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- 1. Allied Care Experts(ACE) Medical Center – Tacloban Department of Pediatrics A Case Presentation of S.O.Y. Maurice Clemense Oballo-Uy, MD Level 1 Resident September 19, 2023
- 2. OBJECTIVES 1. To presenta case of S.O.Y., a 16-year-old male who came in for syncope and urticaria. 2. To present the history, physical examination and clinical manifestations of the patient. 3. To discuss the etiology and pathophysiology of Anaphylaxis. 4. To discuss the manifestations and differential diagnosis of the case. 5. To discuss the diagnosis, treatment, complications and prognosis of Anaphylaxis.
- 3. -S.O.Y. -16-year-old -Male -Filipino, -born on December26, 2006 -Roman Catholic, -Basey, Western Samar, Philippines -Admitted last July 27, 2023 General Profile
- 4. CHIEF COMPLAINT Loss of Consciousness, Rashesand Slurring of Speech
- 5. History of PresentIllness 16 hours PTA (5PM) Chest pain DOB Body Weakness • described as heaviness • nonradiating while lying on bed Syncope • 2 episodes, 2nd attack was witnessed by his sibling, described as complete loss of consciousness of approximately <1min preceded by blurring and tunneled vision with spontaneous recovery No noted fever, seizure, abdominal pain, vomiting, incontinence, oral trauma, confusion nor myalgias
- 6. History of PresentIllness Patient was brought to a district hospital Pruritic erythematous wheals at the face and chest BP 160/100 mmHg CBC PC, Blood Chemistry, Serum electrolytes • Given Carvedilol 25 mg/tab, 1 dose • Given Diphenhydramine 50 mg one dose intravenously which afforded temporary relief Urinalysis, ECG, CXR PAL • Normal • Hgb 163 g/L, Hct0.50 l/l, with neutrophilia at 81% and decreased lymphocytes of 15%, Plt ct of 329 l/I • BUA 530 umol/L • Crea 90.4 umol/L • BUN levels at 3.60 mmol/L, • SGPT 34.4 U/L • SGOT 22.7 U/L • K 3.3 mmol/L • Na levels at 137 mmol/L • ionized calcium 109 mmol/L
- 7. History of PresentIllness 12 hours PTA (9PM) • Hypersensitivity Disorder Transfer to private hospital Essential Hypertension • stayed at hospital for <24hours • Hydrocortisone 100mg IVTT every 12 hours, Diphenhydramine 25mg IVTT every 12 hours, Omeprazole 40mg IVTT every 24 hours Cough • Salbutamol nebulization every 6 hours • Carvedilol 25 mg/tab, one tablet once daily • BP level range was 130-160/90- 100mmHg
- 8. History of PresentIllness 2 hours PTA (7AM) • Syncope Still at the private hospital Chest discomfort • preceded by pallor, diaphoresis, tinnitus, blurring and tunneled vision and bilateral lower extremity weakness • Witnessed by cousin Dyspnea • PS 5-6/10, nonradiating
- 9. History of PresentIllness 2 hours PTA (7AM) • Slurring of speech Still at the private hospital Body weakness • Assessed by nurse on duty • Awake, lying in bed, diaphoretic, pale with slurred speech • VS: BP 160/100 mmHg, tachycardia at 110, tachypnea at 45cpm, afebrile at 37.4C. • No incontinence, head and oral trauma, seizures or vomiting noted. Chest heaviness Abdominal pain, dull aching PS 7- 8/10
- 10. History of PresentIllness 2 hours PTA (7AM) • Hypertensive Still at the private hospital Tachypneic, Tachycardic • Assessed by physician on duty Febrile 38.4C Generalized body weakness Motor strength 3/5, 100%sensation and normorefflexia on all 4 extremities Slurring of speech Recurrence and worsening of wheals on the face, chest and abdomen
- 11. History of PresentIllness 2 hours PTA (7AM) • Hypertensive Still at the private hospital Tachypneic, Tachycardic • Assessed by physician on duty Febrile 38.4C Generalized body weakness Motor strength 3/5, 100%sensation and normorefflexia on all 4 extremities Slurring of speech Recurrence and worsening of wheals on the face, chest and abdomen Clonidine 75mg/ tab, one tablet sublingual Paracetamol 300mg IVTT stat dose
- 12. History of PresentIllness 2 hours PTA (7AM) • Hypertensive Still at the private hospital Tachypneic, Tachycardic • Assessed by physician on duty Febrile 38.4C Generalized body weakness Motor strength 3/5, 100%sensation and normorefflexia on all 4 extremities Slurring of speech Recurrence and worsening of wheals on the face, chest and abdomen Clonidine 75mg/ tab, one tablet sublingual Paracetamol 300mg IVTT stat dose Referred to our institution for close monitoring at the intensive care unit & evaluation of other pediatric subspecialties (Pediatric Neurology, Pediatric Allergology, Pediatric Cardiology and Pediatric Intensivist)
- 13. Review of Systems ●SKIN (+)Blanchable, eythematous, raised rashes (+)Flushed skin ● HEENT (+)Headache (+)Dizziness (+)Blurring and tunneling of vision (-)Ear pain (-)No loss of voice (-)No hoarsness ● RESPIRATORY/CARDIAC (+)Dyspnea (+)Cough, nonproductive (+)Chest pain (+)Palpitations ● HEMATOLOGIC ● GASTROINTESTINAL (-)Loss of appetite (+)Abdominal Pain (-)Post-tussive Vomiting (-)Diarrhea ● URINARY (-)Dysuria (-)Urinary incontinence ● MUSCULOSKELETAL (-)Joint pain (-)Body malaise ● NEUROLOGIC (-)Seizures (+)Syncopal attacks, 3 episodes (1x 2022, 2x 2023) (-)Tremors/Numbness
- 14. PRENATAL ● 27 year-oldG3P3 ● Nonhypertensive ● Nondiabetic ● Non-alcoholic ● Non-smoker ● Urinary Tract Infection on the second trimester of pregnancy but no medications were given NATAL ● Born live term via NSD at home assisted by a traditional birth attendant ● No cord coil ● Clear amniotic fluid ● Good cry, good activity ● Birth weight unrecalled POSTNATAL • Newborn screening and hearing tests not done • Breastfed for 6 months • Immunizations given at RHU • Developmental milestones at par with age • Received Covid 19 vaccination (Pfizer) for 2 doses
