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Abstracts from the Food Allergy and Anaphylaxis Meeting 2016

View Article: PubMed Central

ABSTRACT

Correspondence: Guillaume Pouessel - guillaume.pouessel@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP01

Introduction: Incidence of anaphylaxis is increasing. Data regarding anaphylaxis mortality are limited, but conflicting. Our objective was to document anaphylaxis mortality rate (deaths per million population), time trends and specificities according to triggers (iatrogenic, venom, food, unknown), age groups, sex and geographical regions (North and South) in France, between 1979 and 2011.

Methods: Data were obtained (1) from database of the National Mortality Center (CEPIDC) to collect cases in which anaphylaxis was included as a cause of death, sex, age, and geographic region of death, (2) from the database of the National Institute for Economical and Statistical studies (INSEE) to define the referent populations. We used a multivariable log-linear Poisson regression model to assess the impact of time period, age, sex and geographic region on anaphylaxis deaths.

Results: During the period study, 1603 deaths were collected: 1564 in adults and 39 in children (age <18 year). The overall prevalence of anaphylaxis fatalities was 0.84 per million population (95% IC 0.80–0.88), ranging from 0.08 per million (95% IC 0.05–0.10) in pediatric population to 1.12 per million (95% CI 1.06 to 1.17) in adult population. Annual percentage change for case fatality rate was −2.0% (95% CI −2.5 to −1.5; p < 10−4) indicating a decrease in case fatality rate during the study period. Anaphylaxis fatality rate was higher in men (1.08 per million [95% IC 1.00 1.16] than women (0.86 per million [95% IC 0.80–0.92]) (p < 10−4). Triggers of anaphylaxis fatalities were iatrogenic (63%), mostly drugs, venom (14%) and food (0.6%). Unspecified anaphylaxis was frequent (23%). The highest rate was in persons aged >70 years (3.50 per million population per year [95% IC 3.25–3.76]) and the lowest in the pediatric population (p < 10−4). Only venom-induced mortality rate was higher in South of France (0.16 per million [95% IC 0.13–0.19]) compared with the North (0.11 per million [95% IC 0.09–0.13]) (p = 0.004). Only 8 food-induced fatalities were recorded (age <35 years in 7 cases).

Conclusion: Overall anaphylaxis mortality rate is decreasing over the three last decades in France. We confirm that iatrogenic causes are the most frequent causes. Older age and male sex are risk factors of fatal anaphylaxis of any cause except for food-induced anaphylaxis.

Correspondence: Linus Grabenhenrich - linus.grabenhenrich@charite.de

Clinical and Translational Allergy 2017, 7(Suppl 1):OP02

Introduction: After a severe anaphylactic reaction, a diagnostic workup is recommended to confirm or rule out the elicitor(s) in question. The type of diagnostic chosen is usually based on the elicitor and severity of the reaction and might follow local experiences. We aimed to describe elicitor-specific diagnostic habits in the workup of severe anaphylaxis, comparing European countries.

Methods: The Network for Online Registration of Anaphylaxis (NORA) collected details about elicitors, symptoms and severity, treatment and the diagnostic workup of patients who experienced at least one episode of severe anaphylaxis, as documented within medical records of participating tertiary referral centres.

