Causes and Diagnostic Usefulness of Tryptase Measurements for Anaphylaxis in a Korean Tertiary Care General Hospital

Lin Liang,박경희,이재현,박중원 연세대학교의과대학 2022 Yonsei medical journal Vol.63 No.12

Purpose: The causes of anaphylaxis in a general hospital may differ from those occurring in a community setting. Underlying diseases in admitted patients and vague presenting symptoms can make the diagnosis of anaphylaxis difficult. Serum tryptase measurements may provide valuable evidence for diagnosing anaphylaxis in admitted patients. Materials and Methods: This study was designed as a retrospective study of 53 patients with an anaphylaxis episode at a Korean tertiary care general hospital. Tryptase levels were measured at baseline and different time points from the onset of anaphylaxis. Results: Drugs (42 cases; 79.2%) and foods (10 cases; 18.9%) were the most common causes of anaphylaxis. In drug-induced anaphylaxis, antibiotics (24.5%), anticancer medications, which included monoclonal antibodies (22.6%), and contrast agents (11.3%) were the most frequent causes. The muscle relaxant eperisone (5.7%), neuromuscular blocking agent rocuronium (5.7%), and its antagonist sugammadex (3.8%) were other frequent triggering agents. Wheat-dependent exercise-induced anaphylaxis was the most common entity in food-induced anaphylaxis. Tryptase concentrations were higher in patients with higher grades of anaphylaxis, as well as in accidental anaphylaxis, compared to meticulously provoked anaphylaxis. Overall diagnostic sensitivity was higher for tryptase algorithm criteria (≥[1.2×baseline+2] µg/L: 71.4%) than for abnormal tryptase level criteria (≥11.4 µg/L: 52.8%). Conclusion: The triggers of anaphylaxis in a Korean tertiary care hospital were diverse, including beta-lactam antibiotics, anticancer medications, contrast medias, eperisone, nonsteroidal anti-inflammatory drugs, rocuronium, sugammadex, and wheat. Tryptase measurements provided valuable evidence for diagnosis, and the sensitivity of algorithm criteria was superior to that of the abnormal value criteria.

Prevalence of anaphylaxis and prescription rates of epinephrine auto-injectors in urban and rural areas of Korea

조현석,권재우 대한내과학회 2019 The Korean Journal of Internal Medicine Vol.34 No.3

Background/Aims: Despite the clinical importance anaphylaxis and the recent increase in its occurrence, studies regarding the epidemiology of anaphylaxis, risk factors for anaphylaxis, and epinephrine auto-injector (EAI) prescription status for patients with anaphylaxis remain poorly described. Thus, we investigated the prevalence of anaphylaxis and prescription rates of EAI in urban and rural areas in Korea. Methods: We used data from the 2010 to 2014 Health Insurance Review and Assessment database. Anaphylaxis was identified through physician-certified diagnoses using the International Classification of Diseases 10th (ICD-10) codes (T780, T782, T805, T886). Data on prescription rates of EAI were collected from the Korea Orphan & Essential Drug Center, the only pharmacy exclusively dealing with EAI in Korea. The prescription rates of EAI were defined as the number of EAI prescribed against the number of patients with anaphylaxis. Results: The prevalence of anaphylaxis over the 5-year period was 0.023%. The annual prevalence of anaphylaxis increased over the 5-year period. Anaphylaxis was more common in males than in females (54% vs. 46%) and in the population aged 50 to 59 years old. For regional analysis, urban areas showed a relatively lower prevalence of anaphylaxis (17.3 per 100,000 individuals) along with higher prescription rates (12.0%) of EAI for patients with anaphylaxis. In contrast, rural areas showed a relatively higher prevalence of anaphylaxis (28.8 per 100,000 individuals) along with lower prescription rates (3.1%) of EAI. Conclusions: The prevalence of anaphylaxis has increased annually in Korea. There were regional differences in the prevalence of anaphylaxis and prescription rates of EAI between urban and rural areas in Korea.