- 15. 24-HOUR DIET RECALL 2slices canned luncheon meat (Maling), ½ cup rice ½ cup pork adobo, ½ cup rice ¼ cup ground pork, ½ cup rice ½ slice fried bangus, ½ cup rice biscuit BREAKFAST LUNCH SNACK DINNER BREAKFAST
- 16. Past Medical History ●Known allergies to various foods (egg, canned and preserved goods, chicken, crustaceans) ● Episodes of asthma-like attacks ○ shortness of breath and wheezing since 1 month old ○ no maintenance medications ○ last attack was last 2009 and was given Cetirizine and Salbutamol nebulization which afforded with relief of dyspnea. ● In 2022, admitted at a local government hospital due to difficulty of breathing and loss of consciousness for less than 1 minute- discharged improved after 3 days with unrecalled home medications ● Diagnosed with Cold Urticaria, 7 days prior to admission ○ Private Dermatologist ○ Advised to take Fexofenadine Hydrochloride 120mg/tab, once daily and to apply Clobetasol propionate 0.05% cream to affected areas as well as Vitamin C Supplementation-with good compliance in the past 6 days
- 17. FAMILY GENOGRAM MATERNAL AUNT Anaphylaxis with Epipen emergency use 43 Y/O MOTHER Hypertensive 49 Y/O FATHER Hypertensive 19 Y/O 17 Y/O 16 Y/O Allergy Cold Urticaria Hypertension 13 Y/O 8 Y/O 3 Y/O MATERNAL GRANDPARENTS Hypertensive PATERNAL GRANDPARENTS Hypertensive and Diabetics
- 18. Personal and SocialHistory • Both parents manage a family-owned business • He lives in a two-storey fully concrete house with good ventilation and electricity source, which is shared with nine household members-no sick family members • The source of drinking water is mineralized bought from a refilling station • The garbage is collected three times weekly • The family owns cats as pets • No noted exposure to cigarette smoking
- 19. HEEADSSS HOME • Liveswith parents and five other siblings. • Has hown room in a concrete 2-storey family-owned house. • Has a good relationship and open communication with all family members EDUCATION • Grade 11 honor student and athlete in Liceo del Verbo Divino, Tacloban City • Goes to the same school with two other siblings • Denies experiencing bullying in school • Felt safe in school EATING HABITS • Not a picky eater with good appetite • Reported allergies to foods such as chicken, eggs, crustaceans, and canned goods • Not concerned about his weight nor body changes
- 20. HEEADSSS ACTIVITIES • Playsvolleyball and enjoys playing mobile games • Spends an ample time in different social media platforms DRUGS/ ALCOHOL • Denies illicit drug use • Nonsmoker and non-alcoholic beverage drinker SEXUALITY • Have a bisexual orientation and is attracted to both sexes, male and female, but denies engaging in sexual activities in any form
- 21. HEEADSSS SUICIDALITY • Hadsuicidal ideation during the pandemic but claims that he never made a plan or acted upon this ideations • He felt low and depressed because of the social isolation but denies hurting himself • He negates any major family problems SAFETY • Feels safe at home and in the neighborhood • Denies any experience of abuse. He has not encountered any major accidents • His confidant is his female cousin of the same age bracket who currently lives with them
- 22.
- 23. GENERAL SURVEY: The patientwas drowsy with slurred speech, but is coherent and obeys commands, oriented to time, place and person, well- nourished, well-developed, in cardiorespiratory distress Vital Signs (at the ER): BP: 135/52 mmHg HR: 90 bpm RR: 27 cpm Temp: 37.9 C CRT <2 seconds O2 sat: 100% on O2 support at 5LPM via nasal cannula
- 24. Weight: 65 kg Height:157 cm BMI: 26.4 kg/m2 (93th percentile for boys aged 16 years old or overweight)
- 25. Head: Symmetrical facial featureswith generalized wheals (blanchable, eythematous, raised rashes, some linear and annular) sparing periorbital and perioral areas; no palpable head mass, hair normal texture and equally distributed EENT: Anicteric sclerae, pink palpebral conjunctiva, eyes not sunken; symmetrical, midline nose with nasal discharge, angioedema of eyelid, lips and tongue; tonsils not assessed; no cervical lymphadenopathy
- 26. CARDIOVASCULAR SYSTEM: Adynamic precordium, tachycardic,regular rhythm, distinct S1 and S2, no murmur CHEST AND LUNGS: Urticarial rashes and wheals on chest and back; symmetrical chest expansion, fine crackles left lung field, no wheeze, no retractions
- 27. EXTREMITIES: Grossly normal extremities withurticarial rashes, no edema, no clubbing, full and equal pulses ABDOMEN: Flabby, with urticarial rashes noted, normoactive bowel sounds, soft, nontender, tympanitic all over SEXUAL DEVELOPMENT (TANNER’S SEXUAL MATURITY RATING): Stage IV- increased size of penis, nonedematous, with growth in breadth and development of glans; testes and scrotum larger, scrotal skin darker
- 28. MENTAL STATUS drowsy, coherent,slurred speech, oriented to time, place and person GLASCOW COMA SCALE 12 (E4V2M6) CN I- no anosmia CN II, III- pupils equal, reactive to light and accomodation with good peripheral vision CN III, IV, VI- no nystagmus, intact EOM CN V, VII- (+) corneal reflex CN VII-no facial asymmetry CN VIII-no hearing loss; responsive to verbal stimuli CN IX, X- intact gag reflex CN XI-able to turn head and shrug shoulder against mild resistance CN XII-tongue at midline, no fasciculations
- 29. Motor- No atrophy;decreased muscle strength at 3/5 Sensory- Intact sensory function of both lower and upper extremities to light touch and pressure, withdraws from painful stimulus equally Reflex- Normoreflexia 2+ Cerebellar-no dysdiadokinesia, well-coordinated movements Meningeal- no nuchal rigidity, negative Kernig’s sign, negative Brudzinki’s sign Pathologic-negative Babinski, negative Chaddok
- 30.