Results: Between June 2011 and April 2016, the registry collected data for 6465 cases of severe anaphylaxis, 74% of which reported to know the elicitor, with a remaining 20% having only a suspicion and 6% cases of idiopathic anaphylaxis. The allergen was known and confirmed by a diagnostic test in 4410 (92% of known elicitors). Of these, 68% had a reaction to this allergen for the first time, and 32% reported at least one earlier reaction to the same allergen. In first-time reactors (n = 3001) 7% reported that the allergen was confirming by a diagnostic test already before this reaction, for food 14%, insects 3%, drugs 2%, and 80% for SIT-induced anaphylaxis. Of cases with recurrent anaphylaxis (n = 1409), 30% had a test confirming the allergen before the reported reaction, for food 44%, insects 16%, drugs 18%, and 91% for SIT-induced anaphylaxis. Of all diagnostically confirmed cases of food-induced anaphylaxis (n = 1555), 78% were assessed by a skin test (SPT, positive in 93%), 90% by specific IgE (sIgE, 94% positive), 27% tryptase (7% positive), and 13% underwent an oral food challenge (positive in 88%). Patients with anaphylaxis caused by drugs had the following tests (positives of these): SPT 88% (49%), sIgE 31% (46%), tryptase 48% (11%), and provocation 19% (68%). For reactions against insect venom: SPT 79% (84%), sIgE 98% (97%), and tryptase 93 (8%). Irrespective of the elicitor, SPTs were performed more often in Austria, Ireland and Greece (92, 96, and 99%, respectively), and less often in Italy (64%). Tryptase was almost never measured in Ireland, Greece and France, whereas determination of specific IgE was carried out similarly between European countries.

Conclusion: The choice of diagnostic measure depended on the elicitor and varied by country. Especially the assessment of tryptase is handled very differently between allergens in question and countries. These differences may indicate aspects of the diagnostic workup with a certain degree of ambiguity, which might benefit from further harmonization.

Correspondence: Morten J. Christensen - morten.junker.christensen@rsyd.dk

Clinical and Translational Allergy 2017, 7(Suppl 1):OP03

Introduction: Wheat protein is responsible for various phenotypes of allergic diseases. More recently an increased number of immediate type 1 allergic reactions to hydrolyzed wheat proteins (HWP) have been reported.

The aim of this study was to characterize the clinical profile and evaluate patients with a case-history of anaphylaxis related to ingestion of a product containing HWP. Furthermore, to describe patients with other types of wheat allergy co-sensitized for HWP.

Methods: From May 2010 to August 2015 we investigated 56 patients (31 female, 25 male, mean age 39.0 years [1.5–77.2]) sensitized to commercialized HWP, either by specific immunoglobulin E (sIgE) (ThermoFischer, Uppsala, Sweden) and/or skin prick test (SPT). Based upon case-history patients were divided into 3 groups: (1) allergic reaction to ingestion of a HWP containing product (n = 9) (2) ingestion of a wheat product; WIA (n = 19), (3) ingestion of a wheat product in combination with exercise; WDEIA (n = 28). All patients were orally challenged with the incriminated food.

Results: The total positive rate of sIgE to HWP was 47/56 (83.9%), SPT 35/42 (83.3%) and BHR 22/42 (52.3%). Fourteen patients were triple positive to commercialized HWP of whom 7/9 patients in the HWP group. In total 9 (16%) patients were identified with a case-history of anaphylaxis related to a HWP containing product. Seven of 9 had a case-history to the same hydrolyzed wheat product (AMO Letbagt®). The average serum level of HWP-sIgE and the SPT were higher in patients with a case-history of HWP, respectively (median 5.3 kU/L ±6.8) (p < 0.05) and (median 6.0 mm ±4.1) (p < 0.05) compared to the WIA and WDEIA groups. A complete negative pattern was determined with specific wheat proteins normally associated with other phenotypes of wheat allergy, omega-5 gliadin (f416), gliadin (f98), High Molecular Weight (Tri a 26) and α-amylase trypsin inhibitor (Tri a 30). Basophil histamine release (BHR) for HWP was extremely positive in 8/9 HWP patients with activity retained to dilutions up to 10−12. The most striking finding was the ultrahigh sensitivity of BHR in diagnosing allergy to HWP. It is, however, interesting, that the HWP patient tolerates ingestion of unmodified wheat.

Conclusion: Reactivity to HWP seems to be confined to patients specifically sensitized to this heterogeneous group of products without concomitant allergy to normal wheat. Irrelevant co-sensitization is also seen in classical wheat allergy.

