Anaphylaxis is life threatening emergency. Where early management can someone's life. I discussed about Anaphylaxis, Sign Symptoms, Clinical Diagnosis and Management.

1. Anaphylaxis
We will Discuss the Anaphylaxis in a Nutshell…😁
Peanut Shellfish
Life threatening acute allergic reaction..

2. A Scene from Movie – Hitch (2005)

3. Case in Patenga, 2019
A 23 Years Old boy was Brought into the Emergency department by
his Friends. The patient had been well until he and his friends ate
Roadside Masala Crabs while they were for a outing in Patenga Sea
Beach. The Patient Initially complained of Intense Itching and
Shortness of Breath. His friends observed him having Frothy
Discharge from Mouth and Nose. Later His parents informed the
Doctor that he was Allergic to Shrimp.
That Night he Died in ICU.
What was the most Likely Cause of his Death?

4. Table of Contents
- What is Hypersensitivity Reaction?
- What is Anaphylaxis?
About the Disease
- Causes of Anaphylaxis
- Causes of Anaphylactoid
reaction
Aetiology
02
- Sensitization phase
- Re-exposure phase
Pathophysiology
03
- Sign & Symptoms
Clinical Manifestations
04
- Investigations
- Differential Diagnosis
Diagnosis
06
- Physician Supervised Treatment
Management
07
01
- Risk Factors
- Criteria for admission
Complications
08
EpiPen
Prevention
09
Case Definition
05
- Major & Minor Criteria
- Brightons Criteria

5. What is Hypersensitivity Reaction?
It is the term used when an Immune response results in exaggerated or
inappropriate reactions harmful to the host.
Can be subdivided into four main types.
Type Antibody or Cell
Mediated
Clinical Manifestation or Disease
Type -1 (Immediate,
Anaphylactic)
Antibody (IgE) Systemic Anaphylaxis, Urticaria (hives), asthma, hay
fever, allergic rhinitis & conjunctivitis, eczema.
Type -2 (Cytotoxic) Antibody (IgG) Hemolytic anemia, neutropenia, Rh incompatibility
(erythroblastosis fetalis), rheumatic fever.
Type -3 (Immune
Complex)
Antibody (IgG) Systemic lupus erythematosus (SLE), rheumatoid
arthritis, poststreptococcal glomerulonephritis
Type -4 (Delayed) Cell Mediated Contact dermatitis, tuberculin test, erythema
multiforme.

6. What is Anaphylaxis?
- Ana (Without), Phylaxis (Protection).
- It is a Potentially life threatening
systemic allergic reaction which is
characterized by circulatory collapse,
bronchospasm, laryngeal stridor, often
associated with angioedema and
urticaria.

7. Common causes of Anaphylaxis
Peanuts
Tree Nuts
Fish and Shellfish
Milk
Egg
Soy Products
Food Dyes
Foods
Bee Venom
Wasp Venom
Ants
Hornets
Insect Stings
- Penicillin and
Other Antibiotics, Insulin
- Latex
- Vaccines (Covid19, Influenza)
- I/V Anesthetic agents (Eg.
Suxamethonium, Propofol)
Chemical and Drugs
- It is the protein in peanut, shellfish and bee venom that crosslink adjacent IgEs and trigger the release of
mediators from Mast cell and Basophil.
- Drug such as penicillin are haptens that need to bind to human protein to crosslink adjacent IgEs

8. Causes of Anaphylaxis Continued..
To which most people do not exhibit clinical symptoms, However some individuals
respond to those substances by producing large amount of IgE.
Non-allergic individuals responds to the same antigen by producing IgG, Which
doesn’t cause release of Mediators as there are no receptor for IgG on Mast Cell
and Basophils.
34%
37%
20%
7%
2%
Causes of anaphylaxis in a study of 266 Patients (Data from Kemp et al)
Food
Idiopathic
Drugs
Exercise
Latex and Others

9. Pathophysiology

10. Mediators & Their Biological effects
1) Pre-formed and Stored within Granules :
2) Synthesized on activation of Mast Cell :
Histamine Vasodilation, Chemotaxis, bronchoconstriction,
increased capillary permeability & mucus secretion
Tryptase Bronchoconstriction, activates complements C3
Eosinophil chemotactic factors Eosinophil chemotaxis
Neutrophil chemotactic factors Neutrophil chemotaxis
Biological Effects
Biological Effects
Leukotrienes Increase vascular permeability, Chemotaxis,
Mucus secretion and smooth muscle contraction
Prostaglandins Bronchoconstriction, Platelet aggregation &
Vasodilation
Thromboxanes Bronchoconstriction
Platelet-activating factor Bronchoconstriction, Chemotaxis of eosinophils
and neutrophils.

