Risk factors By Mayo Clinic staff There aren't many known risk factors for anaphylaxis, but some

things that may increase your risk include:

A personal history of anaphylaxis. If you've experienced anaphylaxis once, your risk of having this serious reaction increases. Future reactions may be more severe than the first reaction. Allergies or asthma. People who have either condition are at increased risk of having anaphylaxis. A family history. If you have family members who've experienced exercise-induced anaphylaxis, your risk of developing this type of anaphylaxis is higher than it is for someone without a family history.

Anaphylaxis Differential Diagnoses

Overview Presentation DDx Workup Treatment Medication

Updated: Dec 9, 2013

References

Diagnostic Considerations The clinical diagnosis of anaphylaxis is based on probability and pattern recognition. Anaphylaxis is considered likely to be present if any 1 of the 3 following clinical criteria is satisfied within minutes to hours:

Acute symptoms involving skin, mucosal surface, or both, as well as at least one of the following: respiratory compromise, hypotension, or end-organ dysfunction

Two or more of the following occur rapidly after exposure to a likely allergen: hypotension, respiratory compromise, persistent gastrointestinal symptoms, or involvement of skin or mucosal surface Hypotension develops after exposure to an allergen known to cause symptoms for that patient: age-specific low blood pressure or decline of systolic blood pressure of more than 30% compared to baseline

However, anaphylaxis occurs as part of a clinical continuum that can begin with relatively mild features and rapidly progress to life-endangering respiratory or cardiovascular manifestations. Delaying the diagnosis until multiorgan manifestations of anaphylaxis are present is risky because the severity of a reaction is difficult or impossible to predict at the time of symptom onset. Other problems to be considered in diagnosing potential anaphylaxis include the following:

Vasodepressor (vasovagal) reaction (probably the most common masquerader) Globus hystericus Hereditary angioedema Other forms of shock (ie, hypovolemic, cardiogenic, septic) Flushing syndrome, including red man syndrome (vancomycin), pancreatic polypeptide tumors, postmenopausal patient, ethanol-induced, autonomic epilepsy Monosodium glutamate poisoning Scombroid fish poisoning Capillary leak syndrome Pulmonary embolism Myocardial dysfunction Foreign body aspiration (young children, especially) Poisoning, acute Neurologic (stroke, seizure)

Nonorganic disease, including panic attack, hyperventilation, vocal cord dysfunction syndrome, somatoform anaphylaxis Differential Diagnoses

Angioedema Malignant Carcinoid Syndrome Mastocytosis, Systemic

Pheochromocytoma Thyroid, Medullary Carcinoma

http://emedicine.medscape.com/article/135065-differential http://emedicine.medscape.com/article/135065-overview Practice Essentials Anaphylaxis is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils.[1, 2] The classic form involves prior sensitization to an allergen with later reexposure, producing symptoms via an immunologic mechanism. Essential update: Antibiotics are the most common cause of perioperative anaphylaxis A review of 30 cases of anaphylaxis that occurred between 2002 and 2013 at the Cleveland Clinic, presented at the 2013 Annual Scientific Meeting of the American College of Allergy, Asthma & Immunology (ACAAI), determined that antibiotics are the most common identifiable cause of perioperative anaphylaxis.[3] Skin and in vitro testing identified the cause of anaphylaxis in 57% of cases; the other 43% had no identifiable cause and were thought likely to reflect non-IgE-mediated reactions to neuromuscular blocking agents.[3] Of the cases in which the cause was identifiable, antibiotics were determined to be the cause in 58%, neuromuscular blocking agents in 23%, and latex in 17%. The antibiotics involved included cefazolin (60%), penicillin (20%), cefuroxime (10%), and metronidazole (10%).[3] Signs and symptoms Anaphylaxis most commonly affects the cutaneous, respiratory, cardiovascular, and gastrointestinal systems. The skin or mucous membranes are almost always involved. A majority of adult patients have some combination of urticaria, erythema, pruritus, or angioedema. However, for poorly understood reasons, children may present more commonly with respiratory symptoms followed by cutaneous symptoms.[4] Initially, patients often describe a sense of impending doom, accompanied by pruritus and flushing. Other symptoms can evolve rapidly, such as the following:

Dermatologic/ocular: Flushing, urticaria, angioedema, cutaneous and/or conjunctival injection or pruritus, warmth, and swelling Respiratory: Nasal congestion, coryza, rhinorrhea, sneezing, throat tightness, wheezing, shortness of breath, cough, hoarseness, dyspnea Cardiovascular: Dizziness, weakness, syncope, chest pain, palpitations Gastrointestinal: Dysphagia, nausea, vomiting, diarrhea, bloating, cramps Neurologic: Headache, dizziness, blurred vision, and seizure (very rare and often associated with hypotension)

Other: Metallic taste, feeling of impending doom

See Clinical Presentation for more detail. Diagnosis Anaphylaxis is primarily a clinical diagnosis. The first priority in the physical examination should be to assess the patients airway, breathing, circulation, and adequacy of mentation (eg, alertness, orientation, coherence of thought). Examination may reveal the following findings:

General appearance and vital signs: Vary according to the severity of the anaphylactic episode and the organ system(s) affected; patients are commonly restless and anxious Respiratory findings: Severe angioedema of the tongue and lips; tachypnea; stridor or severe air hunger; loss of voice, hoarseness, and/or dysphonia; wheezing Cardiovascular: Tachycardia, hypotension; cardiovascular collapse and shock can occur immediately, without any other findings Neurologic: Altered mentation; depressed level of consciousness or may be agitated and/or combative Dermatologic: Classic skin manifestation is urticaria (ie, hives) anywhere on the body; angioedema (soft-tissue swelling); generalized (whole-body) erythema (or flushing) without urticaria or angioedema Gastrointestinal: Vomiting, diarrhea, and abdominal distention

Testing Laboratory studies are not usually required and are rarely helpful. However, if the diagnosis is unclear, especially with a recurrent syndrome, or if other diseases need to be excluded, the following laboratory studies may be ordered in specific situations:

Plasma/urinary histamine and serum tryptase assessment: May help confirm diagnosis of anaphylaxis[2] Urinary 24-hour 5-hydroxyindoleacetic acid levels: If carcinoid syndrome is a consideration

Skin testing, in vitro immunoglobulin E (IgE) tests, or both may be used to determine the stimulus causing the anaphylactic reaction. Such studies may include the following:

Testing for food allergy(ies) Testing for medication allergy(ies) Testing for causes of IgE-independent reactions

See Workup for more detail.

Management Anaphylaxis is a medical emergency that requires immediate recognition and intervention. Patient management and disposition are dependent on the severity of the initial reaction and the treatment response. Measures beyond basic life support are not necessary for patients with purely local reactions. Patients with refractory or very severe anaphylaxis (with cardiovascular and/or severe respiratory symptoms) should be admitted or treated and observed for a longer period in the emergency department or an observation area. Nonpharmacotherapy Supportive care for patients with suspected anaphylaxis includes the following:

Airway management (eg, ventilator support with bag/valve/mask, endotracheal intubation) High-flow oxygen Cardiac monitoring and/or pulse oximetry Intravenous access (large bore) Fluid resuscitation with isotonic crystalloid solution Supine position (or position of comfort if dyspneic or vomiting) with legs elevated

Pharmacotherapy The primary drug treatments for acute anaphylactic reactions are epinephrine and H1 antihistamines. Medications used in patients with anaphylaxis include the following:

Adrenergic agonists (eg, epinephrine) Antihistamines (eg, diphenhydramine, hydroxyzine) H2 receptor antagonists (eg, cimetidine, ranitidine, famotidine) Bronchodilators (eg, albuterol) Corticosteroids (eg, methylprednisolone, prednisone) Positive inotropic agents (eg, glucagon) Vasopressors (eg, dopamine)

Surgical option In extreme circumstances, cricothyrotomy or catheter jet ventilation may be lifesaving when orotracheal intubation or bag/valve/mask ventilation is not effective. Cricothyrotomy is easier to perform than emergency tracheostomy.