Correspondence: Esben Eller - esben.eller@rsyd.dk

Clinical and Translational Allergy 2017, 7(Suppl 1):OP04

Introduction: One of the most used severity scoring instruments, the Sampson 1–5, includes a built-in algorithm indicating symptoms which necessitate adrenalin administration. These include grade 5 anaphylactic symptoms, but also grade 3 and 4 such as laryngeal “puritus, tightness, or dysphagia” and lower respiratory symptoms such as “wheezing, dyspnea or cyanosis”. Our aim was to compare the recommended adrenalin administration with the actual administration in our clinic in relation to the underlying eliciting symptom.

Methods: Data from 2382 positive food challenges (mean age 11.6 years [range: 0.5–74.1y]) performed between Jan. 2000 and Dec. 2015 at the Allergy Centre, Odense, Denmark were included, and severity of reactions was assessed using the Sampson 1–5 severity instrument. All patients were evaluated by experienced specialists during challenge. Actual medications administered during the challenges, i.e. adrenalin, β2-agonist, corticosteroid, or antihistamine were compared with recommended adrenalin treatment according to the algorithm in Sampson 1–5.

Results: Out of 346 challenges scored as grade 4 anaphylaxis, 296 were terminated due to respiratory symptoms requiring adrenalin according to Sampson 1–5, i.e. “barky cough, hoarseness, difficulty swallowing” (laryngeal, n = 79), “wheezing, dyspnea, cyanosis” (lower resp. n = 181) or both (n = 36). Nine of the 115 patients with laryngeal symptoms were treated with adrenalin, all due to inspiratory stridor. No patients with lower respiratory symptoms received adrenalin, but the majority were treated with β2 agonists (188/217), whereas in 30 challenges, symptoms disappeared without treatment or only antihistamine for concomitant urticaria were used. Patients solely with laryngeal symptoms received β2-agonists in 16 challenges, but the majority of them (54/79) received no treatment or only antihistamine. The 36 patients with both laryngeal and lower respiratory symptoms were treated in same manner as patients with only lower respiratory symptoms, i.e. β2 agonist for their bronchial wheeze or asthma. Grade 5 anaphylaxis was seen in 11 challenges, 1 caused by non-adrenalin recommended “loss of bowel control”. In the remaining 10 cases, 7 patients were treated with adrenalin, either due to “hypotension < 90 mm Hg” (n = 3) or “unconsciousness” (n = 4). Three children fainted, but regained consciousness without administration of adrenalin. Grade 5 anaphylaxis should almost always be treated with adrenalin, whereas adrenalin only was administrated to inspiratory stridor and not to bronchial expiratory wheeze or asthma in grade 4 anaphylaxis. Respiratory signs were instead medicated according to symptoms, i.e. with β2-agonist to relieve bronchoconstriction. All patients were evaluated by experienced specialists, and therefore this practice should be addressed with care in less experienced settings.

Conclusion: Inspiratory stridor was the main cause of adrenalin treatment in grade 4 anaphylaxis, whereas the majority of lower respiratory symptoms were treated with inhalant β2 agonists, thereby overcoming the need for adrenalin. This needs to be considered in future treatment recommendations.

†The first two authors have equal contribution.

Correspondence: Leonor Carneiro-Leão - leonorcarneiroleao@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP05

Introduction: Adrenaline auto-injectors (AAI) are the first line treatment for anaphylaxis in community settings. Two are currently available in Portugal (Anapen® and Epipen®).

Our aim was to evaluate patient’s ability to properly use AAIs; impact of device switching and patients’ preferences.

Methods: Patients who had been prescribed an AAI in our department were invited to demonstrate correct technique of AAI by simulating adrenaline administration using training devices. First, simulation with their prescribed AAI; second, evaluation of device switching, without any previous training, by simulating injection with a different AAI (Epipen® or Anapen®, as well as Emerade®-currently unavailable in Portugal). Finally, they were asked which device they liked the best.