11. Clinical Manifestations
Sign-Symptoms depend in large part on
- On the route of entry of the allergen
- on the location of mast cell bearing the IgE specific for the allergen.
For Example:
- Someone exposed to pollen in the air get hay fever
- Who ingest allergens in food get Diarrhea

12. Sign-Symptoms
- Skin : Itching, Flushing, Hives (Urticaria), sweating,
Swelling
- CNS : Lightheadness, Loss of Conciousness, Confusion,
Headache
- Eyes : Itching, Tearing, Redness or Swelling around the
eyes
- Nose and Mouth : Sneezing, Runny Nose, Nasal
Congestion, Swelling of the Tongue or a Metallic Taste
- Lungs and Throat : Difficulty breathing, Coughing,
Chest Tightness, Wheezing, Increased Mucus
Production, Throat Swelling or Itching, Change in
Voice, Sensation of Choking
- Heart and Circulation : Dizziness, Weakness, Fainting,
Rapid-Slow or Irregular Heart Rate and Hypotension
- Digestive System : Nausea, Vomiting, Cramps or
Diarrhea
- Others : Loss of Bladder control
Davidson’s Principles and Practice of Medicine, 23rd edition. Page : 75

13. Frequency of Symptoms in Anaphylaxis
Symptoms Percentage
Urticaria / Angioedema 85-90%
Upper airway oedema 50-60%
Dyspnea or Wheeze 45-50%
Flushing 45-55%
Dizziness, Hypotension, Syncope 30-35%
GIT Symptoms (Diarrhea, Cramps) 25-30%
Rhinitis 15-20%
Adapted from “Lieberman P in : Allergy: Principle and Practice, Elsevier Inc, 2009

14. Case Definition of Anaphylaxis
J.U Ruggeberg et al.Vaccine 25 (2007) 5675-5684
For all levels of diagnostic certainty
Anaphylaxis is a clinical syndrome characterized by
• sudden onset AND
• rapid progression of signs and symptoms AND
• involving multiple (≥2) organ systems, as follows
Level 1 of diagnostic certainty
• ≥1 major dermatological AND
• ≥1 major cardiovascular AND/OR ≥1 major respiratory
criterion
Level 2 of diagnostic certainty
• ≥1 major cardiovascular AND ≥ 1 major respiratory
criterion OR
• ≥1 major cardiovascular OR respiratory criterion AND
• ≥1 minor criterion involving ≥1 different system (other
than cardiovascular or respiratory system) OR
• (≥1 major dermatologic) AND (≥1 minor cardiovascular
AND/OR minor respiratory criterion)
Level 3 of diagnostic certainty
• ≥1 minor cardiovascular OR respiratory criterion AND
• ≥1 minor criterion from each of ≥2 different
systems/catagories
No KNOWN or
UNKNOWN
allergen exposure
LIKELY
allergen
exposure
KNOWN
allergen
exposure
Decreased BP,
collapse, syncope,
incointinence
Respiratory signs
Acute onset of
skin signs-
Urticaria, angio-
oedema
And at least 1 of
the following
Skin signs
Respiratory
signs
Low BP
GI signs
And 2 or more of
the following
Low BP
And
Anaphylaxis