- 31. 16-year-old Male Asian, livesin Basey, Western Samar, Philippines Syncope Urticaria Allergy to foods (egg, canned and preserved goods, chicken and crustaceans) Cold Urticaria Acute onset of symptoms after intake of known allergen (canned luncheon meat) Difficulty of breathing
- 32. Chest pain/ heaviness, nonradiating Body weakness Syncopalattacks, recurrent Cough, nonproductive Slurring of speech Urticarial rash, pruritic erythematous, generalized wheals, recurrent Hypertension Diaphoresis Abdominal pain
- 33. Spontaneous recovery No seizure No vomitingNo fever No incontinence No confusion No myalgias No oral trauma No headache
- 34. ROS-no weight change ROS- no night sweats ROS-no orthopnea ROS- no hoarseness ROS- flushed skin ROS- no bleeding history ROS- no loss of voice ROS- cough, productive ROS- no cyanosis
- 35. ROS-no anorexia ROS- nochange in bowel movements History of asthma- like attacks (SOB and wheezing) Strong family history of BA Strong family history of hypertension Previous admission (2022, DOB & LOC) Strong family history of Anaphylaxis with epinephrine pen use Plays vollleyball Bisexual orientation
- 36. Had suicidal ideations Feltlow and depressed because of social isolation PE- drowsy with slurred speech PE- coherent, obeys command oriented to time, place and person In cardiorespiratory distress BP 135/52 mmHg, HR 90bpm, RR 27 cpm, T37.9C, CRT <2 secs, 100% on O2 support BMI 26.4 overweight PE-Generalized urticaria (linear and annular wheals sparing periorbital and perioral areas)
- 37. Midline nose with nasal discharge Angioedemaof eyelids, lips and tongue PE-fine crackles, left lung field; no wheeze; good air entry Soft abdomen, normoactive bowel sounds, nontender GCS 12 (E4V2M6) Nonedematous penis, stage IV Full equal pulses, no edema No facial asymmetry, tongue midline Decreased muscle strength 3/5 in all extremities
- 38. Weak functional grip No lossof sensation Normoreflexia No involuntary movements No nuchal rigidity No Babinski
- 39. Admitting Diagnosis Hypertensive Emergency; T/cStroke in the Young; Hypersensitivity Disorder probably secondary to food intake
- 40. HYPERTENSIVE EMERGENCY Age >13years old: >30mmHg above 95th percentile or 16 years old Height 157 cm SBP 95th percentile: 130mmHg DBP 95th percentile: 80mmHg BP 160/110mmHg Signs of end-organ damage: • Headache • Visual changes • Seizure • Altered mental status • Chest pain • Shortness of breath
- 41. Differential Diagnosis 01 04 02 05 03 06 Hypertensive Emergency Hypersensitivity Reaction Strokein the Young Coarctation of the Aorta Pheochromocyto ma Systemic Mastocytosis 07 Serum Sickness 08 Parasitism (Schistosomiasis Infection)
- 43. DIFFERENTIAL DIAGNOSIS HYPERSENSITIVITY REACTION STROKE IN THEYOUNG COARCTATION OF AORTA PHEOCHROMOCYTOMA TRIGGER • Known allergen Canned luncheon meat AGE and SEX-RELATED FACTORS • Adolescent • Male CO-FACTORS • Acute infection- presence of fever • Asian Filipino CONCOMITANT DISEASE • Cold Urticaria • Hypertension • Felt depressed and low; suicidal ideation
- 44. DIFFERENTIAL DIAGNOSIS HYPERSENSITIVITY REACTION STROKE IN THEYOUNG COARCTATION OF AORTA PHEOCHROMOCYTOMA GENERAL • Body weakness • Diaphoresis SKIN OR MUCOSAL INVOLVEMENT • Generalized urticaria • Angioedema • Flushed skin RESPIRATORY • Difficulty of breathing • Cough, productive CARDIOVASCULAR • Tachycardia • Palpitation
- 45. DIFFERENTIAL DIAGNOSIS HYPERSENSITIVITY REACTION STROKE IN THEYOUNG COARCTATION OF THE AORTA PHEOCHROMOCYTOMA END-ORGAN DYSFUNCTION • Syncope • Chest pain GASTROINTESTINAL SYMPTOMS • Abdominal pain CNS SYMPTOMS • Headache • Dizziness • Slurring of speech • Blurring of vision TOTAL 17 12 5 10
- 46. DIFFERENTIAL DIAGNOSIS SYSTEMIC MASTOCYTOSIS SERUM SICKNESS TRIGGER • Knownallergen Canned luncheon meat AGE and SEX-RELATED FACTORS • Adolescent • Male CO-FACTORS • Acute infection- presence of fever • Asian Filipino CONCOMITANT DISEASE • Cold Urticaria • Hypertension • Felt depressed and low; suicidal ideation
- 47. DIFFERENTIAL DIAGNOSIS SYSTEMIC MASTOCYTOSIS SERUM SICKNESS GENERAL • Bodyweakness • Diaphoresis SKIN OR MUCOSAL INVOLVEMENT • Generalized urticaria • Angioedema • Flushed skin RESPIRATORY • Difficulty of breathing • Cough, productive CARDIOVASCULAR • Tachycardia • Palpitation
- 48. DIFFERENTIAL DIAGNOSIS SYSTEMIC MASTOCYTOSIS SERUM SICKNESS END-ORGAN DYSFUNCTION •Syncope • Chest pain GASTROINTESTINAL SYMPTOMS • Abdominal pain CNS SYMPTOMS • Headache • Dizziness • Slurring of speech • Blurring of vision TOTAL 10 6
- 49. Differential Diagnosis 01 04 02 05 03 06 Hypertensive Emergency Hypersensitivity Reaction=17 Stroke inthe Young=12 Coarctation of the Aorta=5 Pheochromocyto ma=10 Systemic Mastocytosis=10 07 Serum Sickness=6
- 50.