Results: Thirty-two patients were enrolled, 16 (50%) females, with a mean (SD) age of 42.9 (±15.8) years; 18 (56%) with hymenoptera venom allergy and 14 (44%) food allergy. Anapen® was prescribed to 15 (47%) and Epipen® to 17 (53%). Six did not acquire any AAI; 21 (66%) admitted carrying it on a daily basis. Eleven (34%) could not demonstrate successful adrenaline administration with their prescribed AAI, 5 with Anapen® and 6 with Epipen®. Nine (60%) of the 15 patients who were prescribed an Anapen® could not administer adrenaline with an Epipen®; 11 (65%) of the 17 with a prescribed Epipen® were unable to use an Anapen®. Only 2 (6%) were incapable of properly managing an Emerade®. The most common error in patients switching from Epipen® to Anapen® was not removing the needle cap (9 patients). In the group switching Anapen® to Epipen®, the most common misuse was not massaging the injection site (10 patients); 6 tried to remove the orange tip as if it was a cap. The preferred AAI was Emerade® in 20 (63%) and Epipen® in 12 (37%).

Conclusions: Patients at-risk for anaphylaxis are provided with portable auto-injectors, educated and trained on their use. One-third of the patients did not always carry them. More than one-third was unable to successfully demonstrate adrenaline administration with their prescribed AAI. Almost two-thirds failed to simulate injection when switched to the alternative one available in Portugal without any training. Design appears to play a role in a successful switch since 94% of the patients changing from either Anapen® or Epipen® to Emerade® were able to correctly use it. It was also the overall preferred auto-injector. These emergency medical devices should be patient friendly.

Correspondence: Dikla Pivko Levy - diklapivko@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP06

Introduction: Anaphylaxis is a severe, life threatening systemic hypersensitivity reaction. The diagnosis of anaphylaxis is not always easy to make in the pediatric emergency department (ED) setting. Therefore, children are often dangerously underdiagnosed and undertreated. There is sparse information on the incidence and triggers of anaphylaxis in Israel.

Our objective was to assess the true incidence of anaphylaxis treated in the Pediatric ED, to identify triggers associated with anaphylaxis, to describe the management of anaphylactic reactions and identify potential gaps in diagnosis and treatment.

Methods: A retrospective chart review of cases presenting to the Pediatric ED of the Dana-Dweck Children’s hospital, at the Tel Aviv Sourasky Medical Center between January 1st 2013 to December 31th 2014, with a diagnosis of anaphylaxis or allergic reaction. The clinical features, causative agents, treatment administered and recommendations at discharge were recorded.

Results: During the study period, there were a total of 56,596 visits to the ED. 437 patients were diagnosed with an allergic or anaphylactic reaction. Of these 59 (13.5%) met the diagnostic criteria for anaphylaxis, but only 22 were given the correct diagnosis. The mean age of presentation was 6.9 years, with a male predominance of 66%. Food was the most common causative agent (78%). Specifically, exposure to treenuts (28% (and cow milk (24%) were responsible for a majority of the cases. The majority of children (78% (had known food allergies and presented with breathing difficulties (64%), followed by urticaria (62%). Twenty children (37.7%) were treated with IM adrenaline prior to ED arrival and only fifteen (26%) were treated with IM adrenaline in the ED. Most of the children (86%) were discharged home. Almost 30% were discharged without a prescription to an automated Adrenaline injector.

Conclusion: The rate of anaphylaxis in the study period was 0.1% of all visits to the pediatric ED. Most cases of anaphylaxis were underdiagnosed. As a result, treatment guidelines regarding the use of IM Adrenalin were not always followed and many children were discharged without a prescription for an adrenaline auto-injector.

No MeSH data available.