수원의 한 대학병원에서 10년간 경험한 아나필락시스 환자 분석

김무정 ( Moo Jung Kim ),최길순 ( Gil Soon Choi ),엄수정 ( Soo Jung Um ),성준모 ( Jun Mo Sung ),신유섭 ( Yoo Seob Shin ),박한정 ( Han Jung Park ),예영민 ( Young Min Ye ),남동호 ( Dong Ho Nahm ),이수영 ( Su Young Lee ),박해심 ( Hae 대한천식알레르기학회 2008 천식 및 알레르기 Vol.28 No.4

Background: Anaphylaxis is a systemic hypersensitivity reaction consisting of various etiologies and clinical features. In Korea, reports regarding anaphylaxis are very few. Objective: To evaluate the general characteristics and clinical features of anaphylaxis, especially with regard to the severity of it. Method: A retrospective study was conducted in inpatients, outpatients and patients encountered at the emergency department at the Ajou University Hospital during 1997~2008. The medical records of a total of 158 patients who met diagnostic criteria for anaphylaxis were reviewed. Result: Drugs (51.2%) was the most common cause of anaphylaxis followed by insect stings (25.3%), foods (10.8%) and exercise (6.3%) in our hospital. The common manifestations were dyspnea (70.3%), urticaria (57.6%), dizziness (48.1%) and hypotension (46.2%). There were 65 patients (41.1%) with moderate anaphylaxis and 93 patients (58.9%) with severe anaphylaxis. The patients with older age or underlying cardiovascular disease had more severe anaphylaxis (P<0.05, respectively). Although there were no significant correlation between the severity and etiology of anaphylaxis, some drugs such as antibiotics, NSAIDs, and radiocontrast media tended to develop severe anaphylaxis. Conclusion: We confirmed that drugs, insect stings, foods, and exercise are the major causes of anaphylaxis. In addition, the patients with older age or a cardiovascular disease had a tendency to develop severe anaphylaxis. (Korean J Asthma Allergy Clin Immunol 2008;28:298-304)

