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Fatal anaphylaxis

S Allan Bock, MD
Section Editor
John M Kelso, MD
Deputy Editor
Anna M Feldweg, MD


Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. It has been estimated to be fatal in 0.7 to 2 percent of cases [1,2]. In humans, fatal anaphylaxis is difficult to study because it is rare, unpredictable, and often unwitnessed. In addition, there may be few postmortem findings and laboratory tests may be negative.

This topic will review the incidence, etiologies, epidemiology, clinical characteristics, possible risk factors, and postmortem diagnosis of fatal anaphylaxis as they pertain to these fundamental questions. The diagnosis and management of anaphylaxis in adults is presented separately [3]. (See "Anaphylaxis: Emergency treatment" and "Pathophysiology of anaphylaxis".)


The annual incidence of fatal anaphylaxis is not known precisely, although available estimates are less than one per million in the population [4-13]:

A study of anaphylaxis deaths in the United States found annual rates of 0.21 to 0.76 per million [5].

Centralized registries of fatal anaphylactic reactions from all causes have been established in the United Kingdom, France, and some other countries [6,7]. In the United Kingdom, one case of fatal anaphylaxis per three million individuals yearly (approximately 20 deaths a year) has been reported [8].

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Literature review current through: Nov 2017. | This topic last updated: Sep 07, 2017.
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  1. Moneret-Vautrin DA, Morisset M, Flabbee J, et al. Epidemiology of life-threatening and lethal anaphylaxis: a review. Allergy 2005; 60:443.
  2. Brown AF, McKinnon D, Chu K. Emergency department anaphylaxis: A review of 142 patients in a single year. J Allergy Clin Immunol 2001; 108:861.
  3. Simons FE, Ardusso LR, Dimov V, et al. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol 2013; 162:193.
  4. Simon MR, Mulla ZD. A population-based epidemiologic analysis of deaths from anaphylaxis in Florida. Allergy 2008; 63:1077.
  5. Ma L, Danoff TM, Borish L. Case fatality and population mortality associated with anaphylaxis in the United States. J Allergy Clin Immunol 2014; 133:1075.
  6. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144.
  7. Moneret-Vautrin DA, Kanny G, Morisset M, et al. Severe food anaphylaxis: 107 cases registered in 2002 by the Allergy Vigilance Network. Eur Ann Allergy Clin Immunol 2004; 36:46.
  8. Pumphrey R. Anaphylaxis: can we tell who is at risk of a fatal reaction? Curr Opin Allergy Clin Immunol 2004; 4:285.
  9. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46:1099.
  10. Low I, Stables S. Anaphylactic deaths in Auckland, New Zealand: a review of coronial autopsies from 1985 to 2005. Pathology 2006; 38:328.
  11. Jerschow E, Lin RY, Scaperotti MM, McGinn AP. Fatal anaphylaxis in the United States, 1999-2010: temporal patterns and demographic associations. J Allergy Clin Immunol 2014; 134:1318.
  12. Pouessel G, Claverie C, Labreuche J, et al. Fatal anaphylaxis in France: Analysis of national anaphylaxis data, 1979-2011. J Allergy Clin Immunol 2017; 140:610.
  13. Kivistö JE, Dunder T, Protudjer JL, et al. Adult but no pediatric anaphylaxis-related deaths in the Finnish population from 1996 to 2013. J Allergy Clin Immunol 2016; 138:630.
  14. Sheikh A, Alves B. Hospital admissions for acute anaphylaxis: time trend study. BMJ 2000; 320:1441.
