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Anaphylaxis 2016

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2 Diagnosis Key Points Î The definition of anaphylaxis has, to this date, eluded precision. Î In 2006, experts on anaphylaxis concluded that there were 3 presentations consistent with anaphylaxis: 1. an acute onset of a reaction that included the skin and/or mucosal tissue and involvement of the respiratory tract and/or a decrease in blood pressure 2. the rapid onset of a reaction after exposure to a likely allergen that involved 2 organ systems (respiratory tract, skin, decrease in blood pressure, and/or persistent gastrointestinal symptoms); or 3. a decrease in blood pressure alone after exposure to a known allergen. Î Despite the apparent success of these definitions of anaphylaxis, identification of patients who present with atypical anaphylaxis remains a problem. > The National Institute of Allerg y and Infectious Diseases/Food Allerg y and Anaphylaxis Network criteria yield a sensitivity of 96.7% and a specificity of 82.4% giving a positive predictive value of 68.6% and a negative predictive value of 98.4%. (Campbell RL et al. JACI 2012; 129(3):748-752.) Î The underuse of epinephrine in the treatment of anaphylaxis is to some degree understandable if the correct diagnosis is not made. Î Better recognition of atypical or unusual presentations of anaphylaxis should intuitively lead to greater use of epinephrine and perhaps even a decrease in anaphylactic morbidity and mortality. Î Patients in anaphylaxis can develop cardiac manifestations 1. secondary to respiratory compromise or hypotension 2. as a direct effect of treatment with epinephrine or vasopressors, and/or 3. owing to vasoactive mediator release from mast cells in the heart. Î Therefore, it should not be surprising that anaphylaxis can present with prominent cardiac symptoms, such as chest pain in children and adults, electrocardiographic changes, and even myocardial damage. Î Abdominal symptoms can also be present as a manifestation of anaphylaxis. These may include nausea, vomiting, diarrhea, and cramping abdominal pain.

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