Gadopentetate dimeglumine (Gd-DTPA) is commonly used for enhancement in magnetic resonance imaging, but rarely causes serious adverse reactions. The patient presented in this report had a cardiac arrest and multiple organ dysfunction syndrome within a short time after administration of Gd-DTPA. Immediately after receiving an intravenous injection of Gd-DTPA, the patient felt nausea and chest tightness, and developed systemic erythema. He was successfully treated using veno-arterial extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy without any serious complications or neurological deficits. We report a patient who was successfully treated for Gd-DTPA-induced cardiac arrest with ECMO. Thus, ECMO may be an effective treatment for cardiac arrest secondary to anaphylaxis.

Peach allergy is among the most frequent food allergies in the Mediterranean area, often eliciting severe anaphylactic reactions in patients. Due to the risk of severe symptoms, studies in humans are limited, leading to a lack of therapeutic options. This study aimed to develop a peach allergy mouse model as a tool to better understand the pathomechanism and to allow preclinical investigations on the development of optimized strategies for immunotherapy. CBA/J mice were sensitized intraperitoneally with peach extract or PBS, using alum as adjuvant. Afterwards, extract was administered intragastrically to involve the intestinal tract. Allergen provocation was performed via intraperitoneal injection of extract, measuring drop of body temperature as main read out of anaphylaxis. The model induced allergy-related symptoms in mice, including decrease of body temperature. Antibody levels in serum and intestinal homogenates revealed a Th2 response with increased levels of mMCPT-1, peach- and Pru p 3-specific IgE, IgG1 and IgG2a as well as increased levels of IL-4 and IL-13. FACS analysis of small intestine lamina propria revealed increased amounts of T cells, neutrophils and DCs in peach allergic mice. These data suggest the successful establishment of a peach allergy mouse model, inducing systemic as well as local gastrointestinal reactions.

The development of allergic diseases is common in the young but rare in the elderly. We encountered an elderly patient with food-dependent exercise-induced anaphylaxis (FDEIA). An 82-year-old man was rushed to the hospital for symptoms of anaphylaxis. Because the symptoms occurred after ingestion of wheat products and exercise, we made a diagnosis of FDEIA based on a high ω5-gliadin IgE level and a positive exercise test. Based on our review of the existing literature, this was the oldest patient to ever be diagnosed with FDEIA in Japan. This case suggests that physicians should keep in mind that older adults can develop FDEIA.

The lifetime prevalence of urticaria, a severe allergic disease, is almost 20%. It not only limits the quality of life of those affected, but also their general performance at work and in their daily activities. This publication is the first section of the Urticaria Guideline. It covers the classification and diagnosis of urticaria, taking into account the major advances in research into its causes, triggering factors and pathomechanisms. It also addresses strategies for the efficient diagnosis of the different subtypes of urticaria. This is crucial for individual, patient-oriented treatment, which is covered in the second part of the guideline, published separately. This German-language guideline was developed according to the criteria of the AWMF on the basis of the international English-language S3 guideline with special consideration of health system characteristics in the German-speaking countries. This first part of the guideline describes the classification of urticaria, distinguishing spontaneously occurring wheals (hives) and angioedema from forms of urticaria with inducible symptoms. Urticaria is defined as sudden onset of wheals, angioedema, or both, but is to be distinguished from conditions in which wheals occur as a short-term symptom, such as anaphylaxis. The diagnosis is based on (a limited number of) laboratory tests, but especially on medical history. In addition, validated instruments are available to measure the severity, activity and course of the disease.

Background: Children with anaphylaxis often emergently present for treatment. Providers' adherence to the principles of optimal management according to the most recent national guidelines is unknown. Objective: To assess the variation in management approaches for allergic reactions and anaphylaxis between allergy/immunology (AI) and emergency medicine (EM) providers. Methods: This was a cross-sectional survey study of AI and EM providers in the University of Colorado affiliated hospitals and Colorado Asthma and Allergy Society. The survey consisted of six cases of patients with allergic reactions, with four cases that represented patients with anaphylaxis that resolved by the time of discharge. For each vignette, the participants were asked about preferred initial therapy, adjunctive therapies, monitoring, outpatient prescription medications, and discharge instructions provided. Survey derivation and validation was accomplished by a multidisciplinary team of experts by using a modified Delphi process. Results: A total of 413 clinicians were contacted, of whom 194, (47%) responded, including 69 pediatric EM, 50 general EM, and 49 AI providers, and 26 did not identify a provider type. There were no statistically significant differences in correct recognition of anaphylaxis between the AI and EM providers. For each case, statistically significant differences were noted in the use of corticosteroids during and after resolution of anaphylaxis: AI providers reported giving fewer prescriptions than did the EM providers for corticosteroids in all cases of anaphylaxis (p < 0.001). The AI providers were less likely to prescribe scheduled antihistamines than were the EM providers in half of the cases (p < 0.02). Conclusion: Across the specialties, there were high rates of recognition of epinephrine as first-line treatment for anaphylaxis. The majority of the EM providers prescribed scheduled corticosteroids and antihistamines after resolution of anaphylaxis, whereas most of the AI providers did not prescribe scheduled corticosteroids. Analysis of the current data suggests against the routine use of corticosteroids in the management of anaphylaxis, particularly continued use after resolution of symptoms. AI involvement in the creation of EM and hospital protocols for allergic reactions could improve overall care.

