Anaphylaxis: Confirming the diagnosis and determining the cause(s)
- John M Kelso, MD
John M Kelso, MD
- Section Editor – Anaphylaxis
- Division of Allergy, Asthma, and Immunology
- Scripps Clinic, San Diego, CA
Anaphylaxis is a potentially life-threatening emergency that requires immediate diagnosis and treatment. (See "Anaphylaxis: Emergency treatment".)
Patients who have experienced anaphylaxis (or suspected anaphylaxis) require evaluation to confirm the diagnosis and determine the cause(s) and possible contributing factors, such as other medical conditions (comorbidities) and concurrent medications.
REFERRAL TO AN ALLERGY/IMMUNOLOGY SPECIALIST
Referral to a board-certified allergy specialist is indicated in all cases of certain or suspected anaphylaxis [1-5]. A thorough evaluation is required to accomplish the following objectives:
●Confirm the diagnosis
●Confirm or determine the cause
- Simons FE. Anaphylaxis. J Allergy Clin Immunol 2010; 125:S161.
- Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
- Sampson HA, Muñoz-Furlong A, Bock SA, et al. Symposium on the definition and management of anaphylaxis: summary report. J Allergy Clin Immunol 2005; 115:584.
- Simons FE, Ardusso LR, Bilò MB, et al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol 2011; 127:587.
- Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477.
- Campbell RL, Park MA, Kueber MA Jr, et al. Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis. J Allergy Clin Immunol Pract 2015; 3:88.
- Simons FE. Anaphylaxis, killer allergy: long-term management in the community. J Allergy Clin Immunol 2006; 117:367.
- Pumphrey RS, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol 2007; 119:1018.
- Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
- Alves B, Sheikh A. Age specific aetiology of anaphylaxis. Arch Dis Child 2001; 85:348.
- Simons FE. Anaphylaxis in infants: can recognition and management be improved? J Allergy Clin Immunol 2007; 120:537.
- Simons FE, Schatz M. Anaphylaxis during pregnancy. J Allergy Clin Immunol 2012; 130:597.
- Campbell RL, Hagan JB, Li JT, et al. Anaphylaxis in emergency department patients 50 or 65 years or older. Ann Allergy Asthma Immunol 2011; 106:401.
- Robson-Ansley P, Toit GD. Pathophysiology, diagnosis and management of exercise-induced anaphylaxis. Curr Opin Allergy Clin Immunol 2010; 10:312.
- Matsuo H, Kaneko S, Tsujino Y, et al. Effects of non-steroidal anti-inflammatory drugs (NSAIDs) on serum allergen levels after wheat ingestion. J Dermatol Sci 2009; 53:241.
- Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126:1105.
- Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol 2010; 125:S116.
- Bilò MB, Bonifazi F. The natural history and epidemiology of insect venom allergy: clinical implications. Clin Exp Allergy 2009; 39:1467.
- Golden DB, Moffitt J, Nicklas RA, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127:852.
- Khan DA, Solensky R. Drug allergy. J Allergy Clin Immunol 2010; 125:S126.
- Mirakian R, Ewan PW, Durham SR, et al. BSACI guidelines for the management of drug allergy. Clin Exp Allergy 2009; 39:43.
- Castells M. Rapid desensitization for hypersensitivity reactions to medications. Immunol Allergy Clin North Am 2009; 29:585.
- Bernstein IL, Li JT, Bernstein DI, et al. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008; 100:S1.
- Rezvani M, Bernstein DI. Anaphylactic reactions during immunotherapy. Immunol Allergy Clin North Am 2007; 27:295.
- Kelso JM, Li JT, Nicklas RA, et al. Adverse reactions to vaccines. Ann Allergy Asthma Immunol 2009; 103:S1.
- Commins SP, Satinover SM, Hosen J, et al. Delayed anaphylaxis, angioedema, or urticaria after consumption of red meat in patients with IgE antibodies specific for galactose-alpha-1,3-galactose. J Allergy Clin Immunol 2009; 123:426.
