[PPT] - Causes of Anaphylaxis Motohiro Ebisawa, MD, Ph D, FAAAAI Sagamihara PowerPoint Presentation

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Motohiro Ebisawa, MD, Ph D, FAAAAI

Sagamihara National Hospital Clinical Research Center for Allergy and Rheumatology Department of Allergy

AAAAI 2014 San Diego

“Causes of Anaphylaxis”

WAF Symposium “Anaphylaxis: From Mechanisms to Novel Therapies”

SLIDE 2

WAO Journal 2011; 4:13–37)

WAO POSITION PAPER

WAO Guidelines for the Assessment & Management of Anaphylaxis

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WAO Journal 2011; 4:13–37)

WAO POSITION PAPER

WAO Guidelines for the Assessment & Management of Anaphylaxis

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Overview of Anaphylactic Triggers

35 20 20 20 5 3

5 10 15 20 25 30 35 % of Cases Food Drug/Bio Insect Sting Idiopathic Exercise Allergen Vaccines

Golden. Anaphylaxis, 2004、AAAAI education slide

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Triggers of Anaphylaxis: Food

Milk
Eggs
Seafood
Peanuts
Tree nuts
Wheat
Other

Modified from AAAAI education slide

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Case1: Food-induced anaphylaxis (A case of wheat OFC) 4 years old boy developed skin flush with wheezing and dyspnea.

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Causes of food-induced anaphylaxis among children

Study Country

Publication year

Caused by food-induced anaphylaxis Cases (n) Ref. 1st 2nd 3rd

Järvinen KM et al.

USA 2008 Peanuts Cow’s milk Nuts 95

J Allergy Clin Immunol. Rudders SA et al.

USA 2010 Peanuts Cow’s milk Nuts 846

J Allergy Clin Immunol. Russell S et al.

USA 2010 Peanuts shellfish Cow’s milk 124

Pediatr Emerg Care. Braganza SC et al.

Australia 2006 Dairy Egg Peanuts 57

Arch Dis Child. de Silva IL et al.

Australia 2008 Peanuts cashew nut Cow milk 104

Allergy

D. L. M. Goh et al.

Singapore 1999 Bird's nest Crustacean seafood Egg and milk 124

Allergy Piromrat K et al.

Thailand 2008 Prawn

Asian Pac J Allergy Immunol. Imai T

Japan* 2004 Hen's egg Cow’s milk Wheat 408

Arerugi

*: infant only

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Causes of food-induced anaphylaxis among adults

Study Country

Publication year

Caused by food-induced anaphylaxis Cases (n) Ref. 1st 2nd 3rd

Greenhawt MJ et al.

USA 2009 Cow’s milk Nuts Shellfish 104

J Allergy Clin Immunol. Asero R et al.

Italy 2009 Peach Shrimp Nuts 58

Int Arch Allergy Immunol. Moneret-Vautrin DA et al.

France 1995 Hen’s egg Fish or crustaceans milk or fruit- latex group 794

Ann Gastroenterol Hepatol Brown AF et al.

Australia 2001 Fish and Seafood Nuts Mango or Lemon drink 22

J Allergy Clin Immunol. Imai T

Japan 2004 Fish Buckwheat Meat 130

Arerugi

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Causes of food-induced anaphylaxis from childhood to adulthood

Study Country

Publication year

Age Caused by food-induced anaphylaxis Cases (n) Ref. 1st 2nd 3rd

Ross MP et al.

USA 2008 2-66y Seafood nuts 23

J Allergy Clin Immunol. Min-Suk Yang et al.

Korea 2008 5–76y Wheat flour Buckwheat Seafood 29

Ann Allergy Asthma Immunol. Imamura T et al.

Japan 2008 0-93y Milk Eggs Wheat 319

Pediatr Allergy Immunol Cianferoni A et al.

Italy 2001 ? Seafood 113

Ann Allergy Asthma Immunol.

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USA

1994-1999

32 cases* Peanut 20 Tree nuts 10 Milk 1 Fish 1

*Including a case of antigen suspected to cause JACI 2001,107:191- 3

UK

1999-2006

48 cases Peanut 9 Nuts 9 Milk 6 Fish 1 Shellfish 1 Snail 1 Sesame 1 Egg 1 Tomato 1

(uncertain 18)

JACI 2007,119:1018-9

USA

2001-2006

31 cases Peanut 17 Tree nuts 8 Milk 4 Shrimp 1

JACI 2007,119:1016-8

Australia

1997-2005

7 cases Peanut 3 Fish 1

(no information 1) (undetermined 2)

JACI 2009,123:434- 42

Japan

1999-2004

4 cases Shrimp 1 Buckwheat1 Fish 1 Chocolate 1

Nihon Kyukyu Igakukai Zasshi2005,16：564-6

Worldwide cases of fatal food-induced anaphylaxis

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J Allergy Clin Immunol 2013;131:31-5

Anaphylaxis from ingestion of mites: Pancake anaphylaxis

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Gelatin sensitization

Clinical group

Positive test results

No. tested

Percent 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 222 Miscellaneous 290 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.