- 51. DAY 1 (ER) SubjectiveObjective Assessment Plan Drowsy, follows command (+) headache (+) dizziness (+) dyspnea (+) blurring of vision (+) slurring of speech (-) chest pain BP135/52 mmHg HR90 bpm RR 27bpm T37.8C 100% O2 sat at 5LPM face mask General: Flushed skin with nonpruritic wheals on the face, chest and back and swelling of the lips, tongue and eyelids with sunken eyeballs Lungs: SCE, fine crackles but no wheeze and with good air entry Cardio: Adynamic precordium, tachycardic, no murmur Abdomen: Flat, with erythematous, raised wheals, normoactive bowel sounds with generalized tenderness GCS 12 (E4V2M6) no facial asymmetry and tongue was midline Motor: full range of motion in all extremities against gravity but not against resistance and weak functional grip Sensory: No loss of sensation Reflexes: Normoreflexia No involuntary movements were noted Hypertensive Emergency; T/c Stroke in the Young; Hypersensitivity Disorder probably secondary to food intake NPO temporarily PNSS 1L (FMR 100cc/hr) ICU admission Medications started: 1.Diphenhydramine 50mg IV stat dose 2.Ranitidine IV 2mkday every 8 hours 3.Paracetamol 300mg IV stat dose then as needed for fever with temperature equal to or more than 38C
- 52. A case of16-year-old, male with chief complaints of syncope and urticarial rashes
- 53. DAY 1 (ER) SubjectiveObjective Assessment Plan Drowsy, follows command (+) headache (+) dizziness (+) dyspnea (+) blurring of vision (+) slurring of speech (-) chest pain BP135/52 mmHg HR90 bpm RR 27bpm T37.8C 100% O2 sat at 5LPM face mask General: Flushed skin with nonpruritic wheals on the face, chest and back and swelling of the lips, tongue and eyelids with sunken eyeballs Lungs: SCE, fine crackles but no wheeze and with good air entry Cardio: Adynamic precordium, tachycardic, no murmur Abdomen: Flat, with erythematous, raised wheals, normoactive bowel sounds with generalized tenderness GCS 12 (E4V2M6) no facial asymmetry and tongue was midline Motor: full range of motion in all extremities against gravity but not against resistance and weak functional grip Sensory: No loss of sensation Reflexes: Normoreflexia No involuntary movements were noted Hypertensive Emergency; T/c Stroke in the Young; Hypersensitivity Disorder probably secondary to food intake Labs: CBC with Platelet count Serum Electrolytes Blood Urea Nitrogen Creatinine SGPT 15 Lead ECG CXR PAL Whole Abdominal Ultrasound Covid Ag Patient was referred to a Pediatric Intensivist, Pediatric Cardiologist, Pediatric Neurologist and Pediatric Allergologist for further evaluation and management
- 54. DAY 1 CBC PCHgb Hct RBC WBC Neutrophils Lymphocytes Monocytes Eosinophil Basophil Platelet count 7/27/23 160 0.47 5.84 7.93 0.82 0.10 0.08 0.00 0.00 308 Urinalysis Color Transparency pH Specific gravity Glucose Protein WBC RBC Epithelial cells Bacteria Mucus Thread Amorphous urates 7/27/23 Amber Slightly hazy 6.0 1.020 Negative Negative 2-5 1-2 Rare Few Few Few Serum Electrolytes Sodium Potassium Chloride Ionized Calcium 7/27/23 137.6 mmol/L 3.08 mmol/L 100.9 mmol/L 1.15 mmol/L
- 55. 7/27/23 WHOLE ABDOMINALULTRASOUND Result Top normal size liver with fatty infiltration grade I-II. No focal mass. Normal sized gallbladder with 8 pieces gallbladder polyps of 0.2 cm in sizes but no cholecystitis. Mild splenomegaly with splenic index of 1,064 Normal size kidneys with at least 2 pieces sandy crystals of less than 0.2 cm in sizes No hemiperitoneum, no hemothorax and no hemopericardium No pleural effusion, no pericardial effusion and no free intra-abdominal fluid Normal sonogram of the pancreas, ureters, urinary bladder and prostate gland No intraabdominal mass or abscess Unremarkable abdominal aorta, inferior vena cava, iliac artery and vein
- 56. DAY 1 (ER) SubjectiveObjective Assessment Plan Drowsy, follows command (+) headache (+) dizziness (+) dyspnea (+) blurring of vision (+) slurring of speech (+) cough, occasional (-) abdominal pain (-) chest pain BP in all extremities -right arm 120/70 mmHg, -left arm 120/80 mmHg, -right leg 130/60 mmHg, -left leg 140/60 mmHg Hypertensive Emergency; T/c Stroke in the Young; Anaphylaxis secondary to food intake Pediatric Cardio: • BP in all extremities and monitor BP every hour • Suggested Cranial CT scan with contrast Pediatric Neuro: • Started Citicoline 500mg IV every 12 hours • Requested Plain Cranial CT scan Pediatric Intensive Care: • Shift Ranitidine to Omeprazole 40 mg IV OD • Diphenhydramine 50 mg IV every 8 hours • Stool examination with fecal occult blood test • Suggest referral to Allergology • KCl correction at KIR 0.015 mEqs/kg/hr Pediatric Allergology: • Standby Epinephrine 0.3 ml IM for recurrence of urticaria and difficulty of breathing • TSH, T3, T4, ANA, anti-DSDNA and ESR • Stool examination with Kato-Katz at Schistosomiasis Research and Training Laboratory
- 57. DAY 1 7/27/23 CRANIALCT SCAN WITHOUT IV CONTRAST Result No acute intracranial hemorrhage, territorial infarction, mass lesion, cortical dysplasia, abnormal extra-axial fluid collection, hydrocephalus nor midline shift The Hippocampi are symmetrical with no evidence of abnormal densities. No neuronal migration abnormality is noted. Mild bilateral maxillary, bilateral sphenoid and bilateral ethmoid sinusitis.