  15. Sheikh A, Alves B. Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clin Exp Allergy 2001; 31:1571.
  16. Colver AF, Nevantaus H, Macdougall CF, Cant AJ. Severe food-allergic reactions in children across the UK and Ireland, 1998-2000. Acta Paediatr 2005; 94:689.
  17. Turner PJ, Gowland MH, Sharma V, et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012. J Allergy Clin Immunol 2015; 135:956.
  18. Foucard T, Malmheden Yman I. A study on severe food reactions in Sweden--is soy protein an underestimated cause of food anaphylaxis? Allergy 1999; 54:261.
  19. Schwartz HJ, Yunginger JW, Schwartz LB. Is unrecognized anaphylaxis a cause of sudden unexpected death? Clin Exp Allergy 1995; 25:866.
  20. Pumphrey RS, Davis S. Under-reporting of antibiotic anaphylaxis may put patients at risk. Lancet 1999; 353:1157.
  21. Gruchalla RS. 10. Drug allergy. J Allergy Clin Immunol 2003; 111:S548.
  22. Srinivasa MR, Phelan C. Death due to anaphylactic shock after ingestion of Imodium instants (Loperamide). Allergy 2007; 62:965.
  23. Fasting S, Gisvold SE. [Serious intraoperative problems--a five-year review of 83,844 anesthetics]. Can J Anaesth 2002; 49:545.
  24. Reid MJ, Lockey RF, Turkeltaub PC, Platts-Mills TA. Survey of fatalities from skin testing and immunotherapy 1985-1989. J Allergy Clin Immunol 1993; 92:6.
  25. Bernstein DI, Wanner M, Borish L, et al. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol 2004; 113:1129.
  26. Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol 2001; 107:191.
  27. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
  28. 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.
  29. Pumphrey RS, Stanworth SJ. The clinical spectrum of anaphylaxis in north-west England. Clin Exp Allergy 1996; 26:1364.
  30. Levy MB, Goldberg MR, Nachshon L, et al. Lessons from cases of mortality due to food allergy in Israel: cow's milk protein should be considered a potentially fatal allergen. Isr Med Assoc J 2012; 14:29.
  31. Noma T, Yoshizawa I, Ogawa N, et al. Fatal buckwheat dependent exercised-induced anaphylaxis. Asian Pac J Allergy Immunol 2001; 19:283.
  32. Flannagan LM, Wolf BC. Sudden death associated with food and exercise. J Forensic Sci 2004; 49:543.
  33. More DR, Kohlmeier RE, Hoffman DR. Fatal anaphylaxis to indoor native fire ant stings in an infant. Am J Forensic Med Pathol 2008; 29:62.
  34. Johansson B, Eriksson A, Ornehult L. Human fatalities caused by wasp and bee stings in Sweden. Int J Legal Med 1991; 104:99.
  35. Harvey P, Sperber S, Kette F, et al. Bee-sting mortality in Australia. Med J Aust 1984; 140:209.
  36. Mosbech H. Death caused by wasp and bee stings in Denmark 1960-1980. Allergy 1983; 38:195.
  37. Barnard JH. Studies of 400 Hymenoptera sting deaths in the United States. J Allergy Clin Immunol 1973; 52:259.
  38. Ji KM, Li M, Chen JJ, et al. Anaphylactic shock and lethal anaphylaxis caused by Houttuynia Cordata injection, a herbal treatment in China. Allergy 2009; 64:816.
  39. Gangemi S, Spagnolo EV, Cardia G, Minciullo PL. Fatal anaphylactic shock due to a dental impression material. Int J Prosthodont 2009; 22:33.
  40. Minciullo PL, Spagnolo EV, Cascio A, et al. Fatal anaphylactic shock and Taenia solium infestation: a possible link? Ann Allergy Asthma Immunol 2009; 103:449.
  41. Zimmerman B, Urch B. Peanut allergy: children who lose the positive skin test response. J Allergy Clin Immunol 2001; 107:558.
  42. Ownby DR, Tomlanovich M, Sammons N, McCullough J. Anaphylaxis associated with latex allergy during barium enema examinations. AJR Am J Roentgenol 1991; 156:903.