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Fig1: See text for description

Mentions: Results: After spiking a mix of β-lg and ovalbumin into different bakery products, specific MRM signals were detected for both proteins. As an example, two XIC graphs for one of the MRM transitions investigated in β-lg are reported below (Fig. 1).The signal is clearly visible in the product spiked with as little as 0,05 mg/kg of β-lg (B), but is absent in the blank (A).Fig. 1


Abstracts from the Food Allergy and Anaphylaxis Meeting 2016
See text for description
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5384531&req=5

Fig1: See text for description
Mentions: Results: After spiking a mix of β-lg and ovalbumin into different bakery products, specific MRM signals were detected for both proteins. As an example, two XIC graphs for one of the MRM transitions investigated in β-lg are reported below (Fig. 1).The signal is clearly visible in the product spiked with as little as 0,05 mg/kg of β-lg (B), but is absent in the blank (A).Fig. 1

View Article: PubMed Central

ABSTRACT

Correspondence: Guillaume Pouessel - guillaume.pouessel@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP01

Introduction: Incidence of anaphylaxis is increasing. Data regarding anaphylaxis mortality are limited, but conflicting. Our objective was to document anaphylaxis mortality rate (deaths per million population), time trends and specificities according to triggers (iatrogenic, venom, food, unknown), age groups, sex and geographical regions (North and South) in France, between 1979 and 2011.

Methods: Data were obtained (1) from database of the National Mortality Center (CEPIDC) to collect cases in which anaphylaxis was included as a cause of death, sex, age, and geographic region of death, (2) from the database of the National Institute for Economical and Statistical studies (INSEE) to define the referent populations. We used a multivariable log-linear Poisson regression model to assess the impact of time period, age, sex and geographic region on anaphylaxis deaths.

Results: During the period study, 1603 deaths were collected: 1564 in adults and 39 in children (age <18 year). The overall prevalence of anaphylaxis fatalities was 0.84 per million population (95% IC 0.80–0.88), ranging from 0.08 per million (95% IC 0.05–0.10) in pediatric population to 1.12 per million (95% CI 1.06 to 1.17) in adult population. Annual percentage change for case fatality rate was −2.0% (95% CI −2.5 to −1.5; p < 10−4) indicating a decrease in case fatality rate during the study period. Anaphylaxis fatality rate was higher in men (1.08 per million [95% IC 1.00 1.16] than women (0.86 per million [95% IC 0.80–0.92]) (p < 10−4). Triggers of anaphylaxis fatalities were iatrogenic (63%), mostly drugs, venom (14%) and food (0.6%). Unspecified anaphylaxis was frequent (23%). The highest rate was in persons aged >70 years (3.50 per million population per year [95% IC 3.25–3.76]) and the lowest in the pediatric population (p < 10−4). Only venom-induced mortality rate was higher in South of France (0.16 per million [95% IC 0.13–0.19]) compared with the North (0.11 per million [95% IC 0.09–0.13]) (p = 0.004). Only 8 food-induced fatalities were recorded (age <35 years in 7 cases).

Conclusion: Overall anaphylaxis mortality rate is decreasing over the three last decades in France. We confirm that iatrogenic causes are the most frequent causes. Older age and male sex are risk factors of fatal anaphylaxis of any cause except for food-induced anaphylaxis.

Correspondence: Linus Grabenhenrich - linus.grabenhenrich@charite.de

Clinical and Translational Allergy 2017, 7(Suppl 1):OP02

Introduction: After a severe anaphylactic reaction, a diagnostic workup is recommended to confirm or rule out the elicitor(s) in question. The type of diagnostic chosen is usually based on the elicitor and severity of the reaction and might follow local experiences. We aimed to describe elicitor-specific diagnostic habits in the workup of severe anaphylaxis, comparing European countries.

Methods: The Network for Online Registration of Anaphylaxis (NORA) collected details about elicitors, symptoms and severity, treatment and the diagnostic workup of patients who experienced at least one episode of severe anaphylaxis, as documented within medical records of participating tertiary referral centres.