- 58. Creatinine BUN SGPT/ALTT4 TSH ANA ESR Normal values 44.2- 93.7umol/L 2.5- 6.4mmol/L <50 0- 10mm/hr 7/27/23 75.44 umol/L 4.14mmol/L 34.40 U/L 122.03 nmol/L 1.27 uIU/ml negative 5mm/hr T3 T4 TSH Normal values 0.92- 2.33 66-181 0.27- 4.20 7/27/23 122.03 nmol/L 1.27 uIU/ml DAY 1
- 59. 7/27/23 CHEST XRAYAPL PORTABLE Result Left Basal Pneumonia
- 60. DAY 1 (ICU) SubjectiveObjective Assessment Plan Drowsy, follows command (+) headache (+) dizziness (+) dyspnea (+) blurring of vision (+) slurring of speech (+) cough, occasional (-) abdominal pain (-) chest pain BP in all extremities -right arm 120/70 mmHg, -left arm 120/80 mmHg, -right leg 130/60 mmHg, -left leg 140/60 mmHg Hypertensive Emergency; T/c Stroke in the Young; Anaphylaxis secondary to food intake -Transferred to PICU -Quantitative input and output monitored and blood sugar every 12 hours while on NPO -Oxygen support was decreased to 2LPM via nasal cannula at 97% saturation
- 61. DAY 1 (ICU) SubjectiveObjective Assessment Plan 6 hours after admission, Awake, alert, conversant (-) headache (-) dizziness (-) dyspnea (-) blurring of vision (-) slurring of speech (-) abdominal pain (-) chest pain BP 127/61 mmHg HR 114 bpm RR 21 cpm T38C 97% O2 saturation via nasal cannula General: Skin not flushed; disappearance of wheals and urticaria; Decreased angioedema of eyelid, lips and tongue Lungs: SCE, fine crackles but no wheeze and with good air entry Cardio: Adynamic precordium, tachycardic, no murmur Abdomen: Flat, with erythematous, raised wheals, normoactive bowel sounds with generalized tenderness GCS 15 (E4V5M6) no facial asymmetry and tongue was midline Motor: 3/5 in all extremities; weak functional grip Sensory: 100% in all extremities Reflexes: Normoreflexia No involuntary movements were noted Hypertensive Emergency; T/C Stroke in the Young; Anaphylaxis secondary to food intake; Pediatric Community Acquired Pneumonia-C -Started on Cefuroxime 1,500mg/ dose every 8 hours for treatment of basal pneumonia and Salbutamol nebulization every 6 hours -Paracetamol 300mg IVTT for fever -Patient’s feeding was resumed with soft, hypoallergenic diet -Hypokalemia correction was continued for another cycle
- 62.