甘豆湯煎湯液이 순환기 Anaphylaxis에 미치는 影響

李柱憲,文炳淳,李基商 대한동의병리학회 1998 동의생리병리학회지 Vol.12 No.1

Anaphylaxis는 無防禦란 뜻으로 抗原刺戟에 의하여 감작된 生體가 일정기간 후에 동일한 抗原과 接觸했을 때 수분에서 수십분 내에 급격히 증상을 나타내는 현상이다. 甘豆湯은 甘草·黑豆 二味로 구성되어 있으며 甘草는 和中하여 해독작용이 있고, 약리학적으로 혈압상승작용, 抗allergy 작용, histamine과 같은 allergy를 일으키는 物質의 血管 透過性 억제, 心血虛에 의한 不整脈, 動悸에 效果가 있다고 알려져 있다. 黑豆는 散熱하여 해독하는 작용이 있고, 예로부터 黑豆만 사용했을 때 보다 甘草를 加하여 사용했을 때 탁월한 해독효과가 있다고 하였다. 따라서 本 方은 각종 allergy 반응을 일으키는 特定物質에 대한 해독작용과 抗allergy 작용이 있으므로 순환기 anaphylaxis에 效果가 있을 것으로 생각되어, pithed rat에서의 순환기 anaphylaxis 반응에 미치는 效果, guinea pig 심장에서의 anaphylaxis 반응에 미치는 效果, guinea pig의 기관지평활근에 미치는 效果, rat의 PCA 반응에 미치는 效果에 대한 실험을 觀察하여 有意性 있는 다음과 같은 結果를 얻었다. 甘豆湯煎湯液은 in vivo model인 pithed rat에서 순환기 anaphylaxis을 저해하는 작용이 있으며 anaphylaxis에 의한 動物의 치사율을 현저하게 억제하였고, pithed rat에서 지속적인 혈압하강을 有意性있게 억제하였으나 頻脈현상을 차단하지는 못하였다. 甘豆湯煎湯液은 guinea pig 심장에서 anaphylaxis에 의한 심장기능의 부전을 차단하지 못하였고, guinea pig의 기관지평활근에서 LTD₄, histamine, 5-HT 등으로 유발한 수축현상을 억제하지 않았으나, rat에서의 PCA 반응을 有意性있게 억제하였다. 以上의 結果로 보아 甘豆湯煎湯液은 순환기 anaphylaxis를 포함한 type Ⅰ allergy현상을 차단하는 效能이 있으며 이는 직접적으로 anaphylaxis에 관여하는 매개물질을 길항하기 보다는 이들 매개물의 생합성을 차단하거나 肥滿細胞로부터의 遊離를 차단할 가능성이 있다. 따라서 이러한 순환기 anaphylaxis 차단작용은 심장보다 말초혈관에서의 혈관이완이 주 작용으로 보여진다 This study was investigated the inhibitory activity of Gamdutang water extract on type Ⅰ immediate hypersensitivity of anaphylatic type. The results of this study were as follows: 1. Gamdutang water extract ameliorated the cardiovascular anaphylactic response and thus reduced lethality in the vivo rat model (pithed rat). 2. The ameliorating effect was related to the blunting of sustained depressor effect appeared follwing antigen challenge, but the tachycardic response was not influenced. 3. In the isolated guinea pig heart, Gamdutang water extract did not prevent the occurrence of cardiac failure induced by anaphylaxis. 4. Gamdutang water extract did not relax the contractility response of isolated guinea pig trachea to LTD4, histamine or 5-HT. This result indicates that te Gamdutang water extract does not possess direct inhibitory action on these major anaphylactic mediators. 5. Gamdutang water extract could be effective against other types of anaphylaxis since the substance was effective in PCA test. The results suggest that Gamdutang water extract is effective in preventing Type Ⅰ allergy such as anaphylaxis. Gamdutang water extract may not antagonized directly major anaphylactic mediators such as LDT4, histamine or 5-HT. Rather it seems that Gamdutang water extract interferes the release of these mediators from mast cells in the advent of anaphylaxis, or it may inhibit the biosynthesis of these substances. Gamdutang water extract's main site of action seems to be peripheral resistance vessels, not the heart.

Are Registration of Disease Codes for Adult Anaphylaxis Accurate in the Emergency Department?

최병호,김선휴,이지혜 대한천식알레르기학회 2018 Allergy, Asthma & Immunology Research Vol.10 No.2

Purpose: There has been active research on anaphylaxis, but many study subjects are limited to patients registered with anaphylaxis codes. However, anaphylaxis codes tend to be underused. The aim of this study was to investigate the accuracy of anaphylaxis code registration and the clinical characteristics of accurate and inaccurate anaphylaxis registration in anaphylactic patients. Methods: This retrospective study evaluated the medical records of adult patients who visited the university hospital emergency department between 2012 and 2016. The study subjects were divided into the groups with accurate and inaccurate anaphylaxis codes registered under anaphylaxis and other allergy-related codes and symptom-related codes, respectively. Results: Among 211,486 patients, 618 (0.29%) had anaphylaxis. Of these, 161 and 457 were assigned to the accurate and inaccurate coding groups, respectively. The average age, transportation to the emergency department, past anaphylaxis history, cancer history, and the cause of anaphylaxis differed between the 2 groups. Cutaneous symptom manifested more frequently in the inaccurate coding group, while cardiovascular and neurologic symptoms were more frequently observed in the accurate group. Severe symptoms and non-alert consciousness were more common in the accurate group. Oxygen supply, intubation, and epinephrine were more commonly used as treatments for anaphylaxis in the accurate group. Anaphylactic patients with cardiovascular symptoms, severe symptoms, and epinephrine use were more likely to be accurately registered with anaphylaxis disease codes. Conclusions: In case of anaphylaxis, more patients were registered inaccurately under other allergy-related codes and symptom-related codes rather than accurately under anaphylaxis disease codes. Cardiovascular symptoms, severe symptoms, and epinephrine treatment were factors associated with accurate registration with anaphylaxis disease codes in patients with anaphylaxis.

