Stephanie Hompes

Provoking allergens and treatment of anaphylaxis in children and adolescents--data from the anaphylaxis registry of German-speaking countries.

To cite this article: Hompes S, Köhli A, Nemat K, Scherer K, Lange L, Rueff F, Rietschel E, Reese T, Szepfalusi Z, Schwerk N, Beyer K, Hawranek T, Niggemann B, Worm M. Provoking allergens and treatment of anaphylaxis in children and adolescents – data from the anaphylaxis registry of German‐speaking countries. Pediatr Allergy Immunol 2011; 22: 568–574.

Symptom profile and risk factors of anaphylaxis in Central Europe

Anaphylaxis is the most severe manifestation of an IgE‐dependent allergy. Standardized acquired clinical data from large cohorts of well‐defined cases are not available. The aim of this study was to analyse the symptom profile and risk factors of anaphylaxis in a large Central European cohort.

Triggers and treatment of anaphylaxis: an analysis of 4,000 cases from Germany, Austria and Switzerland.

BACKGROUND Anaphylaxis is the most severe manifestation of a mast cell-dependent immediate reaction and may be fatal. According to data from the Berlin region, its incidence is 2-3 cases per 100 000 persons per year. METHOD We evaluated data from the anaphylaxis registry of the German-speaking countries for 2006-2013 and data from the protocols of the ADAC air rescue service for 2010-2011 to study the triggers, clinical manifestations, and treatment of anaphylaxis. RESULTS The registry contained data on 4141 patients, and the ADAC air rescue protocols concerned 1123 patients. In the registry, the most common triggers for anaphylaxis were insect venom (n = 2074; 50.1%), foods (n = 1039; 25.1%), and drugs (n = 627; 15.1%). Within these groups, the most common triggers were wasp (n = 1460) and bee stings (n = 412), legumes (n = 241), animal proteins (n = 225), and analgesic drugs (n = 277). Food anaphylaxis was most frequently induced by peanuts, cow milk, and hens egg in children and by wheat and shellfish in adults. An analysis of the medical emergency cases revealed that epinephrine was given for grade 3 or 4 anaphylaxis to 14.5% and 43.9% (respectively) of the patients in the anaphylaxis registry and to 19% and 78% of the patients in the air rescue protocols. CONCLUSION Wasp and bee venom, legumes, animal proteins, and analgesic drugs were the commonest triggers of anaphylaxis. Their relative frequency was age-dependent. Epinephrine was given too rarely, as it is recommended in the guidelines for all cases of grade 2 and above.

Anaphylaxis in an emergency setting – elicitors, therapy and incidence of severe allergic reactions

Anaphylaxis is a severe potentially life‐threatening hypersensitivity reaction with an estimated lifetime prevalence of 0.5–2.0%. The prevalence and incidence of anaphylactic reactions in Germany are unknown. We therefore assessed anaphylactic patients seen by emergency physicians in the Berlin area covering 4 million people.

Implementation of Anaphylaxis Management Guidelines: A Register-Based Study

Background Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines. Methods Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data. Results 2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time. Conclusion There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted.

Causes and risk factors for anaphylaxis

Anaphylaxis is in most cases an IgE‐dependent immunologic reaction. Mast cells are activated and release several mediators. Recent data about possible triggers of anaphylaxis indicate a clear age‐dependency. The most frequent triggers of anaphylaxis in children are foods; in adults venom and drugs predominate. In 2006 an anaphylaxis registry was established in German‐speaking countries. In the registry the triggers, circumstances, and treatment measures are collected from patients with anaphylaxis. However, the registry cannot supply epidemiological data like prevalence or incidence rates since the registration of cases is based on collaboration with allergy centers only. Similarly, other approaches to obtain data on the epidemiology of anaphylaxis are problematic given that allergic reactions of varying severity are covered by a number of codes in the ICD‐10.