We present a 62-year-old woman with severe heart failure and who required cardiac transplantation. On postoperative day 22, she experienced anaphylaxis to peanut, with an elevated peanut-specific immunoglobulin E level. This case highlights the differential diagnosis of posttransplantation anaphylaxis as well as the appropriate evaluation.

Background: Anaphylaxis is the most severe manifestation of a systemic allergic reaction, and, in the community setting, the immediate administration of an epinephrine autoinjector (EAI) can be life-saving. Physicians are tasked with selecting the most appropriate EAI for each individual and counseling patients and/or their caregivers to maximize the likelihood of successful deployment of the EAI. Objective: To offer an evidence-based expert clinical perspective on how physicians might best tailor EAI selection to their patients with anaphylaxis. Methods: A group of eight adult and pediatric allergists with expertise in anaphylaxis management reviewed and assessed the published data and guidelines on anaphylaxis management and EAI device selection. Results: Personalized EAI selection is influenced by intrinsic individual factors, extrinsic factors such as the properties of the individual EAI (e.g., dose, needle length, overall design) as well as cost and coverage. The number and the variety of EAIs available have expanded in most jurisdictions in recent years, which provide a greater diversity of options to meet the characteristics and needs of patients with anaphylaxis. Conclusion: There currently are no EAIs with customizable dose and needle length. Although precise personalization of each patient's EAI remains an optimistic future aspiration, careful consideration of all variables when prescribing EAIs can support optimal management of anaphylaxis.

Background: Anaphylaxis is an acute life-threatening event that requires emergent diagnosis and treatment. However, focus on prevention of anaphylaxis is essential in reducing anaphylaxis recurrences and associated mortality. Objective: This literature review was aimed to be a comprehensive resource for practicing allergists in managing anaphylaxis in the long term. We discussed the role of the allergist in the long-term outpatient management of anaphylaxis through identifying risk factors, allergen avoidance, prevention of recurrences, and patient education. Methods: A medical literature search that focused on several areas of long-term management of anaphylaxis was conducted. Results: Patients evaluated by an allergist are more likely to have their anaphylaxis trigger identified, to have their underlying mast cell disorder diagnosed, and to receive desensitization or allergen immunotherapy. Allergists can prevent fatal anaphylaxis by preventing and treating anaphylaxis in patients with ischemic heart disease and by optimally treating patients with comorbid asthma. Allergists can offer specific prevention strategies for allergenic trigger and cofactor avoidance. Education should be focused on patients with a higher risk for recurrence of anaphylaxis, such as those patients with a history of severe symptoms or anaphylaxis, with a peanut and/or tree nut trigger, or with a history of asthma, or female gender. Patient counseling involves providing individualized action plans at each visit and discussing proper use, storage, and safety of epinephrine autoinjectors. Multiple doses of epinephrine need to be prescribed to those who are at risk for severe food-induced, venom immunotherapy-related, or venom-induced anaphylaxis. Wording on medical identification products should be reviewed by the allergist. Anaphylaxis resources for health-care providers are summarized in the article. Conclusion: Ongoing education, providing personalized anaphylaxis action plans, reducing risk factors, and avoiding triggers are key to anaphylaxis prevention and long-term management.

Epinephrine is the first line of treatment for anaphylaxis which can occur outside a medical setting in community environments like schools. Patients with diagnosed IgE-mediated food allergy at risk of anaphylaxis are prescribed self-injectable epinephrine and given an individualized anaphylaxis action plan. As students, such patients/families provide their school with completed medication forms, a copy of their anaphylaxis plan, and additional student-specific epinephrine. However, students approved to self-carry prescribed self-injectable epinephrine may forget to do so or have other reasons for lacking prescribed epinephrine such as familial inability to fill the prescription due to cost or other access barriers. Undiagnosed students lacking prescribed epinephrine may also experience anaphylaxis at school. The presence of non-student specific school stock epinephrine allows school nurses and other staff the ability to treat anaphylaxis on-site while awaiting emergency medical services. Notably, not all states legally mandate K-12 schools to stock epinephrine. In states with laws only voluntarily allowing schools to stock epinephrine, it provides the ability to opt-out. Herein, we present a comprehensive review of barriers to school stock epinephrine, related improvement strategies, and workgroup recommendations supporting the need for mandated stock epinephrine in all schools in every state. Proposed solutions include ensuring legal immunity from liability for prescribers; advocacy for legislation to stabilize cost of self-injectable epinephrine; educational initiatives to schools promoting merits and safety of epinephrine and related anaphylaxis training; and partnerships between patient advocacy groups, medical and nursing organizations, public health departments and other health professionals to promote laws and district policies addressing need for stock epinephrine and school nurses to train and supervise school staff.