국내 중부지역 아나필락시스 환자의 임상적 특성 연구

노의정,정은희,이미희,이수진,윤유숙,이재호,우성일,한윤수,박준수,김한진 대한 소아알레르기 호흡기학회 2008 Allergy Asthma & Respiratory Disease Vol.18 No.1

Purpose:Anaphylaxis is a medical emergency requiring immediate recognition and treatment. Despite the serious nature of these reactions, there is no universal agreement on the definition and there have been few epidemiologic studies of anaphylaxis in children. The purpose of the study is to investigate the causative agents, presenting signs and symptoms and course of disease in children suitable for established diagnostic criteria for anaphylaxis in the middle area of South Korea. Methods:We identified potential episodes of anaphylaxis occuring between March 1994 and October 2007 from the university hospitals in the middle area of South Korea. We reviewed all patients' medical records diagnosed with anaphylaxis and other related diagnoses. From chart review, we retrospectively collected demographic and epidemiologic data. Results:We identified 40 patients with anaphylaxis. Patients' ages ranged from 2 months to 17 years, with a mean age of 6.6 years. A causative agent was recognized in 84.5%. The inciting agent included foods in 26 cases (65%), medication in 7 cases (17.5%) and bee sting in 1 case (2.5%). Mucocutaneous manifestations were the most common, respiratory symptoms were in 35 patients, cardiovascular symptoms were in 8 patients, and gastrointestinal symptoms were in 5 patients. Conclusion:We found some cases of anaphylaxis which had misdiagnosed as urticaria or angioedema using the established diagnostic criteria. Therefore, clinicians must accurately know the criteria of anaphylaxis and make an effort to identify cases of anaphylaxis with a high suspicion. Also, we found the epidemiology, causative agents, and symptoms and treatments of anaphylaxis in the middle area of South Korea. Our data will be the basis for anaphylactic studies in South Korea. Purpose:Anaphylaxis is a medical emergency requiring immediate recognition and treatment. Despite the serious nature of these reactions, there is no universal agreement on the definition and there have been few epidemiologic studies of anaphylaxis in children. The purpose of the study is to investigate the causative agents, presenting signs and symptoms and course of disease in children suitable for established diagnostic criteria for anaphylaxis in the middle area of South Korea. Methods:We identified potential episodes of anaphylaxis occuring between March 1994 and October 2007 from the university hospitals in the middle area of South Korea. We reviewed all patients' medical records diagnosed with anaphylaxis and other related diagnoses. From chart review, we retrospectively collected demographic and epidemiologic data. Results:We identified 40 patients with anaphylaxis. Patients' ages ranged from 2 months to 17 years, with a mean age of 6.6 years. A causative agent was recognized in 84.5%. The inciting agent included foods in 26 cases (65%), medication in 7 cases (17.5%) and bee sting in 1 case (2.5%). Mucocutaneous manifestations were the most common, respiratory symptoms were in 35 patients, cardiovascular symptoms were in 8 patients, and gastrointestinal symptoms were in 5 patients. Conclusion:We found some cases of anaphylaxis which had misdiagnosed as urticaria or angioedema using the established diagnostic criteria. Therefore, clinicians must accurately know the criteria of anaphylaxis and make an effort to identify cases of anaphylaxis with a high suspicion. Also, we found the epidemiology, causative agents, and symptoms and treatments of anaphylaxis in the middle area of South Korea. Our data will be the basis for anaphylactic studies in South Korea.

Characteristics of Anaphylaxis in 907 Chinese Patients Referred to a Tertiary Allergy Center: A Retrospective Study of 1,952 Episodes

Nannan Jiang,Jia Yin,Liping Wen,Hong Li 대한천식알레르기학회 2016 Allergy, Asthma & Immunology Research Vol.8 No.4