- 63. DAY 2 (ICU) SubjectiveObjective Assessment Plan Apparent disappearance of symptoms until prior to eating breakfast, (+) recurrence of urticarial rashes on the face, chest and back (+) generalized body weakness (+) occasional cough nonproductive (+) febrile episodes Tmax 39.8C (-) slurring of speech (-) difficulty of breathing (-) syncope (-) seizure (-) chest pain (-) abdominal pain (-) vomiting BP 126/58 mmHg HR 93 bpm RR 13 cpm T37.5C 98% O2 saturation at 2LPM via nasal cannula • Skin flushed; recurrence of wheals and urticaria; recurrence of angioedema of eyelid, lips and tongue • (+) fine crackles but no wheeze and with good air entry • GCS 15 (E4V5M6) no facial asymmetry and tongue was midline • Motor: 3/5 in all extremities; weak functional grip • Negative fluid balance • I: 3,027 O: 4,050 • UO 2.6 cc/kg/hr Biphasic Anaphylaxis secondary to Food Intake; Transient Ischemic Attack; Pediatric Community Acquired Pneumonia- C; Hypokalemia, Secondary; Hypertension Stage 1 • AR 1L (FMR) • Cefuroxime 4.5gm/day (Day 1+1) • Captopril 25mg OD started • For 2D echocardiogram with doppler studies • Repeat CBC platelet count • Lipid Profile • Repeat serum electrolytes determination after 3 cycles of KCl IV correction • CBG 100mg/dL • Citicoline 1gm/day (Day 1+1) • Soft, hypoallergenic diet • Daily food diary • Given Epinephrine 0.3 mg IM stat dose • Started Bilastine 20mg OD 1 hour after dinner • Started Ebastine + Betamethasone tab OD
- 64. DAY 2 Serum Electrolytes Sodium PotassiumChloride Ionized Calcium 7/27/23 137.6 mmol/L 3.08 mmol/L 100.9 mmol/L 1.15 mmol/L 7/28/23 137.9 3.26 104.9 1.19 T3 T4 TSH Normal values 0.92- 2.33 66-181 0.27- 4.20 7/27/23 122.03 nmol/L 1.27 uIU/ml 7/28/23 1.2 nmol/L CBC PC Hgb Hct RBC WBC Neutrophils Lymphocytes Monocytes Eosinophil Basophil Platelet count 7/27/23 160 0.47 5.84 7.93 0.82 0.10 0.08 0.00 0.00 308 7/28/23 145 0.43 5.23 7.21 0.77 0.15 0.08 0.00 0.00 223
- 65. DAY 2 (ICU) SubjectiveObjective Assessment Plan 6 hours after recurrence of anaphylaxis symptoms, patient was conscious, coherent and conversant (+) occasional cough nonproductive (-) fever (-) slurring of speech (-) difficulty of breathing (-) syncope (-) seizure (-) chest pain (-) abdominal pain (-) vomiting (-)headache (-)dizziness BP 119/57 mmHg HR 77 bpm RR 18 cpm T37C 98% O2 saturation at 2LPM via nasal cannula • Skin not flushed; Absence of wheals and urticaria; No recurrence of angioedema of eyelid, lips and tongue; (+) dermatographism • (+) fine crackles but no wheeze and with good air entry • Warm extremities, full equal pulses • GCS 15 (E4V5M6) no facial asymmetry and tongue was midline • Motor: 4/5 in all extremities; improved functional grip Biphasic Anaphylaxis secondary to Food Intake; Transient Ischemic Attack; Pediatric Community Acquired Pneumonia- C; Hypokalemia, Secondary; Hypertension Stage 1 • Oxygen support was then discontinued without episodes of desaturation
- 66. 7/29/23 Pediatric Echocardiographyand Color Flow Doppler Mitral Regurgitation; Tricuspid Regurgitation Clinical Chemistry Total Cholesterol Triglyceride HDL Cholesterol LDL Cholesterol VLDL 7/29/23 3.68 mmol/L 1.08 mmol/L 0.87 mmol/L 2.32 mmol/L (Low) 0.50 mmol/L Clinical Microscopy Fecalysis Fecal Occult Blood Test 7/29/30 Yellow, soft, RBC 0-2, WBC 0-2, No intestinal parasites seen Negative Immunology Anti- dsDNA 7/29/30 11.7
- 67. FOOD DIARY Date Breakfast LunchDinner 7/28/23 “Lugaw” (porridge) and ground meat “Lugaw” (porridge), soup Rice and burger steak
- 68. DAY 3 (ICU) SubjectiveObjective Assessment Plan Oriented, cooperative, conversant and speaks dialect fluently (+) occasional cough nonproductive (+) occasional abdominal pain (-) fever (-) slurring of speech (-) difficulty of breathing (-) syncope (-) seizure (-) chest pain (-) vomiting (-)headache (-)dizziness BP 110/80 mmHg HR 68 bpm RR 19 cpm T36.7C 98% O2 saturation room air • Skin not flushed; Absence of wheals and urticaria; No recurrence of angioedema of eyelid, lips and tongue • Decreased fine crackles but no wheeze and with good air entry • Abdomen flat, NABS, soft, nontender • Warm extremities, full equal pulses • GCS 15 (E4V5M6) no facial asymmetry and tongue was midline • Motor: 5/5 in all extremities; good functional grip Anaphylaxis secondary to Food Intake; Transient Ischemic Attack; Pediatric Community Acquired Pneumonia- C; Hypokalemia, Secondary; Hypertension Stage 1 • May trans-out to regular room • Cefuroxime 4.5gm/day (Day 2) • Increased Captopril to 50mg/day BID • Citicoline 1gm/day (Day 2+1) then discontinued • Diet as tolerated • Daily food diary • Discontinued Diphenhydramine • Standby Epinephrine 0.3 mg for anaphylaxis recurrence • Bilastine 20mg/tab, one tab OD 1 hour after dinner • Ebastine 10mg+ Betamethasone 500mcg/ tab, one tab OD
- 69. FOOD DIARY Date Breakfast LunchDinner 7/28/23 “Lugaw” (porridge) and ground meat “Lugaw” (porridge), soup Rice and burger steak 7/29/23 “Lugaw” (porridge) and stewed pork Rice and ground pork
- 70. DAY 4 (RegularRoom) Subjective Objective Assessment Plan Oriented, cooperative, conversant and speaks dialect fluently (+) occasional cough nonproductive (+) occasional abdominal pain (-) fever (-) slurring of speech (-) difficulty of breathing (-) syncope (-) seizure (-) chest pain (-) vomiting (-)headache (-)dizziness BP 118/66 mmHg HR 61 bpm RR 15 cpm T36C 98% O2 saturation room air • Skin not flushed; Absence of wheals and urticaria; No recurrence of angioedema of eyelid, lips and tongue • Decreased fine crackles but no wheeze and with good air entry • Abdomen flat, NABS, soft, nontender • Warm extremities, full equal pulses • GCS 15 (E4V5M6) no facial asymmetry and tongue was midline • Motor: 5/5 in all extremities; good functional grip • Positive fluid balance • I: 1,460 O: 920 • UO 1.0cc/kg/hr Anaphylaxis secondary to Food Intake; Transient Ischemic Attack; Pediatric Community Acquired Pneumonia- C; Hypokalemia, Secondary; Hypertension Stage 1; Gallbladder Polyp • Discharged improved • Heplock • Cefuroxime 4.5gm/day (Day 3) • Low salt, low fat diet with avoidance of known allergens • Daily food diary • Home meds: • Ebastine + Betamethasone 10mg/ 100mcg tab (Co-Aleva), 1 tab for 3 days more • Captopril 25mg/tab, 1 tablet BID • Cefuroxime 500mg/tab (Cimex), 1 tablet every 12hours for 4 more days • N-Acetylcysteine 600mg/tab, 1 tab ODHS for 3 days • Bilastine 20mg/tab (Bilaxten) OD for 1 month • Epinephrine 0.3 mg IM as emergency medication for recurrence of anaphylaxis
- 71. FOOD DIARY Date Breakfast LunchDinner 7/28/23 “Lugaw” (porridge) and ground meat “Lugaw” (porridge), soup Rice and burger steak 7/29/23 “Lugaw” (porridge) and stewed pork Rice and ground pork 7/30/23 “Lugaw” (porridge) Rice and stewed pork
- 72. FINAL DIAGNOSIS Anaphylaxis Secondary toFood Intake; Transient Ischemic Attack; Pediatric Community Acquired Pneumonia-C; Electrolyte Imbalance-Hypokalemia; Hypertension Stage 1; Gallbladder Polyp
- 73.