  43. Mullins RJ. Anaphylaxis: risk factors for recurrence. Clin Exp Allergy 2003; 33:1033.
  44. Webb LM, Lieberman P. Anaphylaxis: a review of 601 cases. Ann Allergy Asthma Immunol 2006; 97:39.
  45. Greenberger PA, Rotskoff BD, Lifschultz B. Fatal anaphylaxis: postmortem findings and associated comorbid diseases. Ann Allergy Asthma Immunol 2007; 98:252.
  46. Sampson MA, Muñoz-Furlong A, Sicherer SH. Risk-taking and coping strategies of adolescents and young adults with food allergy. J Allergy Clin Immunol 2006; 117:1440.
  47. Hoffman DR. Fatal reactions to hymenoptera stings. Allergy Asthma Proc 2003; 24:123.
  48. Pumphrey RS. Fatal anaphylaxis in the UK, 1992-2001. Novartis Found Symp 2004; 257:116.
  49. Lantner R, Reisman RE. Clinical and immunologic features and subsequent course of patients with severe insect-sting anaphylaxis. J Allergy Clin Immunol 1989; 84:900.
  50. Lenler-Petersen P, Hansen D, Andersen M, et al. Drug-related fatal anaphylactic shock in Denmark 1968-1990. A study based on notifications to the Committee on Adverse Drug Reactions. J Clin Epidemiol 1995; 48:1185.
  51. Pumphrey RS, Roberts IS. Postmortem findings after fatal anaphylactic reactions. J Clin Pathol 2000; 53:273.
  52. Yocum MW, Khan DA. Assessment of patients who have experienced anaphylaxis: a 3-year survey. Mayo Clin Proc 1994; 69:16.
  53. Stark BJ, Sullivan TJ. Biphasic and protracted anaphylaxis. J Allergy Clin Immunol 1986; 78:76.
  54. Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics 2000; 106:762.
  55. 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.
  56. Brown SG. Anaphylaxis: clinical concepts and research priorities. Emerg Med Australas 2006; 18:155.
  57. Pumphrey RS, Gowland MH. Further fatal allergic reactions to food in the United Kingdom, 1999-2006. J Allergy Clin Immunol 2007; 119:1018.
  58. Simons FE. First-aid treatment of anaphylaxis to food: focus on epinephrine. J Allergy Clin Immunol 2004; 113:837.
  59. Sasvary T, Müller U. [Fatalities from insect stings in Switzerland 1978 to 1987]. Schweiz Med Wochenschr 1994; 124:1887.
  60. Mueller UR. Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol 2007; 7:337.
  61. Brown SG. Cardiovascular aspects of anaphylaxis: implications for treatment and diagnosis. Curr Opin Allergy Clin Immunol 2005; 5:359.
  62. Kudoh O, Warabi K, Yamaguchi K, et al. [A case of anaphylactic shock in an elderly man following protamine sulfate administration during emergent off-pump coronary artery bypass grafting]. Masui 2006; 55:605.
  63. Pumphrey RS. Fatal posture in anaphylactic shock. J Allergy Clin Immunol 2003; 112:451.
  64. Ober AI, MacLean JA, Hannaway PJ. Life-threatening anaphylaxis to venom immunotherapy in a patient taking an angiotensin-converting enzyme inhibitor. J Allergy Clin Immunol 2003; 112:1008.
  65. Hepner MJ, Ownby DR, Anderson JA, et al. Risk of systemic reactions in patients taking beta-blocker drugs receiving allergen immunotherapy injections. J Allergy Clin Immunol 1990; 86:407.
  66. Fujita H, Osuna H, Kanbara T, et al. [Wheat anaphylaxis enhanced by administration of acetylsalicylic acid or by exercise]. Arerugi 2005; 54:1203.
  67. Shen Y, Li L, Grant J, et al. Anaphylactic deaths in Maryland (United States) and Shanghai (China): a review of forensic autopsy cases from 2004 to 2006. Forensic Sci Int 2009; 186:1.
  68. Murphy KR, Hopp RJ, Kittelson EB, et al. Life-threatening asthma and anaphylaxis in schools: a treatment model for school-based programs. Ann Allergy Asthma Immunol 2006; 96:398.