15. Major & Minor Criteria
Major Criteria
Dermatologic
or mucosal
• generalized urticaria (hives) or generalized
erythema
• angioedema, localized or generalized
• generalized pruritus with skip rash
Cardiovascular • measured hypotension
• clinical diagnosis of uncompensated shock,
indicated by the combination of at least 3 of the
following:
• tachycardia
• capillary refill time >3 s
• reduced central pulse volume
• decreased level of consciousness or loss of
consciousness
Respiratory • bilateral wheeze (bronchospasm)
• stridor
• upper airway swelling (lip, tongue, throat, uvula, or
larynx)
• respiratory distress--2 or more of the following:
• tachypnoea
• increased use of accessory respiratory
muscles(sternocleidomastoid, intercostals, etc.)
• recession
• cyanosis
• grunting
Minor Criteria
Dermatologic
or mucosal
• generalized pruritus without skin rash
• generalized prickle sensation
• localized injection site urticaria
• red and itchy eye
Cardiovascular • reduced peripheral circulation as indicated by
the combination of at least 2 of
• tachycardia and
• a capillary refill time of >3s without
hypotension
• a decreased level of consciousness
Respiratory • persistent dry cough
• hoarse voice
• difficulty breathing without wheeze or stridor
• sensation of throat closure
• sneezing, rhinorrhea
Gastrointestinal • diarrhea
• abdominal pain
• nausea
• vomiting
Laboratory • Mast cell tryptase elevation > upper normal
limit

16. 4 steps of Brightons criteria
Step 1) : Select the diagnostic categories represented by the clinical symptoms and signs of the suspected case.
Major :
• Dermatologic and Mucosal
• Cardiovascular
• Respiratory
Minor
• Dermatologic and Mucosal
• Cardiovascular
• Respiratory
• Gastrointestinal
• Laboratory
Select the column from the table representing the highest-ranking diagnostic category present.
(i.e: major > minor, dermatology > laboratory
Step 2) :
Step 3) : Select a row from the table indicating the second highest ranking diagnostic category present.
The intersection gives the level of diagnostic certainty of the case based on the Brightons definition.
Blank intersections do not fulfill the case definition at any level.
Step 4) :
Algorithm
Symptom One
DERM CVS RESP cvs resp
Symptom
Two
CVS 1 - 2 - 2
RESP 1 2 - 2 -
derm - 2 2 3* 3*
cvs 2 - 2 - 3*
resp 2 2 - 3* -
git - 2 2 3* 3*
lab - 2 2 3* 3*
Capitals: 1 or more MAJOR criteria in that system;
Lower case: 1 or more minor criteria.
Columns or Rows in CAPITALS indicate that 1 or
more MAJOR criteria are present in that category.
Columns or Rows in Lower case indicate that 1 or
More minor criteria are present.
Level 3 diagnostic certainty requires 2 or more rows
To be present in either the “cvs” or “resp” minor
Criteria column.
1 - Level 1 diagnostic certainty
2 - Level 2 diagnostic certainty
3*- Level 3 diagnostic certainty requires two or
more minor criteria to be present in this column

17. What is Anaphylactoid Reaction?
Non IgE mediated mast cell degranulation, which appear clinically similar to
anaphylactic reaction.
Causes of Anaphylactoid reaction:
Drugs: Physical: Idiopathic:
- The differences between “Anaphylaxis” and “Anaphylactoid reaction” is Previous sensitization
doesn’t required in Anaphylactoid reaction. May occur in 1st Exposure.
- The clinical features of “Anaphylaxis” and “Anaphylactoid reaction” are indistinguishable.
“Anaphylaxis যেভাবেই য াক েডি েবে IgE যেটাই য ার”
- Aspirin
- NSAIDs
- Opiates
- Radio Contrast media
- Exercise
- Cold
No cause is identified
in 20% cases

18. Diagnosis
Diagnosis is Usually Clinical. The Diagnosis of an Anaphylactic
Reaction depends on History revealing the onset of Sign-Symptoms
within Minutes after the responsible material is encountered.
- Serum Tryptase Concentration : Released along with histamine
can be Measureable (Confirmatory)
- Specific IgE Test (Confirmatory)
- Skin Prick Test
Investigations

19. Management: Anaphylactic Reaction?
ABCDE - Airway, Breathing, Circulation, Disability, Exposure
Diagnosis – Look for :
• Acute onset of illness
• Life-threatening Airway and/or Breathing and/or Circulation problems
• And usually skin changes
• Call for Help
• Lie patient in “Trendelenburg” Position (Lie flat,
Head Decline, Raise Leg)
Adrenaline (Epinephrine)
When skills and equipment available:
• Establish airway
• High flow oxygen
• I/V fluid
• Chlorphenamine
• Hydrocortisone
Monitor
• Pulse oximetry
• ECG
• Blood Pressure
Life-threatening problems:
Airway: swelling,
hoarseness, stridor.
Breathing: rapid breathing,
wheeze, fatigue, cyanosis,
Spo2 < 92%, confusion
Circulation: pale, clammy,
low BP, faintness,
drowsy/coma