- 74. Serious allergic reaction Rapid in onset May cause death Anaphylaxis Nelson’s Textbookof Pediatrics 21st Edition
- 75. Anaphylaxis ETIOLOGY Hospital Medications Latex Community Food-most common 50% Peanut Red Meat Nelson’sTextbook of Pediatrics 21st Edition
- 76. Anaphylaxis Epidemiology USOverall annual incidence >150,00 cases/year Australia Parental Survey- 0.59%of children age 3-17 yr of age had experienced at least 1 anaphylactic event Risk factors 1. Asthma and severity of asthma 2. Systemic mastocytosis 3. Monoclonal mast cell- activitang syndrome 4. Elevated baseline serum tryptase level Nelson’s Textbook of Pediatrics 21st Edition
- 77.
- 78. Anaphylaxis Pathophysiology Immunologic (IgE dependent) APCs presentAg to Th cells Th cells stimulate B-cell to differentiate into plasma cells and produce IgE against Ag IgE binds to FceRI on mast cell and basophils, sensitizing to antige Initial Exposure to Antigen e.g. passage of food proteins in maternal breastmilk (Sensitization) On Re-exposure, Ag causes cross-linkage of IgE/FceRI on mast cells and basophils Inappropriate mast cell and basophil activation Immediate phase (second to mins) mast cell and basophil degranulation Late phase (mins to hours) mast cell and basophil degranulation Release of preformed mediators Histamine vasodilation Increased permeability Lipid mediators (prostaglandins, leukotrienes) Smooth muscle contraction in airways Other mediators (Tryptase, PAF) Increase mucus secretion Inflammatory mediators Recruitment of inflammatory cells
- 80. Govindapala, D., Senarath,U.S., Wijewardena, D. et al. An unusual presentation of anaphylaxis with severe hypertension: a case report. J Med Case Reports 16, 327 (2022)
- 81. Nelson’s Textbook ofPediatrics 21st Edition
- 82. Nelson’s Textbook of Pediatrics21st Edition
- 83. Anaphylaxis Clinical Manifestation Ingested allergens (food,meds) -delayed mins to 2 hours Injected allergens (insect stings, meds) -rapid onset Nelson’s Textbook of Pediatrics 21st Edition
- 84. Anaphylaxis Clinical Manifestation Flushing Nausea and vomitng Lowerback pain Faintness and LOC (severe case) Sneezing Abdominal cramping Urticaria and angioedema Pruritus mouth and face, periocular pruritus, oral and cutaneous pruritus Dry staccato cough, hoarseness Nasal congestion Weakness Dyspnea Sensation of warmth and apprehension (sense of impending doom) Deep cough & wheeze
- 85. In severe cases,some degree of laryngeal edema is typically encountered. Acute onset of severe bronchospasm in a previously well person with asthma should suggest the diagnosis of anaphylaxis Cutaneous symptoms may be absent in up to 10% of cases
- 86. Anaphylaxis Laboratory Findings -indicate presenceof IgE antibodies but is not definitive Histamine • Elevated for brief period but is unstable and difficult to measure Tryptase • More stable and remain elevated in several hours, but often not elevated especially in food-related anaphylaxis • "20+2 rule" • Level during symptomatic episode must =/> a 20% increase over BST (baseline serum tryptase) + 2 ng/ml The Journal of Allergy and Clinical Immunology, 2021
- 87. National Institute of Health(NIH) sponsored-expert panel Nelson’s Textbook of Pediatrics 21st Edition
- 88. National Institute of Health(NIH) sponsored-expert panel
- 89. EPINEPHRINE IM (first line)/ IV Oxygen,IV fluids H1 and H2 antihistamine antagonist, IM/IV Inhaled Beta agonist and corticosteroids Anaphylaxis Treatment Nelson’s Textbook of Pediatrics 21st Edition
- 90. EPINEPHRINE IM (first line)/ IV Oxygen,IV fluids H1 and H2 antihistamine antagonist, IM/IV Inhaled Beta agonist and corticosteroids Anaphylaxis Treatment
- 91. EPINEPHRINE IM (first line)/ IV Oxygen,IV fluids H1 and H2 antihistamine antagonist, IM/IV Inhaled Beta agonist and corticosteroids Anaphylaxis Treatment
- 92. EPINEPHRINE IM (first line)/ IV Oxygen,IV fluids H1 and H2 antihistamine antagonist, IM/IV Inhaled Beta agonist and corticosteroids Anaphylaxis Treatment
- 93. EPINEPHRINE IM (first line)/ IV Oxygen,IV fluids H1 and H2 antihistamine antagonist, IM/IV Inhaled Beta agonist and corticosteroids Anaphylaxis Treatment
- 94.
