Patient information: Anaphylaxis symptoms and diagnosis

ANAPHYLAXIS OVERVIEW

Anaphylaxis is a potentially deadly allergic reaction that is rapid in onset. It is most often triggered by foods, medications, and insect stings. There are many other possible triggers.

Anaphylaxis is an unpredictable condition. Many people who experience it have a known allergy and some have had one or more milder allergic reactions previously. Others, who are not even aware that they have an allergy, can suddenly experience severe anaphylaxis. Even the first episode of anaphylaxis can be fatal.

The severity of anaphylactic reactions can be minimized by recognizing the symptoms early, having proper medication available for self-treatment, and seeking emergency medical care promptly. This topic reviews the symptoms and diagnosis of anaphylaxis. Treatment and prevention of anaphylaxis are discussed separately. A separate topic discusses how to use an epinephrine autoinjector. (See "Patient information: Anaphylaxis treatment and prevention" and "Patient information: Use of an epinephrine autoinjector".)

ANAPHYLAXIS SYMPTOMS

Symptoms of anaphylaxis generally begin within minutes to an hour of exposure to a trigger. Less commonly, symptoms do not develop for several hours.

The most common symptoms of anaphylaxis are hives (urticaria) and swelling of the skin (angioedema), which occur in 80 to 90 percent of reactions. Respiratory symptoms occur in about 50 percent of reactions, and are especially common in people who also have asthma or another chronic respiratory disease. Extremely low blood pressure, causing lightheadedness, dizziness, blurred vision, or loss of consciousness (passing out) occurs in about 30 percent of reactions.

Anaphylaxis can cause symptoms throughout the body:

• Skin: Itching, flushing, hives (urticaria), or swelling (angioedema)
• Eyes: Itching, tearing, redness, or swelling of the skin around the eyes
• Nose and mouth: Sneezing, runny nose, nasal congestion, swelling of the tongue, or a metallic taste
• Lungs and throat: Difficulty getting air in or out, repeated coughing, chest tightness, wheezing or other sounds of labored breathing, increased mucus production, throat swelling or itching, hoarseness, change in voice, or a sensation of choking
• Heart and circulation: Dizziness, weakness, fainting, rapid, slow, or irregular heart rate, or low blood pressure
• Digestive system: Nausea, vomiting, abdominal cramps, or diarrhea
• Nervous system: Anxiety, confusion, or a sense of impending doom

A severe form of anaphylaxis causes sudden collapse without other obvious symptoms, such as hives or flushing. This form of anaphylaxis occurs most commonly after a person is given a medication into a vein or is stung by an insect.

Up to 20 percent of people with anaphylaxis have biphasic (two-phase) or protracted (prolonged) anaphylaxis. A person with biphasic anaphylaxis has a reaction that resolves and then recurs hours later without further exposure to the trigger. The late phase reaction usually occurs within eight hours, but may occur up to 72 hours after the initial symptoms. A person with protracted anaphylaxis has signs and symptoms that persist for hours or even days despite treatment, although this is rare.

ANAPHYLAXIS TRIGGERS

The trigger for a person's anaphylaxis may be obvious or it may be difficult to identify.

Common anaphylaxis triggers can include:

• Foods: In children, hen's eggs, cow's milk, peanuts, tree nuts, fish, wheat, and soy are the most common food triggers.

In teens and adults, peanuts, tree nuts, fish, and crustaceans (shellfish such as shrimp) are the most common triggers.

Any food, including fruits and vegetables, and some spices and food additives, can cause anaphylaxis.

• Medications, especially certain antibiotics (such as penicillin or amoxicillin), medications for pain and fever (such as aspirin or ibuprofen), some x-ray dyes (also called radiocontrast media), and others
• Venom from insects, including bees, hornets, wasps, and fire ants
• Latex from natural rubber, found in some latex gloves, balloons, condoms, sports equipment, and medical products
• Allergen immunotherapy ("allergy shots"), such as those given for the treatment of allergic rhinitis (hay fever)
• Exercise, either by itself, or after eating certain foods (eg, wheat, celery, seafood), medications (eg, aspirin), or exposure to cold air/water
• Less common triggers include exposure to airborne allergens (such as horse dander), human seminal fluid, and cold temperatures.