Purpose: Comprehensive evaluation of anaphylaxis in China is currently lacking. In this study, we characterized the clinical profiles, anaphylactic triggers, and emergency treatment in pediatric and adult patients. Methods: Outpatients diagnosed with “anaphylaxis” or “severe allergic reactions” in the Department of Allergy, Peking Union Medical College Hospital from January 1, 2000 to June 30, 2014 were analyzed retrospectively. Results: A total of 1,952 episodes of anaphylaxis in 907 patients were analyzed (78% were adults and 22% were children). Foods are the most common cause (77%), followed by idiopathic etiologies (15%), medications (7%) and insects (0.6%). In food-induced anaphylaxis, 62% (13/21) of anaphylaxis in infants and young children (0-3 years of age) were triggered by milk, 59% (36/61) of anaphylaxis in children (4-9 years of age) were triggered by fruits/vegetables, while wheat was the cause of anaphylaxis in 20% (56/282) of teenagers (10-17 years of age) and 42% (429/1,016) in adults (18-50 years of age). Mugwort pollen sensitization was common in patients with anaphylaxis induced by spices, fruits/vegetables, legume/peanuts, and tree nuts/seeds, with the prevalence rates of 75%, 67%, 61%, and 51%, respectively. Thirty-six percent of drug-induced anaphylaxis was attributed to traditional Chinese Medicine. For patients receiving emergency care, only 25% of patients received epinephrine. Conclusions: The present study showed that anaphylaxis appeared to occur more often in adults than in infants and children, which were in contrast to those found in other countries. In particular, wheat allergens played a prominent role in triggering food-induced anaphylaxis, followed by fruits/vegetables. Traditional Chinese medicine was a cause of drug-induced anaphylaxis. Furthermore, exercise was the most common factor aggravating anaphylaxis. Education regarding the more aggressive use of epinephrine in the emergency setting is clearly needed.

신체활동과 운동 알레르기 면역반응의 기전적 분석

곽이섭 ( Yi Sub Kwak ) 한국운동생리학회 2015 운동과학 Vol.24 No.3

PURPOSE: It is well known that physical activity is beneficial for people with positive results for physical status and mental wellbeing. However, physical exercise decrease the immune response and may induce a allergy anaphylaxis at some situation as follows. A common example is exercise-induced asthma, exercise-induced urticaria, exercise-induced anaphylaxis and FDEIAn (food-dependent exercise-induced allergy anaphylaxis). Generally, anaphylaxis is a severe, potentially fatal, hypersensitivity reaction of rapid onset. It is a dramatic clinical emergency. Actually, there are lots of etiologic factors of anaphylaxis, the principal immunologic triggers are foods, insect stings, and drugs. In recent, physical exercise is also related with the anaphylaxis. In this paper, we present the current views of physiological mechanisms underlying physical anaphylaxis within the context of exercise immunology. we also deals with a detailed 2 kinds of EIA (exercise-induced asthma, exercise-induced anaphylaxis) and exercise prescription and medical treatment for exercise-induced asthma, exercise-induced anaphylaxis and CU (chronic urticaria). METHODS: At first, we analyzed and presented the causes, symptoms, pathophysiology, testing, treatment and prescription of exercise-induced asthma, exercise-induced urticaria, exercise-induced anaphylaxis and FDEIAn through many experiments and references. RESULTS: Exercise-induced asthma is a typical asthmatic attack which follows a strenuous exercise lasting 5 to 10 minutes in circumstances of dry and cold air situation. Avoid of exercise in that conditions and drug treatment (beta-2 adrenergic agonists) must preferentially be preventive. Physical urticarias are a unique subgroup of CU in which patients develop urticaria secondary to environmental stimuli. Common triggers include cold and heat temperature, water, sunlight and even physical exercise. it is responsible for approximately 20-30% of all cases of chronic urticaria. FDEIAn is induced by different types and various intensities of physical exercise, and this is distinct from food allergy. It is useful to test both in vivo and in vitro an extensive panel of foods. Avoidance of allergenic foods for at least 4 h before exercise has prevented further episodes in all our patients with specific FDEIAn. CONCLUSIONS: It is concluded that anaphylaxis remains a continuous challenge for the diagnosis and treatment. The adequate management of anaphylaxis requires rapid diagnosis, implementation of primary and secondary prevention measures, and immediate administration of subcutaneous epinephrine. Furthermore, patient education is necessary to heighten awareness of the sign and symptoms of 2 kinds of EIA and FEDIAn.

