; Resp, wheeze, dry persistent cough, or dyspnea; RS, rhinorrhea and bouts of sneezing. *The patient underwent an oral provocation challenge with CMF2 in the hospital and had similar respiratory-related symptoms. J Allergy Clin Immunol 2012;130:1361-7.
Triggers of Anaphylaxis: Insect Stings and Bites • Bees • Vespids • Fire ants and other ants • Scorpions • Deer & horse flies • Mosquitoes Modified from AAAAI education slide
Iatrogenic Triggers of Anaphylaxis • Diagnostic agents – Contrast media • Medications – Antibiotics – Aspirin and other NSAIDs • Biological response modifiers – Anti-venoms – Monoclonal antibodies • Blood transfusions • Allergen immunotherapy Joint Task Force on Practice Parameters: AAAAI, ACAAI, and JCAAI. J Allergy Clin Immunol 2005;115:S483-523
Triggers of Anaphylaxis: Anaphylaxis during Anesthesia Causal agent Reactions (%) No. of patients neuromuscular blocking agents NMBAs 58.08 1067 Succinylcholine 356 Rocuronium 313 Atracurium 206 Atracurium 109 Latex 19.65 361 Antibiotics 12.85 236 Penicillin 115 Cephalosporin 88 Others 9.42 187 Total 1851 Agents involved in IgE-mediated reactions during anesthesia (1816 patients, 1851 substances) between Jan 1, 1997, and Dec 31, 2004 J Allergy Clin Immunol 2011;128:366-73
Triggers of Anaphylaxis: Latex • Some groups are at increased risk – Healthcare workers – Children with spina bifida – Patients with multiple surgeries • Increased incidence during the 1990’s was due largely to implementation of universal precautions. • Incidence has decreased since non-powder gloves have become available Kelly KJ et al, J Allergy Clin Immunol 1994;93:813-6
Triggers of Anaphylaxis: Physical • Exercise-induced • Food or medication are often co-triggers • Wheat , celery, peanut and multiple others • May be more common than previously noted. • Cold-induced • Heat-induced Burgess B. EMedHome.com
Summary of world wide multiple food-dependent exercise-induced anaphylaxis case reports Caused by FEIAn Publication Cases Study Country Age Ref. year (n) 1st 2nd 3rd Shellfish or Arerugi Kano H et al. Japan 2000 9-43y Wheat Shrimp 18 fish Arerugi Harada S et al. Japan 2000 >20 Wheat Shrimp 167 Arerugi Harada S et al. Japan 2000 <20 Shrimp Wheat 167 Grapes Shrimps J Allergy Clin Aihara Y et al. Japan 2001 12-15y Wheat Vegetables 13 Immunol and crab buckwheat Ann Allergy Apple or Asthma Yang MS et al. Korea 2008 5-76y Wheat 18 shrimp Immunol Ann Acad Med Teo SL et al. Singapore 2009 9-20y Shellfish 5 Singapore Corn, barley, Ann Mathelier-Fusade shrimp, apple, Dermatol France 2002 ? Wheat 7 P et al. paprika, Venereol mustard Int Arch Allergy Romano A et al. Italy 2001 ? Tomatoes Wheat Peanuts 54 Immunol 279 J Allergy Clin Shadick NA et al. USA 1999 13-77y Shellfish Alcohol Tomatoes (EIA Immunol patients)
Case 2: A case of food-dependent exercise-induced anaphylaxis Fourteen years old junior high school student developed anaphylaxis after eating seafood in his lunch and playing football with his friends
Age distribution of Food-dependent exercise-induced anaphylaxis (n) reported from 1979 to 2004 40 30 20 Ag e 10 n=84 0 0- 10- 20- 30- 40- 50- 60- 70- (by Aihara Y arerugi 2007)
Causative foods of FEIAn reported from 1979 to 2004 Food Case (n) (%) Wheat 29 (38.2) Vegetable 24 (31.6) Nut 16 (21.1) Fruit 7 (9.2) Plant oil 4 (5.3) Shellfish 3 (3.9) Others 6 (7.9) Total 76 (by Aihara Y arerugi 2007)
WAO POSITION PAPER WAO Guidelines for the Assessment & Management of Anaphylaxis
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