- Summers CW, Pumphrey RS, Woods CN, et al. Factors predicting anaphylaxis to peanuts and tree nuts in patients referred to a specialist center. J Allergy Clin Immunol 2008; 121:632.
- González-Pérez A, Aponte Z, Vidaurre CF, Rodríguez LA. Anaphylaxis epidemiology in patients with and patients without asthma: a United Kingdom database review. J Allergy Clin Immunol 2010; 125:1098.
- Iribarren C, Tolstykh IV, Miller MK, Eisner MD. Asthma and the prospective risk of anaphylactic shock and other allergy diagnoses in a large integrated health care delivery system. Ann Allergy Asthma Immunol 2010; 104:371.
- Triggiani M, Patella V, Staiano RI, et al. Allergy and the cardiovascular system. Clin Exp Immunol 2008; 153 Suppl 1:7.
- Mueller UR. Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol 2007; 7:337.
- Brockow K, Jofer C, Behrendt H, Ring J. Anaphylaxis in patients with mastocytosis: a study on history, clinical features and risk factors in 120 patients. Allergy 2008; 63:226.
- Bonadonna P, Perbellini O, Passalacqua G, et al. Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels. J Allergy Clin Immunol 2009; 123:680.
- Metcalfe DD, Schwartz LB. Assessing anaphylactic risk? Consider mast cell clonality. J Allergy Clin Immunol 2009; 123:687.
- Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10:354.
- TenBrook JA Jr, Wolf MP, Hoffman SN, et al. Should beta-blockers be given to patients with heart disease and peanut-induced anaphylaxis? A decision analysis. J Allergy Clin Immunol 2004; 113:977.
- Ruëff F, Przybilla B, Biló MB, et al. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol 2009; 124:1047.
- Caviglia AG, Passalacqua G, Senna G. Risk of severe anaphylaxis for patients with Hymenoptera venom allergy: Are angiotensin-receptor blockers comparable to angiotensin-converting enzyme inhibitors? J Allergy Clin Immunol 2010; 125:1171; author reply 1171.
- Nassiri M, Babina M, Dölle S, et al. Ramipril and metoprolol intake aggravate human and murine anaphylaxis: evidence for direct mast cell priming. J Allergy Clin Immunol 2015; 135:491.
- Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003; 112:451.
- Schwartz LB. Diagnostic value of tryptase in anaphylaxis and mastocytosis. Immunol Allergy Clin North Am 2006; 26:451.
- Komarow HD, Hu Z, Brittain E, et al. Serum tryptase levels in atopic and nonatopic children. J Allergy Clin Immunol 2009; 124:845.
- Simons FE, Frew AJ, Ansotegui IJ, et al. Risk assessment in anaphylaxis: current and future approaches. J Allergy Clin Immunol 2007; 120:S2.
- Müller UR. Elevated baseline serum tryptase, mastocytosis and anaphylaxis. Clin Exp Allergy 2009; 39:620.
- Greenberger PA. Idiopathic anaphylaxis. Immunol Allergy Clin North Am 2007; 27:273.
- REFERRAL TO AN ALLERGY/IMMUNOLOGY SPECIALIST
- CONFIRMING THE DIAGNOSIS OF ANAPHYLAXIS
- History of exposures and activities
- - Comorbidities
- - Concurrent medications and other substances
- Review of treatment
- Laboratory test results obtained at the time of anaphylaxis
- TESTING FOR ALLERGEN CAUSE(S)
- Sensitization to allergens
- Testing for related allergies
- THE PATIENT WITH AN IDENTIFIABLE CAUSE
- THE PATIENT WITH NO IDENTIFIABLE CAUSE
- DIFFERENTIAL DIAGNOSIS OF ANAPHYLAXIS
- SUMMARY AND RECOMMENDATIONS