특발성 아나필락시스 환자에서 오말리주맙의 치료 효과

반가영 ( Ga Young Ban ),양은미 ( Eun Mi Yang ),김지혜 ( Ji Hye Kim ),신유섭 ( Yoo Seob Shin ),예영민 ( Young Min Ye ),남동호 ( Dong Ho Nahm ),박해심 ( Hae Sim Park ) 대한천식알레르기학회 2015 Allergy Asthma & Respiratory Disease Vol.3 No.5

Anaphylaxis is a severe and life-threatening systemic reaction. Despite the extensive evaluation to determine the cause, 30%-60% of cases of anaphylaxis in adults remain idiopathic. Recently, omalizumab treatment has been postulated to treat refractory idiopathic anaphylaxis. We report a case of idiopathic anaphylaxis treated with omalizumab and investigated its pharmacological mechanism. A 66-year-old female presented to our clinic with recurrent anaphylaxis. She suffered from anaphylaxis 2-3 times a month for 6 months. She had past medical history of nonallergic bronchial asthma. History was carefully undertaken and anaphylaxis was not related to any specific foods, drugs, exercise, and insect bites. Serum specific IgE antibodies to common food allergens showed negative results. Oral provocation tests to food additives revealed to be negative. To screen systemic mastocytosis and mast cell activating syndrome, baseline tryptase level was checked, and it was within normal range. From comprehensive evaluation, she was diagnosed as having idiopathic anaphylaxis. She could not tolerate oral medications due to gastrointestinal discomfort, therefore, omalizumab treatment (150 mg, monthly) was started. After 6 months of treatment, anaphylaxis did not occur with complete remission status. To evaluate the pharmacological mechanism of omalizumab treatment, basophil histamine releasability test was performed. Histamine releasability induced by anti-IgE did not change after 6 months of treatment, while that induced by calcium inophore decreased. Omalizumab treatment can induce remission or favorable effects on idiopathic anaphylaxis, which may be derived from increased threshold of mast cell degranulation. Long-term studies in a larger cohort will be needed to confirm its efficacy. (Allergy Asthma Respir Dis 2015;3:380-383)

소아 아나필락시스 상병등록의 적절성

조연주 ( Yeon Joo Cho ),김선휴 ( Sun Hyu Kim ),이혜지 ( Hyeji Lee ),최병호 ( Byungho Choi ),김미진 ( Mi Jin Kim ),홍정석 ( Jung Seok Hong ) 대한천식알레르기학회 2017 Allergy Asthma & Respiratory Disease Vol.5 No.3

Purpose: The aim of this study was to survey the accuracy of registration as anaphylaxis codes and the clinical characteristics of ana-phylaxis registered correctly and incorrectly in pediatric anaphylaxis. Methods: This study was conducted retrospectively using the medical records of patients under 15 years who visited a training hos-pital Emergency Department (ED) for 5 years. The study subjects were divided into the correct group (registered as anaphylaxis codes correctly) and the incorrect group (registered as other anaphylaxis related codes). Results: Of the 133 patients, 14 belonged to the correct group and 119 to the incorrect group. The median age of the correct group was 9 years old and that of the incorrect group was 2 years old. Sex, transportation to the ED, elapsed time from exposure to ED ar-rival, past history of allergy, causes of anaphylaxis except drug, severity of symptom, mental status, and antihistamine use were not different between the 2 groups. Drugs as the cause of anaphylaxis and cardiovascular/neurologic symptoms were more common in the correct group. Gastrointestinal symptoms were more frequent in the incorrect group. Intravenous fluid, steroid, bronchodilator, and epinephrine were more commonly used as the treatment for anaphylaxis in the correct group. The pediatric patients treated with epinephrine tended to be registered anaphylaxis correctly. Conclusion: More patients were registered incorrectly as other anaphylaxis-related disease codes rather than correctly as the anaphylaxis disease codes in pediatric ana-phylaxis. Epinephrine use was the associated factor for being registered correctly as the ana-phylaxis disease codes in pediatric anaphylaxis. (Allergy Asthma Respir Dis 2017:5:159-164)