Results: Between June 2011 and April 2016, the registry collected data for 6465 cases of severe anaphylaxis, 74% of which reported to know the elicitor, with a remaining 20% having only a suspicion and 6% cases of idiopathic anaphylaxis. The allergen was known and confirmed by a diagnostic test in 4410 (92% of known elicitors). Of these, 68% had a reaction to this allergen for the first time, and 32% reported at least one earlier reaction to the same allergen. In first-time reactors (n = 3001) 7% reported that the allergen was confirming by a diagnostic test already before this reaction, for food 14%, insects 3%, drugs 2%, and 80% for SIT-induced anaphylaxis. Of cases with recurrent anaphylaxis (n = 1409), 30% had a test confirming the allergen before the reported reaction, for food 44%, insects 16%, drugs 18%, and 91% for SIT-induced anaphylaxis. Of all diagnostically confirmed cases of food-induced anaphylaxis (n = 1555), 78% were assessed by a skin test (SPT, positive in 93%), 90% by specific IgE (sIgE, 94% positive), 27% tryptase (7% positive), and 13% underwent an oral food challenge (positive in 88%). Patients with anaphylaxis caused by drugs had the following tests (positives of these): SPT 88% (49%), sIgE 31% (46%), tryptase 48% (11%), and provocation 19% (68%). For reactions against insect venom: SPT 79% (84%), sIgE 98% (97%), and tryptase 93 (8%). Irrespective of the elicitor, SPTs were performed more often in Austria, Ireland and Greece (92, 96, and 99%, respectively), and less often in Italy (64%). Tryptase was almost never measured in Ireland, Greece and France, whereas determination of specific IgE was carried out similarly between European countries.

Conclusion: The choice of diagnostic measure depended on the elicitor and varied by country. Especially the assessment of tryptase is handled very differently between allergens in question and countries. These differences may indicate aspects of the diagnostic workup with a certain degree of ambiguity, which might benefit from further harmonization.

Correspondence: Morten J. Christensen - morten.junker.christensen@rsyd.dk

Clinical and Translational Allergy 2017, 7(Suppl 1):OP03

Introduction: Wheat protein is responsible for various phenotypes of allergic diseases. More recently an increased number of immediate type 1 allergic reactions to hydrolyzed wheat proteins (HWP) have been reported.

The aim of this study was to characterize the clinical profile and evaluate patients with a case-history of anaphylaxis related to ingestion of a product containing HWP. Furthermore, to describe patients with other types of wheat allergy co-sensitized for HWP.

Methods: From May 2010 to August 2015 we investigated 56 patients (31 female, 25 male, mean age 39.0 years [1.5–77.2]) sensitized to commercialized HWP, either by specific immunoglobulin E (sIgE) (ThermoFischer, Uppsala, Sweden) and/or skin prick test (SPT). Based upon case-history patients were divided into 3 groups: (1) allergic reaction to ingestion of a HWP containing product (n = 9) (2) ingestion of a wheat product; WIA (n = 19), (3) ingestion of a wheat product in combination with exercise; WDEIA (n = 28). All patients were orally challenged with the incriminated food.

Results: The total positive rate of sIgE to HWP was 47/56 (83.9%), SPT 35/42 (83.3%) and BHR 22/42 (52.3%). Fourteen patients were triple positive to commercialized HWP of whom 7/9 patients in the HWP group. In total 9 (16%) patients were identified with a case-history of anaphylaxis related to a HWP containing product. Seven of 9 had a case-history to the same hydrolyzed wheat product (AMO Letbagt®). The average serum level of HWP-sIgE and the SPT were higher in patients with a case-history of HWP, respectively (median 5.3 kU/L ±6.8) (p < 0.05) and (median 6.0 mm ±4.1) (p < 0.05) compared to the WIA and WDEIA groups. A complete negative pattern was determined with specific wheat proteins normally associated with other phenotypes of wheat allergy, omega-5 gliadin (f416), gliadin (f98), High Molecular Weight (Tri a 26) and α-amylase trypsin inhibitor (Tri a 30). Basophil histamine release (BHR) for HWP was extremely positive in 8/9 HWP patients with activity retained to dilutions up to 10−12. The most striking finding was the ultrahigh sensitivity of BHR in diagnosing allergy to HWP. It is, however, interesting, that the HWP patient tolerates ingestion of unmodified wheat.