Background: Although allergic contact dermatitis is a type IV hypersensitivity reaction, type I hypersensitivity reactions, such as anaphylaxis, have been reported during patch testing. Objective: The aim of this study was to identify reported cases of anaphylaxis from patch testing and estimate its rate. Methods: A literature review was conducted on PubMed to identify previously reported cases of anaphylaxis after patch testing and suspected allergens. In addition, a survey was distributed to expert patch testing dermatologists to determine the rate of anaphylaxis after patch testing. Results: Three anaphylaxis cases due to patch testing were found in the literature. Twenty-seven of 36 expert patch testers completed the survey for a 75% response rate. These dermatologists have tested an estimated 201,720 patients in their combined careers. From them, 2 cases of patch test anaphylaxis were reported. The rate of anaphylaxis from patch testing was calculated to be 1 in 100,860 tests among our cohort. Conclusions: Patch testing induced anaphylaxis is rare and may be more likely in patients with a history of anaphylaxis. Although rare, dermatologists should have a management plan in place.

MASK-air® , a validated mHealth app (Medical Device regulation Class IIa) has enabled large observational implementation studies in over 58,000 people with allergic rhinitis and/or asthma. It can help to address unmet patient needs in rhinitis and asthma care. MASK-air® is a Good Practice of DG Santé on digitally-enabled, patient-centred care. It is also a candidate Good Practice of OECD (Organisation for Economic Co-operation and Development). MASK-air® data has enabled novel phenotype discovery and characterisation, as well as novel insights into the management of allergic rhinitis. MASK-air® data show that most rhinitis patients (i) are not adherent and do not follow guidelines, (ii) use as-needed treatment, (iii) do not take medication when they are well, (iv) increase their treatment based on symptoms and (v) do not use the recommended treatment. The data also show that control (symptoms, work productivity, educational performance) is not always improved by medications. A combined symptom-medication score (ARIA-EAACI-CSMS) has been validated for clinical practice and trials. The implications of the novel MASK-air® results should lead to change management in rhinitis and asthma.

Rhabdomyolysis refers to skeletal muscle breakdown causing a release of different intracellular proteins including myoglobin and several electrolytes in the bloodstream. Elevations diagnose rhabdomyolysis in serum creatine kinase. Mass envenomation by multiple wasp stings can cause rhabdomyolysis followed by acute kidney injury, although it is scarce. A 24-year-old male presented to our tertiary centre in an anaphylaxis-like state after multiple wasps sting, rapidly developing rhabdomyolysis followed by acute kidney injury. Despite having an ectopic kidney with a pre-existing renal parenchymal disease, he recovered and was discharged, which in itself is a rare entity of low clinical incidence. Wasp stings can potentially result in serious clinical manifestations, which need to be watched over, assessed and promptly treated.

Multisystem inflammatory syndrome in children (MIS-C) is a rare, but severe complication of coronavirus disease 2019 (COVID-19). It develops approximately 4 weeks after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and involves hyperinflammation with multisystem injury, commonly progressing to shock. The exact pathomechanism of MIS-C is not known, but immunological dysregulation leading to cytokine storm plays a central role. In response to the emergence of MIS-C, the European Academy of Allergy and Clinical Immunology (EAACI) established a task force (TF) within the Immunology Section in May 2021. With the use of an online Delphi process, TF formulated clinical statements regarding immunological background of MIS-C, diagnosis, treatment, follow-up, and the role of COVID-19 vaccinations. MIS-C case definition is broad, and diagnosis is made based on clinical presentation. The immunological mechanism leading to MIS-C is unclear and depends on activating multiple pathways leading to hyperinflammation. Current management of MIS-C relies on supportive care in combination with immunosuppressive and/or immunomodulatory agents. The most frequently used agents are systemic steroids and intravenous immunoglobulin. Despite good overall short-term outcome, MIS-C patients should be followed-up at regular intervals after discharge, focusing on cardiac disease, organ damage, and inflammatory activity. COVID-19 vaccination is a safe and effective measure to prevent MIS-C. In anticipation of further research, we propose a convenient and clinically practical algorithm for managing MIS-C developed by the Immunology Section of the EAACI.

A 29-year-old Japanese man with food-dependent exercise-induced anaphylaxis (FDEIA) underwent tooth extraction under general anesthesia. FDEIA is a rare condition in which anaphylaxis occurs due to exercise load or oral administration of NSAIDs after ingestion of allergens. Wheat is often the cause in FEDIA, defined as wheat-dependent exercise-induced anaphylaxis (WDEIA). It is an allergy that is not well known in the dental field. Patients may ingest the causative food on a regular basis because they do not develop without factors such as exercise. Post extraction period was uneventful as the patient was instructed not to ingest wheat before the treatment or while he was taking NSAIDs. We were able to safely extract teeth without causing anaphylaxis.