Elicitors and co-factors in food-induced anaphylaxis in adults

Food-induced anaphylaxis (FIA) in adults is often insufficiently diagnosed. One reason is related to the presence of co-factors like exercise, alcohol, additives and non-steroidal anti-inflammatory drugs. The objective of this analysis was to retrospectively investigate the role of co-factors in patients with FIA. 93 adult patients with suspected FIA underwent double-blind, placebo-controlled food challenges with suspected allergens and co-factors.The elicitors of anaphylaxis were identified in 44/93 patients. 27 patients reacted to food allergens upon challenge, 15 patients reacted only when a co-factor was co-exposed with the allergen. The most common identified allergens were celery (n = 7), soy, wheat (n = 4 each) and lupine (n = 3). Among the co-factors food additives (n = 8) and physical exercise (n = 6) were most frequent. In 10 patients more than one co-factor and/or more than one food allergen was necessary to elicit a positive reaction.The implementation of co-factors into the challenge protocol increases the identification rate of elicitors in adult food anaphylactic patients.

Cabbage Allergy: A Rare Cause of Food-induced Anaphylaxis

Broccoli (Brassica oleracea var. Italica) belongs to the mustard/cabbage family, Brassicaceae. Other vegetables in this botanical family are cauliflower, cabbage, turnip, kale and Brussels sprouts. All of these are regarded as replacement vegetables in the diet of subjects allergic to pollen-associated food. CASE REPORT We report here the case of a 42-year-old Caucasian woman, who experienced 2 anaphylactic episodes in the 6 months prior to presentation, following ingestion of vegetables including broccoli. She developed angioedema of the lips and dyspnoea twice, both times necessitating emergency treatment. The patient had previously experienced similar episodes of angioedema following ingestion of peach and chamomile tea. Once, she experienced generalized urticaria after eating tree nuts and berry fruits. The patient has a 20-year positive history of allergic rhinoconjunctivitis during the summer months. No other allergic diseases, such as atopic dermatitis, asthma or contact dermatitis, e.g. nickel sensitization were known. Due to paroxysmal tachycardia the patient took a beta-blocker during the onset of the reactions, which was switched to a calcium antagonist prior to the challenge procedures. Skin-prick test (SPT) with commercial inhalant pollen al-lergens (ALK-Abelló, Wedel, Germany) was positive for grass (7 mm), mugwort (5 mm) and ambrosia (8 mm). SPT with food allergen extracts (ALK-Abelló) and fresh food were positive for native hazelnut and wheat extract (4 mm each), peanut extract, native lupin and raw broccoli (5 mm each) and for paprika spice (6 mm). SPT to the lipid transfer protein (LTP) from peach (5 mm) was also positive. Total immunoglobulin E (IgE) level (ImmunoCAP System, Thermo Fisher Scientific, Uppsala, Sweden) was 94.6 kU/l. Specific IgE (sIgE) was positive for mugwort (6.65 kU/l), grass (2.89 kU/l), bell pepper (0.83 kU/l), and LTP of peach (Pru p 3, 12.30 kU/l) and mugwort (Art v 3, 1.76 kU/l). The sIgE for broccoli was below the detection limit (0.13 kU/l). Double-blind, placebo-controlled food challenges (DBPCFC) were performed with bell pepper, lupin and broccoli. After ingesting cooked broccoli (80 g) the patient developed intensive long-lasting oral allergic symptoms with a mucosal erythema and a numbness of the tongue. The placebo, bell pepper and lupin challenges were negative. DISCUSSION As cooked broccoli elicited the symptoms in our patient , we suspected LTP to be the allergen responsible. LTPs are assumed to be highly thermostable and resistant to peptic digestion (1). It has been described that extensive heating can unfold LTPs, e.g. of wheat or barley (2, 3). However, …