Conclusion: Reactivity to HWP seems to be confined to patients specifically sensitized to this heterogeneous group of products without concomitant allergy to normal wheat. Irrelevant co-sensitization is also seen in classical wheat allergy.

Correspondence: Esben Eller - esben.eller@rsyd.dk

Clinical and Translational Allergy 2017, 7(Suppl 1):OP04

Introduction: One of the most used severity scoring instruments, the Sampson 1–5, includes a built-in algorithm indicating symptoms which necessitate adrenalin administration. These include grade 5 anaphylactic symptoms, but also grade 3 and 4 such as laryngeal “puritus, tightness, or dysphagia” and lower respiratory symptoms such as “wheezing, dyspnea or cyanosis”. Our aim was to compare the recommended adrenalin administration with the actual administration in our clinic in relation to the underlying eliciting symptom.

Methods: Data from 2382 positive food challenges (mean age 11.6 years [range: 0.5–74.1y]) performed between Jan. 2000 and Dec. 2015 at the Allergy Centre, Odense, Denmark were included, and severity of reactions was assessed using the Sampson 1–5 severity instrument. All patients were evaluated by experienced specialists during challenge. Actual medications administered during the challenges, i.e. adrenalin, β2-agonist, corticosteroid, or antihistamine were compared with recommended adrenalin treatment according to the algorithm in Sampson 1–5.

Results: Out of 346 challenges scored as grade 4 anaphylaxis, 296 were terminated due to respiratory symptoms requiring adrenalin according to Sampson 1–5, i.e. “barky cough, hoarseness, difficulty swallowing” (laryngeal, n = 79), “wheezing, dyspnea, cyanosis” (lower resp. n = 181) or both (n = 36). Nine of the 115 patients with laryngeal symptoms were treated with adrenalin, all due to inspiratory stridor. No patients with lower respiratory symptoms received adrenalin, but the majority were treated with β2 agonists (188/217), whereas in 30 challenges, symptoms disappeared without treatment or only antihistamine for concomitant urticaria were used. Patients solely with laryngeal symptoms received β2-agonists in 16 challenges, but the majority of them (54/79) received no treatment or only antihistamine. The 36 patients with both laryngeal and lower respiratory symptoms were treated in same manner as patients with only lower respiratory symptoms, i.e. β2 agonist for their bronchial wheeze or asthma. Grade 5 anaphylaxis was seen in 11 challenges, 1 caused by non-adrenalin recommended “loss of bowel control”. In the remaining 10 cases, 7 patients were treated with adrenalin, either due to “hypotension < 90 mm Hg” (n = 3) or “unconsciousness” (n = 4). Three children fainted, but regained consciousness without administration of adrenalin. Grade 5 anaphylaxis should almost always be treated with adrenalin, whereas adrenalin only was administrated to inspiratory stridor and not to bronchial expiratory wheeze or asthma in grade 4 anaphylaxis. Respiratory signs were instead medicated according to symptoms, i.e. with β2-agonist to relieve bronchoconstriction. All patients were evaluated by experienced specialists, and therefore this practice should be addressed with care in less experienced settings.

Conclusion: Inspiratory stridor was the main cause of adrenalin treatment in grade 4 anaphylaxis, whereas the majority of lower respiratory symptoms were treated with inhalant β2 agonists, thereby overcoming the need for adrenalin. This needs to be considered in future treatment recommendations.

†The first two authors have equal contribution.

Correspondence: Leonor Carneiro-Leão - leonorcarneiroleao@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP05

Introduction: Adrenaline auto-injectors (AAI) are the first line treatment for anaphylaxis in community settings. Two are currently available in Portugal (Anapen® and Epipen®).

Our aim was to evaluate patient’s ability to properly use AAIs; impact of device switching and patients’ preferences.

Methods: Patients who had been prescribed an AAI in our department were invited to demonstrate correct technique of AAI by simulating adrenaline administration using training devices. First, simulation with their prescribed AAI; second, evaluation of device switching, without any previous training, by simulating injection with a different AAI (Epipen® or Anapen®, as well as Emerade®-currently unavailable in Portugal). Finally, they were asked which device they liked the best.