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Clinical features of subjects presenting with anaphylaxis to CMF with scGOS

J Allergy Clin Immunol 2012;130:1361-7. Patient no. Sex Atopy phenotype Age at reaction

No. of

episodes Milk eliciting reaction Volume eliciting reaction (mL) Time (min) Reaction 1 F AR, AS, AD, AC 5 y, 6 mo 3 Gain IQ Step3 (CMF2) (1) 100 (2) 120* (3) 40 10 RS, Resp 2 F AR, AD 6 y, 6 mo 1 Mamil Gold Step4 (CMF1) 250 30 AE, RS Resp 3 M AR 38 y 1 Mamil Gold Step3 (CMF1) 180 10 AE, RS Resp 4 F AR 6 y 1 Mamil Gold Step4 (CMF1) 250 15 AE, GU, GI RS, Resp 5 M AD, AR, AS 8 y 1 Gain IQ Step3 (CMF2) 180 5 AE, GU, RS Resp

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.

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Triggers of Anaphylaxis: Insect Stings and Bites

Bees
Vespids
Fire ants and other ants
Scorpions
Deer & horse flies
Mosquitoes

Modified from AAAAI education slide

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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

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Triggers of Anaphylaxis: Anaphylaxis during Anesthesia

Causal agent Reactions (%)

No. of patients

NMBAs

neuromuscular blocking agents

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

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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

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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

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Summary of world wide multiple food-dependent exercise-induced anaphylaxis case reports

Study Country Publication year Age Caused by FEIAn Cases (n) Ref. 1st 2nd 3rd Kano H et al. Japan 2000 9-43y Wheat Shrimp Shellfish or fish 18 Arerugi Harada S et al. Japan 2000 >20 Wheat Shrimp 167 Arerugi Harada S et al. Japan 2000 <20 Shrimp Wheat 167 Arerugi Aihara Y et al. Japan 2001 12-15y Shrimps and crab Wheat Grapes Vegetables buckwheat 13 J Allergy Clin Immunol Yang MS et al. Korea 2008 5-76y Wheat Apple or shrimp 18 Ann Allergy Asthma Immunol Teo SL et al. Singapore 2009 9-20y Shellfish 5 Ann Acad Med Singapore Mathelier-Fusade P et al. France 2002 ? Wheat Corn, barley, shrimp, apple, paprika, mustard 7 Ann Dermatol Venereol Romano A et al. Italy 2001 ? Tomatoes Wheat Peanuts 54 Int Arch Allergy Immunol Shadick NA et al. USA 1999 13-77y Shellfish Alcohol Tomatoes 279

(EIA patients)

J Allergy Clin Immunol

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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

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Age distribution of Food-dependent exercise-induced anaphylaxis reported from 1979 to 2004

Ag e

n=84

(by Aihara Y arerugi 2007)

10 20 30 40 0- 10- 20- 30- 40- 50- 60- 70-

(n)

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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)

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WAO POSITION PAPER

WAO Guidelines for the Assessment & Management of Anaphylaxis

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Co-morbid conditions and risk factors for food-induced anaphylaxis and Food-dependent exercise-induced anaphylaxis

Factors FIA FEIA Ref.

Disease Asthma* ○

JACI. 2009; 124: 625

Cardiovascular disease ○

Clin Exp Immunol. 2008;153:7 Curr Opin Allergy Clin Immunol. 2007; 7:337

Infection ○ ○

JACI. 2010; 125: S161

Other disorder** ○

JACI. 2010; 125: S161

Medication Beta-adrenergic blockers ○

Curr Allergy Asthma Rep. 2008; 8: 37

Angiotensin-converting enzyme (ACE) inhibitors ○

Curr Allergy Asthma Rep. 2008; 8: 37

Alpha-adrenergic blockers ○

Curr Allergy Asthma Rep. 2008; 8: 37

Antidepressants ○

Curr Allergy Asthma Rep. 2008; 8: 37

NSAIDs, aspirin ○ ○

J Dermatol Sci. 2007; 47: 109 Br J Dermatol. 2001; 145: 336

Other Alcohol intake ○ ○

Addict Biol. 2004; 9:195

Fatigue ○ ○

JACI. 2010; 125: S161

Stress ○ ○

JACI. 2010; 125: S161

Type of exercise ○ ○

JACI. 2010; 125: S161

Atmospheric condition and seasonal ○

JACI. 2010; 125: S161

* **

especially if poorly controlled 1) mastocytosis and clonal mast cell disorder, 2) chronic lung disease 3) anatomical airway obstruction , 4) Depression and other psychiatric disease