UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Biphasic and protracted anaphylaxis

Author
Phillip L Lieberman, MD
Section Editor
John M Kelso, MD
Deputy Editor
Anna M Feldweg, MD

INTRODUCTION

Most episodes of anaphylaxis begin quickly, escalate, and then resolve completely, particularly when appropriate treatment is administered. However, some anaphylactic reactions resolve and recur hours later or do not resolve completely for hours or even days.

Atypical patterns of anaphylaxis, the incidence of atypical patterns of reactions, and proposed risk factors for these reactions will be reviewed here. The diagnosis and treatment of anaphylaxis, fatal anaphylaxis, and other topics related to anaphylaxis are discussed elsewhere. (See "Anaphylaxis: Emergency treatment" and "Fatal anaphylaxis" and "Differential diagnosis of anaphylaxis in children and adults".)

DEFINITIONS AND INCIDENCE

There are three recognized temporal patterns of anaphylaxis: uniphasic, biphasic, and protracted [1].

Uniphasic anaphylaxis — Uniphasic anaphylactic reactions are the most common type, accounting for an estimated 80 to 90 percent of all episodes. A uniphasic response usually peaks within 30 minutes to one hour after symptoms appear and resolves either spontaneously or with treatment within the next 30 minutes to one hour.

Protracted anaphylaxis — A protracted anaphylactic reaction lasts hours to days without clearly resolving completely. The exact frequency of protracted episodes of anaphylaxis is unknown, although they appear to be uncommon. The literature consists only of case reports and small series [2-6].

                    