20. Management continued…
During an anaphylactic attack, an emergency medical team may perform Cardiopulmonary Resuscitation (CPR)
If the patient stops breathing or his heart stops beating.
Treatment Comment
Prevent further contact with allergen Prevent ongoing mast cell activation
Place patient in ‘Trendelenburg Position’ Increase venous return to heart
Ensure airway patency Prevents hypoxia
Administer adrenaline (epinephrine) promptly:
0.3 – 1.0 mL 1 : 1000 IM in adults. Repeat at
5-10 min intervals if initial response is inadequate
I/M route is important because of peripheral
vasoconstriction. Acts within minutes.
Increase BP, reverse bronchospasm.
Administer antihistamines:
Chlorphenamine 10 mg IM or slow IV injection
Blocks effect of histamine on target cells
Administer glucocorticoids:
Hydrocortisone 200mg IV
Reduces cytokine release,
Prevents rebound symptoms in severe cases.
Provide supportive treatment:
Nebulized B2 agonists (Sulbutamol)
IV Fluids Oxygen
Reverse bronchospasm
Restore plasma volume
Reverses hypoxia

21. Factors affecting the Incidence and or Severity of Anaphylaxis
o Age
o Comorbidities (BA, Cardiac Diseases)
o Concurrent medication/Chemical Use (B-blockers, ACEi therapy,
Rapid I/V Allergen)
o Failure to administer epinephrine immediately
o Positive family history
● Unresolved symptoms
● High risk for biphasic reaction
● Delayed epinephrine treatment
● Co-Morbidities
Criteria for Hospital Admission

22. Biphasic Reactions
● Delayed anaphylactic reaction developing after initial reaction has
resolved.
● Occurs in about 1-20% of all anaphylactic reactions.
● Asymptomatic intervals range from 1-28 hours.
● Can occur up to 72 hours from initial reaction.
● Length of observation should be at least 24 hours.
● The only intervention that has been shown to reduce the prevalence and
severity of biphasic allergic reactions is “early treatment with IM
Epinephrine”

23. Prevention
- Avoidance of the inciting allergens such as pollen, is helpful in
prophylaxis.
- If there is a definite history of a past anaphylactic reaction to
medication, it is advisable to select a structurally unrelated agent.
- Proper labeling of ingredients of food products.
- Desensitization can also be helpful.
- Wear and carry warning identification tags. (“MedicAlert Bracelet”)
Complications
- Airway Blockage
- Cardiac Arrest
- Respiratory arrest
- Shock

24. Differential Diagnosis
Causes of Generalized Flushing
• Carcinoid
• Phaeochromocytoma
• Systemic mastocytosis
• Hereditary angioedema.
Causes of hypotension
• Vasovagal syncope
• Cardiogenic shock
• Cardiac arrythmia
Causes of respiratory distress, Laryngeal obstruction
• Status asthmaticus
• Pulmonary embolus
• Idiopathic angioedema

25. EpiPen
Epinephrine, The only medication that can stop the progression
of anaphylaxis and reverse the symptoms.
The epinephrine auto-injector was introduced in 1980. Such as
“EpiPen” & “EpiPen Jr” are designed for single dose I/M injection
for emergency treatment of anaphylaxis.
EpiPen
0.3mg
EpiPen Jr
0.15mg

26. Our Team
Intern Doctor of Medicine,
BBMH
Intern Doctor of Medicine,
BBMH
Dr. Misbaul Hoque Dr. Umme Habiba Shipa

27. References:
● Davidson’s Principles and Practice of Medicine (23rd Edition)
● Harrison’s Principles of Internal Medicine (19th Edition
● Lange - Review of Medical Microbiology and Immunology (16th Edition)
● Anaphylaxis: Case definition and guidelines for data collection, analysis, and
presentation of immunization safety data (ELSEVIER)

28. Quote for NORMAL People :
Thank You
STOP running away from your Problems,
It is Time to face them..
Quote for ALLERGIC People :
KEEP running away from your Problems,
Better never face them..