- 95. Biphasic Anaphylaxis Occurs when anaphylactic symptomsrecur after apparent resolution Mechanism unknown, but appears to be more common when therapy is initiated late and symptoms at presentation are more severe. >90% occur within 4 hours, so patients should be observed 4 hours before discharge from ER. Referrals should be made to appropriate specialists for further evaluation and management Nelson’s Textbook of Pediatrics 21st Edition
- 96. Anaphylaxis Prevention In cases offood-associated exercise-induced anaphylaxis, children must not exercise within 2-3 hr of ingesting triggering food For exercise-induced anaphylaxis, should exercise with a friend, learn to. Recognize erly signs, stop exercising and seek help asap Systemic anaphylaxis due to insect sting should be treated with immunotherapy >90% protective
- 97. Anaphylaxis Prevention Reactions to medsreduced and minimized by using oral meds instead of injected forms; avoid cross-reacting meds Low-osmolarity radiocontrast dyes and pretreatment used in patients with suspected reactions to previous radiocontrast dyes Nonlatex gloves and materials used in OR
- 98. Nelson’s Textbook ofPediatrics 21st Edition
- 100.
- 101. 160 160 160 140 130130 120 110 110 100 100 60 60 60 70 80 16 HOURS PTA 12 HOURS PTA 2 HOURS PTA ADMISSION HOSPITAL DAY 1 HOSPITAL DAY 2 HOSPITAL DAY 3 HOSPITAL DAY 4 BLOOD PRESSURE AND SYMPTOMS Systolic Diastolic Urticaria Slurring of speech Generalized body weakness Motor strength 3/5 Urticaria Body weakness Motor strength 5/5 Urticaria Slurring of speech Motor strength 3/5 Disappearance of symptoms No slurring of speech Motor strength 5/5 Epinephrine 0.3mg IM Discharged Transfer to private hospital managed as Hypersensitivity Disorder; Essential Hypertension Referred to our institution Syncope Urticaria DOB Chest heaviness Body weakness Syncope Urticaria DOB Chest heaviness Body weakness Slurring of speech Motor strength 3/5 Apparent disappearance then recurrence of urticaria No slurring of speech Motor strength 4/5
- 102.
- 103.
Editor's Notes
- #18 Patient is the third among siblings. His 43-year-old hypertensive mother, 49-year-old hypertensive father, and five siblings were all apparently well. On the maternal side, a history of recurrent Anaphylaxis was noted on the Aunt with emergency Epinephrine pen use and Bronchial Asthma. A history of Diabetes Mellitus is noted on the paternal side of the family. Both parents have a family history of Hypertension. No other heredofamilial diseases noted. No history of sudden cardiac death nor malignancy in the family.
- #80 Mechanism, triggers, key cells, mediators, target organs, symptoms Increased mucous membrane secretions, increased capillary permeability and leakage, markedly reduced smooth muscle tone
- #81 Recorded high bp could be due to preexisting hypertension, anxiety leading to sympathetic activation or both. Anaphylaxis-induced high blood pressure is another rare possibility, because postural involvement as evidenced by syncope should theoretically give rise to a low or reduced blood pressure from baseline. Therefore his high BP on admission, points toward a possibility of anaphylaxis-induced hypertension. Hypertensive anaphylaxis has been reported by Govindapala et al. Evidence demonstrates that internal compensatory vasopressor mechanisms are activated within mins of avaphylaxis developmement, resulting in the release of endogenous vasoactive subs. Conversion of Ang I to Ang II is enhanced by chymase, an inflammatory mediator released during mast cell degranulation. These vasoactive subs compensate for vasodilation& fluid extravasation which may be dominant in our patient resulting in hypertension. Observation on this study suggest that in some patients this may result in exaggerated BP response. However, the compensatory mechanism may be inadequate to maintain the bp when posture changes from supine to upright causing syncope.
- #87 The clinical diagnosis is based on a meticulous history and physical examination, sometimes, but not necessarily, supported by a laboratory test such as an elevated serum total tryptase level. Sensitization to allergen triggers suggested by the history needs to be confirmed by skin testing and measurement of allergen-specific IgE. In some sensitized individuals, additional tests are needed to assess the risk of future anaphylaxis episodes. Prompt injection of epinephrine is life-saving. H1-antihistamines and inhaled β2-adrenergic agonists cannot be depended on to prevent fatality. Long-term risk reduction is an integral part of management.
- #91 Epinephrine is the most important medication, there should be no delays in its administration. Given IM route to the lateral thigh, 1:1000 dilution, 0.01 mg/kg, max dose 0.5mg. May be repeated in interval of 5-15 mins if symptoms persist or worsens. If there is no response to multiple doses, IV epinephrine with 1:10000 may be needed. May be given thru ET tube or intraosseous routes. For anaphylaxis refractory to repeated doses of epinephrine in patient receiving beta-adrenergic blockers has anecdotally been treated with glucagon ( a polypeptide with non-catecholamine-dependent inotropic and chronotropic cardiac effects. The patient should be placed in supine position when there is concern for hemodynamic compromise.