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Mar 31 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Golden D. Patterns of anaphylaxis: Acute and late phase features of allergic reactions. In: Anaphylaxis, Wiley, Chichester [Novartis Foundation Symposium 257], 2004. p.101.
  2. Zisa G, Riccobono F, Calamari AM, et al. A case of protracted hypotension as unique symptom of a biphasic anaphylaxis to amoxicillin. Eur Ann Allergy Clin Immunol 2009; 41:60.
  3. Vinuya RZ, Simon MR, Schwartz LB. Elevated serum tryptase levels in a patient with protracted anaphylaxis. Ann Allergy 1994; 73:232.
  4. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med 1992; 327:380.
  5. Limb SL, Starke PR, Lee CE, Chowdhury BA. Delayed onset and protracted progression of anaphylaxis after omalizumab administration in patients with asthma. J Allergy Clin Immunol 2007; 120:1378.
  6. Lockey RF, Bukantz SC. Allergic emergencies. Med Clin North Am 1974; 58:147.
  7. Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol 2005; 95:217.
  8. Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics 2000; 106:762.
  9. Hogan MB, Kelly MA, Wilson NW. Idiopathic anaphylaxis in children. Ann Allergy Asthma Immunol 1998; 81:140.
  10. Järvinen KM, Amalanayagam S, Shreffler WG, et al. Epinephrine treatment is infrequent and biphasic reactions are rare in food-induced reactions during oral food challenges in children. J Allergy Clin Immunol 2009; 124:1267.
  11. Mehr S, Liew WK, Tey D, Tang ML. Clinical predictors for biphasic reactions in children presenting with anaphylaxis. Clin Exp Allergy 2009; 39:1390.
  12. Rudders SA, Banerji A, Corel B, et al. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics 2010; 125:e711.
  13. Stark BJ, Sullivan TJ. Biphasic and protracted anaphylaxis. J Allergy Clin Immunol 1986; 78:76.
  14. Douglas DM, Sukenick E, Andrade WP, Brown JS. Biphasic systemic anaphylaxis: an inpatient and outpatient study. J Allergy Clin Immunol 1994; 93:977.
  15. Brady WJ Jr, Luber S, Carter CT, et al. Multiphasic anaphylaxis: an uncommon event in the emergency department. Acad Emerg Med 1997; 4:193.
  16. Ellis AK, Day JH. Incidence and characteristics of biphasic anaphylaxis: a prospective evaluation of 103 patients. Ann Allergy Asthma Immunol 2007; 98:64.
  17. Brazil E, MacNamara AF. "Not so immediate" hypersensitivity--the danger of biphasic anaphylactic reactions. J Accid Emerg Med 1998; 15:252.
  18. Forrest-Hay A, Taylor C, Tolchard S. Biphasic anaphylaxis in a UK emergency department. Presented at Open Paper Presentations of the 2003 Scientific Symposium of the Resuscitation Council of the United Kingdom (Abstract).
  19. Brady WJ Jr, Luber S, Joyce TP. Multiphasic anaphylaxis: report of a case with prehospital and emergency department considerations. J Emerg Med 1997; 15:477.
  20. Brady WJ Jr, Bright HL. Occurrence of multiphasic anaphylaxis during a transcontinental air flight. Am J Emerg Med 1999; 17:695.
  21. Ellis AK, Day JH. Biphasic anaphylaxis with an unusually late onset second phase: a case report. Canadian J Allergy Clin Immunol 1997; 2:106.
  22. Smit DV, Cameron PA, Rainer TH. Anaphylaxis presentations to an emergency department in Hong Kong: incidence and predictors of biphasic reactions. J Emerg Med 2005; 28:381.
  23. Cortellini G, Corvetta A, Campi P, et al. A case of fatal biphasic anaphylaxis secondary to multiple stings: adrenalin and/or a longer observation time could have saved the patient? Eur Ann Allergy Clin Immunol 2005; 37:343.
  24. Novembre E, Calogero C, Mori F, et al. Biphasic anaphylactic reaction to Ketorolac tromethamine. Int J Immunopathol Pharmacol 2006; 19:449.
  25. Webb LM, Lieberman P. Anaphylaxis: a review of 601 cases. Ann Allergy Asthma Immunol 2006; 97:39.
  26. Grunau BE, Li J, Yi TW, et al. Incidence of clinically important biphasic reactions in emergency department patients with allergic reactions or anaphylaxis. Ann Emerg Med 2014; 63:736.
  27. Brown SG, Stone SF, Fatovich DM, et al. Anaphylaxis: clinical patterns, mediator release, and severity. J Allergy Clin Immunol 2013; 132:1141.
  28. Lee J, Garrett JP, Brown-Whitehorn T, Spergel JM. Biphasic reactions in children undergoing oral food challenges. Allergy Asthma Proc 2013; 34:220.
  29. Inoue N, Yamamoto A. Clinical evaluation of pediatric anaphylaxis and the necessity for multiple doses of epinephrine. Asia Pac Allergy 2013; 3:106.
  30. Nagano C, Ishiguro A, Yotani N, et al. [Anaphylaxis and biphasic reaction in a children hospital]. Arerugi 2013; 62:163.
  31. Liew WK, Chiang WC, Goh AE, et al. Paediatric anaphylaxis in a Singaporean children cohort: changing food allergy triggers over time. Asia Pac Allergy 2013; 3:29.
  32. Confino-Cohen R, Goldberg A. Allergen immunotherapy-induced biphasic systemic reactions: incidence, characteristics, and outcome: a prospective study. Ann Allergy Asthma Immunol 2010; 104:73.
  33. Scranton SE, Gonzalez EG, Waibel KH. Incidence and characteristics of biphasic reactions after allergen immunotherapy. J Allergy Clin Immunol 2009; 123:493.
  34. Popa VT, Lerner SA. Biphasic systemic anaphylactic reaction: three illustrative cases. Ann Allergy 1984; 53:151.
  35. Lertnawapan R, Maek-a-nantawat W. Anaphylaxis and biphasic phase in Thailand: 4-year observation. Allergol Int 2011; 60:283.
  36. Lieberman P. Anaphylaxis and anaphylactoid reactions. In: Middleton's allergy: Principles and practice, 6th ed, Adkinson NF, Yunginger JW, Busse WW, et al (Eds), Mosby, St. Louis, MO 2003. p.1497.
  37. Yang PC, Berin MC, Yu L, Perdue MH. Mucosal pathophysiology and inflammatory changes in the late phase of the intestinal allergic reaction in the rat. Am J Pathol 2001; 158:681.
  38. Choi IW, Kim YS, Kim DK, et al. Platelet-activating factor-mediated NF-kappaB dependency of a late anaphylactic reaction. J Exp Med 2003; 198:145.
  39. Vadas P, Gold M, Perelman B, et al. Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis. N Engl J Med 2008; 358:28.
  40. Alqurashi W, Stiell I, Chan K, et al. Epidemiology and clinical predictors of biphasic reactions in children with anaphylaxis. Ann Allergy Asthma Immunol 2015; 115:217.
  41. Grunau BE, Wiens MO, Rowe BH, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med 2015; 66:381.
  42. Lewis J, Foëx BA. BET 2: in children, do steroids prevent biphasic anaphylactic reactions? Emerg Med J 2014; 31:510.
  43. Lee S, Bellolio MF, Hess EP, Campbell RL. Predictors of biphasic reactions in the emergency department for patients with anaphylaxis. J Allergy Clin Immunol Pract 2014; 2:281.
  44. Ko BS, Kim WY, Ryoo SM, et al. Biphasic reactions in patients with anaphylaxis treated with corticosteroids. Ann Allergy Asthma Immunol 2015; 115:312.
  45. Kemp SF. The post-anaphylaxis dilemma: how long is long enough to observe a patient after resolution of symptoms? Curr Allergy Asthma Rep 2008; 8:45.
  46. Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology, American College of Allergy, Asthma and Immunology, Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005; 115:S483.
  47. Soar J, Deakin CD, Nolan JP, et al. European Resuscitation Council guidelines for resuscitation 2005. Section 7. Cardiac arrest in special circumstances. Resuscitation 2005; 67 Suppl 1:S135.
  48. Manivannan V, Hess EP, Bellamkonda VR, et al. A multifaceted intervention for patients with anaphylaxis increases epinephrine use in adult emergency department. J Allergy Clin Immunol Pract 2014; 2:294.
  49. Rohacek M, Edenhofer H, Bircher A, Bingisser R. Biphasic anaphylactic reactions: occurrence and mortality. Allergy 2014; 69:791.
  50. Cox L, Platts-Mills TA, Finegold I, et al. American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Report on omalizumab-associated anaphylaxis. J Allergy Clin Immunol 2007; 120:1373.