Results: Thirty-two patients were enrolled, 16 (50%) females, with a mean (SD) age of 42.9 (±15.8) years; 18 (56%) with hymenoptera venom allergy and 14 (44%) food allergy. Anapen® was prescribed to 15 (47%) and Epipen® to 17 (53%). Six did not acquire any AAI; 21 (66%) admitted carrying it on a daily basis. Eleven (34%) could not demonstrate successful adrenaline administration with their prescribed AAI, 5 with Anapen® and 6 with Epipen®. Nine (60%) of the 15 patients who were prescribed an Anapen® could not administer adrenaline with an Epipen®; 11 (65%) of the 17 with a prescribed Epipen® were unable to use an Anapen®. Only 2 (6%) were incapable of properly managing an Emerade®. The most common error in patients switching from Epipen® to Anapen® was not removing the needle cap (9 patients). In the group switching Anapen® to Epipen®, the most common misuse was not massaging the injection site (10 patients); 6 tried to remove the orange tip as if it was a cap. The preferred AAI was Emerade® in 20 (63%) and Epipen® in 12 (37%).

Conclusions: Patients at-risk for anaphylaxis are provided with portable auto-injectors, educated and trained on their use. One-third of the patients did not always carry them. More than one-third was unable to successfully demonstrate adrenaline administration with their prescribed AAI. Almost two-thirds failed to simulate injection when switched to the alternative one available in Portugal without any training. Design appears to play a role in a successful switch since 94% of the patients changing from either Anapen® or Epipen® to Emerade® were able to correctly use it. It was also the overall preferred auto-injector. These emergency medical devices should be patient friendly.

Correspondence: Dikla Pivko Levy - diklapivko@gmail.com

Clinical and Translational Allergy 2017, 7(Suppl 1):OP06

Introduction: Anaphylaxis is a severe, life threatening systemic hypersensitivity reaction. The diagnosis of anaphylaxis is not always easy to make in the pediatric emergency department (ED) setting. Therefore, children are often dangerously underdiagnosed and undertreated. There is sparse information on the incidence and triggers of anaphylaxis in Israel.

Our objective was to assess the true incidence of anaphylaxis treated in the Pediatric ED, to identify triggers associated with anaphylaxis, to describe the management of anaphylactic reactions and identify potential gaps in diagnosis and treatment.

Methods: A retrospective chart review of cases presenting to the Pediatric ED of the Dana-Dweck Children’s hospital, at the Tel Aviv Sourasky Medical Center between January 1st 2013 to December 31th 2014, with a diagnosis of anaphylaxis or allergic reaction. The clinical features, causative agents, treatment administered and recommendations at discharge were recorded.

Results: During the study period, there were a total of 56,596 visits to the ED. 437 patients were diagnosed with an allergic or anaphylactic reaction. Of these 59 (13.5%) met the diagnostic criteria for anaphylaxis, but only 22 were given the correct diagnosis. The mean age of presentation was 6.9 years, with a male predominance of 66%. Food was the most common causative agent (78%). Specifically, exposure to treenuts (28% (and cow milk (24%) were responsible for a majority of the cases. The majority of children (78% (had known food allergies and presented with breathing difficulties (64%), followed by urticaria (62%). Twenty children (37.7%) were treated with IM adrenaline prior to ED arrival and only fifteen (26%) were treated with IM adrenaline in the ED. Most of the children (86%) were discharged home. Almost 30% were discharged without a prescription to an automated Adrenaline injector.

Conclusion: The rate of anaphylaxis in the study period was 0.1% of all visits to the pediatric ED. Most cases of anaphylaxis were underdiagnosed. As a result, treatment guidelines regarding the use of IM Adrenalin were not always followed and many children were discharged without a prescription for an adrenaline auto-injector.

No MeSH data available.