Nahrungsmittelanaphylaxie: Daten aus dem Anaphylaxie-Register

ZusammenfassungHintergrundIm Anaphylaxie-Register werden ana-phylaktische Reaktionen in Deutschland, Österreich und der Schweiz erfasst. Derzeit sind 75 allergologische Fachkliniken und Schwerpunktpraxen an das Register angebunden. Die anaphylaktischen Reaktionen werden über einen passwortgeschützten Onlinefragebogen gemeldet. Es werden ausschließlich schwere Reaktionen mit pulmonalen und/oder kardiovaskulären Symptomen ausgewertet.MethodenIn der vorliegenden Arbeit wurden 271 gemeldete Reaktionen, ausgelöst durch Nahrungsmittel, untersucht.ErgebnisseBei Kindern und Jugendlichen wurde die Erdnuss als häufigster Auslöser anaphylaktischer Reaktionen angegeben. Bei Erwachsenen war das Auslöserspektrum komplex und durch verschiedenste Nahrungsmittelallergene, auch in Kombination vorkommend, sowie das Auftreten von Kofaktoren gekennzeichnet. Die häufigsten angegebenen Kofaktoren waren bei Erwachsenen Medikamente sowie bei Kindern und Jugendlichen körperliche Anstrengung. Als häufigster Auslöser wiederholter anaphy-laktischer Reaktionen wurde bei Kindern die Erdnuss angegeben, während bei Erwachsenen wiederholte Reaktionen dann häufig auftraten, wenn das spezifische Nahrungsmittel nicht identifiziert wurde.SchlussfolgerungDemzufolge muss die Analyse ungeklärter Anaphylaxien bei Erwachsenen beispielsweise durch die stärkere Berücksichtigung von Kofaktoren intensiviert werden. Zudem kann durch eine ernährungstherapeutische Betreuung mit Aufklärung zu potenziellen Risiken beim Verzehr von Nahrungsmitteln sowie die Schulung zur korrekten Verwendung der Notfallmedikamente das Risiko wiederholter schwerer Reaktionen verringert werden.SummaryBackgroundIn the anaphylaxis register, data of anaphylactic reactions in Germany, Austria and Switzerland are collected. 75 allergy centers are integrated into the register, information is delivered by a password-controlled internet-based questionnaire. Only severe reactions with pulmonary and/or cardiovascular symptoms are registered.MethodsHere, the authors report on 271 food-induced anaphylactic reactions.ResultsIn children and adolescents, the most common triggers of anaphylaxis registered were peanuts. In adults, a wide range of different food allergens, but also combinations of food allergens and the role of augmentation factors were accused. The most common augmentation factors in adults were drugs, and in children and adolescents exercise. The most frequently registered causes of recurrent reactions in children were peanuts. Among adults, mainly patients with unknown food triggers suffered from recurrent reactions.ConclusionTherefore, the analysis of anaphylactic reactions with unknown triggers needs a thorough allergological work up, e. g., including a detailed analysis regarding possible augmentation factors. Furthermore, nutritional education including the demonstration of putative risks during food consumption as well as training in the use of the emergency kit may contribute to reducing the risk of recurrent reactions.

Auslöser und Risikofaktoren der Anaphylaxie

Der Anaphylaxie liegt eine zumeist IgE-abhängige immunologische Reaktion zugrunde, bei der es zu einer Aktivierung von Mastzellen mit der Freisetzung von verschiedenen Mediatoren kommt. Aktuelle Daten zu den Auslöserprofilen der Anaphylaxie zeigen, dass diese altersabhängig sind. So sind die häufigsten Auslöser einer Anaphylaxie im Kindesalter Nahrungsmittel, während im Erwachsenenalter häufig Insektengifte und Medikamente als Auslöser vorkommen. Das seit 2006 im deutschsprachigen Raum etablierte Anaphylaxie-Register erhebt gezielt Daten zu den Auslösern, Begleitumständen und der Versorgungssituation von Patienten mit einer Anaphylaxie. Das Anaphylaxie-Register kann keine epidemiologischen Daten wie Zahlen zur Prävalenz oder Inzidenz liefern, da sich die Erhebung ausschließlich auf allergologische Zentren beschränkt. Gleichfalls sind Erhebungen zur Anaphylaxie mit Hilfe von ICDKodierungen kritisch zu betrachten, da allergische Reaktionen durch verschiedene ICD-Kodierungen abgebildet werden, die durch einen unterschiedlichen Schweregrad gekennzeichnet sein können. Aktuelle Forschungsarbeiten zur Anaphylaxie fokussieren sich auf die Identifikation von Risikofaktoren. Verschiedene Arbeiten konnten die Bedeutung von Kobzw. Augmentationsfaktoren in gut definierten Kollektiven darstellen. Zu solchen Faktoren gehören körperliche Anstrengung, bestimmte Medikamente, Infektionen, Alkohol und Zusatzstoffe. Über eine einheitliche Kodierung, die Schweregrade und Auslöser berücksichtigt, könnten Daten zur Epidemiologie der Anaphylaxie gewonnen werden. Funktionell ist es von Interesse, die Mechanismen von Kofaktoren zu identifizieren und weitere Biomarker zu identifizieren, um eine Risikoabschätzung für die Anaphylaxie zu etablieren.