Sometimes a specific trigger cannot be identified, even after a thorough evaluation. This condition is called idiopathic anaphylaxis. (See "Patient information: Anaphylaxis treatment and prevention".)

IgE mediated anaphylaxis — In most people, anaphylaxis is caused by the presence of proteins called immunoglobulin E (IgE) antibodies. IgE antibodies are normally produced in the body for the purpose of fighting certain infections. In people with allergies, however, IgE is made in response to non-infectious substances, such as foods, medications, or insect venoms. This IgE then sticks to the outside of mast cells and basophils, a type of white blood cell.

If a person with IgE antibodies to a specific allergen is exposed to that allergen again, the cells may suddenly become activated. The activated cells release large amounts of inflammation-causing chemicals (including histamine) into the blood stream, causing anaphylaxis.

The chemicals released from the cells cause the signs and symptoms typical of anaphylaxis. (See 'Anaphylaxis symptoms' above.) The allergic reaction can be so strong that it becomes life-threatening; for example, sudden severe swelling in the throat can lead to suffocation.

In some people with anaphylaxis, the reaction is caused by a process that does not involve allergens and IgE. However, the symptoms and treatment are the same.

ANAPHYLAXIS RISK FACTORS

Some people are more likely than others to experience anaphylaxis or to develop severe symptoms during anaphylaxis, for example, those who have one or more of the following:

• Previous sudden severe allergic reaction involving the whole body — People who have had allergic reactions to a particular substance in the past are at increased risk of anaphylaxis. However, the severity of past allergic reactions does not reliably predict the severity of future reactions; people with mild reactions in the past may experience severe anaphylactic reactions in the future.
• Asthma — People with asthma are more likely to have more severe respiratory problems during anaphylaxis. The combination of food allergy (especially to peanuts and tree nuts) and asthma seems to put people at risk for life-threatening episodes of anaphylaxis.
• Other diseases — People with chronic lung disease, especially older adults with chronic obstructive pulmonary disease (COPD) or emphysema, are at increased risk of complications during an anaphylactic reaction. People with coronary artery disease and other heart diseases are also at greater risk of developing complications during an anaphylactic reaction.

ANAPHYLAXIS DIAGNOSIS

The diagnosis of anaphylaxis is based upon symptoms that occur suddenly after being exposed to a potential trigger, such as a food, medication, or insect sting.

Is it anaphylaxis or another problem? — A number of other heath problems can cause symptoms that are similar to those of anaphylaxis. These include a severe asthma attack, a heart attack, a panic attack, or even food poisoning. Evaluation by a specialist can help to clarify the diagnosis.

Tryptase is a protein that is released into the blood during an anaphylactic reaction. An increased amount of tryptase can sometimes be measured in a blood sample collected during the first three hours after anaphylaxis symptoms have begun. Unfortunately, tryptase levels are normal in many people with anaphylactic reactions. For example, it is seldom elevated in food-induced anaphylaxis.

ANAPHYLAXIS TREATMENT

The treatment and prevention of anaphylaxis are discussed separately. (See "Patient information: Anaphylaxis treatment and prevention".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Anaphylaxis treatment and prevention
Patient information: Use of an epinephrine autoinjector

Professional Level Information:
Anaphylaxis: Rapid recognition and treatment
Clinical manifestations of food allergy: An overview
Diagnosis of Hymenoptera venom allergy
Diagnostic tools for food allergy
Differential diagnosis of anaphylaxis in children and adults
Drug eruptions
Fatal anaphylaxis
Food-induced anaphylaxis
History and physical examination in the patient with possible food allergy
Immediate hypersensitivity reactions to radiocontrast media
Laboratory tests to support the clinical diagnosis of anaphylaxis
Pathophysiology of anaphylaxis
Stings of Hymenoptera insects: Reaction types and acute management

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies, and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• American Academy of Allergy, Asthma, and Immunology

      (www.aaaai.org/patients/gallery/anaphylaxis.asp)

• American College of Allergy, Asthma, and Immunology

      (www.acaai.org/Member/Be_SAFE_Home.htm)

• Anaphylaxis Foundation and Anaphylaxis Network of Canada

      (www.anaphylaxis.org)

• The Anaphylaxis Campaign

      (www.anaphylaxis.org.uk)

• Food Allergy and Anaphylaxis Network

      (www.foodallergy.org/anaphylaxis/index.html)

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