ANAPHYLAXIS SHOCK

Primary symptoms of
anaphylaxis
Skin: Respiratory:
flushing, itching, dysphonia, cough,
urticaria, angioedema stridor, wheezing,
dyspnea, chest
tightness, asphyxiation,
Gastrointestinal: death
nausea, vomiting, bloating,
cramping, diarrhea Cardiovascular: tachycardia,
hypotension, dizziness,
collapse, death
Other:
feeling of impending
doom, metallic taste
Causes of Anaphylaxis

www.emnet-usa.org
 Agents that cause anaphylaxis:
IgE-dependent triggers
foods (eg peanut, tree nuts, hormones
seafood) animal or human proteins
medications (eg, -lactam
antibiotics) colorants (insect-derived,
venoms eg. carmine)
latex enzymes
allergen immunotherapy
polysaccharides
diagnostic allergens
exercise (with food or medication aspirin and NSAIDs
co-trigger) (possibly through IgE)

Kemp SF and Lockey RF, J Allergy Clin Immunol

2002;110:341-8
 Anaphylaxis: non-
immunologic causes
MULTIMEDIATOR COMPLEMENT ACTIVATION/ACTIVATION
OF CONTACT SYSTEM
radiocontrast media
ethylene oxide gas on dialysis tubing (possibly
through IgE)
protamine (possibly)
ACE-inhibitor administered during renal dialysis with
sulfonated polyacrylonitrile, cuprophane, or
polymethylmethacrylate dialysis membranes

Kemp SF and Lockey RF, J Allergy Clin

Immunol 2002;110:341-8
 Anaphylaxis: non-immunologic
causes
NONSPECIFIC DEGRANULATION OF MAST CELLS
AND BASOPHILS
opiates
physical factors:
- exercise (no food or medication co-trigger)
- temperature (cold, heat)

Kemp SF and Lockey RF, J Allergy Clin Immunol

2002;110:341-8
Mechanisms of allergic anaphylaxis

a severe, acute, systemic

allergic reaction caused by
the rapid, IgE-mediated
release of potent mediators
such as histamine from
tissue mast cells and
peripheral blood basophils
 Acutely released mediators of
anaphylaxis
degranulation of mast cells and basophils causes the
release of:
- preformed granule-associated substances, eg
histamine, tryptase, chymase, carboxypeptidase, and
cytokines
- newly-generated lipid-derived mediators, eg
prostaglandin D2, leukotriene (LT) B4, LTC4, LTD4,
LTE4, and platelet activating factor.

Kemp SF and Lockey RF. J Allergy Clin Immunol 2002; 110:341-8

 Anaphylactic Reaction
Allergen

Mast cell granules IgE antibody

Mast Cell

Immediate reaction
Wheeze
Urticaria
Hypotension
Abdominal cramping

Late-phase reaction

Phil Lieberman: Anaphylaxis,a clinicians manual

 Biphasic/late-phase reaction
Cellular infiltrates: 3 to 6 hours
(LPR)
Eosinophil
CysLTs, GM-CSF,
TNF-, IL-1, IL-3,
Histamine IL-4, IL-6
PAF, ECP, MBP

Allergen
3 to 6 hours Basophil
Histamine,
(CysLTs, PAF, CysLTs, Return
IL-5) TNF-, IL-4, IL-5,
IL-6
of
Monocyte Symptoms
PGs CysLTs CysLTs, TNF-,
PAF, IL-1
Proteases

Mast cell Lymphocyte

IL-4, IL-13, IL-5,
EPR 15 min IL-3, GM-CSF
(Early-Phase Reaction)
 Uniphasic Anaphylaxis
Treatment

Initial
Symptoms

0 Time

Antigen Exposure
 Biphasic Anaphylaxis
Treatment Treatment

Initial 1-8 hours

Second-
Symptoms Phase
Symptoms

0 Classic Model Time

1-72 hours
Antigen
Exposure New Evidence
Laboratory tests in the diagnosis
of anaphylaxis
Plasma histamine
Serum tryptase
24-hr Urinary histamine metabolite

0 30 60 90 120 150 180 210 240 270 300 330

 Th
a
yo n k
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I/Azzam - 2004