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OBJECTIVE: To characterize demographically and clinically the patients with anaphylaxis treated in a third level health institution in Medellin, Colombia. METHODS: A cross-sectional descriptive observational study was carried out, which includedpatients were diagnosed with anaphylaxis between 2009 and 2019. Information was retrieved from medical records through a collection instrument. Subsequently, a descriptive statistical analysis of proportions and measures of central tendency of the variables of interest was performed. RESULTS: A total of 1820 records were reviewed and data from 253 patients were included. Among the reported comorbidities, drug allergy was the most prevalent (28%). The most frequent manifestations of anaphylaxis were cutaneous and respiratory. Most of the cases presented basal tryptase values ≤ 11.4 ng/mL (94.7%). Different etiological agents (food, drugs, insects and latex) were reported, and their frequency varied according to age. Adrenaline, steroids, and antihistamines were the treatments of choice in 39.9, 34.3, and 39.9% of cases, respectively. CONCLUSIONS: The characteristics of anaphylaxis in a medical center in Colombia coincide with those reported in Latin American. The treatment of anaphylaxis is not standardized, which makes it necessary to educate the health personnel and develop national guidelines.

OBJECTIVO: Identificar las características clínicas y demográficas de pacientes con anafilaxia, atendidos en un hospital de tercer nivel de Medellín, Colombia. MÉTODOS: Estudio observacional, descriptivo, de corte transversal, al que se incluyeron pacientes con diagnóstico con anafilaxia entre 2009 y 2019. La información de los pacientes se obtuvo a partir de los expedientes clínicos, mediante un instrumento de recolección. Se realizó un análisis estadístico descriptivo, de proporciones y medidas de tendencia central de las variables de interés. RESULTADOS: Se revisaron 1820 expedientes y se incluyeron los datos de 253 pacientes. Los agentes etiológicos más frecuentes fueron: medicamentos (52.1%), alimentos (34.7%), picadura de insectos (13.8%) y agentes no especificados (17.7%). Las manifestaciones cutáneas y respiratorias fueron las más frecuentes asociadas con anafilaxia. El 94.7% de los casos tuvo concentraciones normales de triptasa. La adrenalina, los corticosteroides y antihistamínicos fueron los fármacos de elección en el 39.9, 34.3 y 39.9% de los casos, respectivamente. CONCLUSIONES: Las características de anafilaxia coinciden con las reportadas en la mayor parte de los estudios en Latinoamérica. Aunque existen guías mundiales de tratamiento de la anafilaxia, no suelen aplicarse de forma uniforme, lo que hace necesario adiestrar al personal de salud y desarrollar guías nacionales al respecto.

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BACKGROUND: The Pfizer-BioNTech® BNT162b2 vaccine, provides 95% effectiveness from the second dose onwards. The reported rate of anaphylaxis to COVID-19 vaccines is 4.7 cases/million doses administered. CASE REPORT: 30-year-old female, health professional, history of allergic rhinitis, asthma, reaction to eye cosmetics and adhesive tape: erythema, edema, and local pruritus. Immediately after application of the first dose of Pfizer-BioNTech vaccine, she presented grade III anaphylaxis. The patient was stratified, phenotyped and skin tests with PEG 3350 were positive. A recommendation was issued not to reapply vaccine containing polyethylene glycol and alternatives were offered. CONCLUSIONS: An adequate risk stratification should be performed before applying mRNA-based COVID-19 vaccines for the first time in at-risk groups. In case of anaphylaxis at the first dose, phenotyping and further study with PEG skin tests should be performed and vaccination alternatives should be offered.

INTRODUCCIÓN: La vacuna Pfizer-BioNTech® BNT162b2 proporciona efectividad del 95% a partir de la segunda dosis. La tasa de anafilaxia reportada de vacunas para COVID-19 es de 4.7 casos por millón de dosis administradas. REPORTE DEL CASO: Paciente femenina de 30 años, profesional de la salud, con antecedentes de rinitis alérgica, asma, reacción a productos cosméticos en los párpados y al pegamento de la cinta adhesiva (eritema, edema y prurito local). Posterior a la aplicación de la primera dosis de la vacuna Pfizer-BioNTechÒ tuvo un evento de anafilaxia grado III. Se estratificó, fenotipificó y efectuaron pruebas cutáneas con PEG-3350, que resultaron positivas. Se sugirió no aplicar la aplicar vacuna de refuerzo que contuviera polietilenglicol y se ofrecieron alternativas de tratamiento. CONCLUSIONES: Es importante efectuar la adecuada estratificación de riesgo antes de aplicar las vacunas para COVID-19 basadas en ARNm por primera vez. En caso de anafilaxia es necesario fenotipificar y ampliar el estudio con pruebas cutáneas con PEG, además de otorgar alternativas de vacunación.

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Food allergy is a common chronic disorder that affects infants, children, adolescents, and adults. The prevalence of food allergy has increased in recent decades throughout the world, not limited to Western countries. Since there is no treatment, this focuses on avoiding allergens, in addition to educating patients and caregivers in the emergency treatment of acute reactions, for example: application of epinephrine. Studies suggest that accidental reactions occur in about 45% of children with food allergies each year, although most reactions are mild or moderate in severity. Hospital admissions for food anaphylaxis vary from 4 to 20 per 100,000 inhabitants; Deaths are rare, with an estimated incidence of 0.03 to 0.3 per million people with food allergy. Death from food anaphylaxis is rare and appears to have remained stable, possibly due to increases in food allergen labeling, diagnostic services, rates of intramuscular epinephrine prescription, and awareness of food allergies. Omalizumab is a drug approved for several disorders (chronic hives or difficult asthma) and may help reduce symptoms associated with food allergy. The relative importance of alternative technologies, management strategies and policies for food allergy varies from one region to another, due to differences in the epidemiology, education, socioeconomic well-being, and cultural preferences of the population.

La alergia alimentaria es un trastorno crónico frecuente que afecta a lactantes, niños, adolescentes y adultos. La prevalencia de alergia alimentaria se ha incrementado en las últimas décadas en todo el mundo, sin limitarse a los países occidentales. Puesto que no existe ningún tratamiento, éste se centra en evitar los alergenos, además de la educación de pacientes y cuidadores en el tratamiento de urgencia de las reacciones agudas, por ejemplo: aplicación de epinefrina. Los estudios sugieren que las reacciones accidentales ocurren en alrededor del 45% de los niños con alergia alimentaria cada año, aunque la mayor parte de las reacciones son de gravedad leve o moderada. Los ingresos hospitalarios por anafilaxia alimentaria varían de 4 a 20 por cada 100,000 habitantes; las muertes son raras, con una incidencia estimada de 0.03 a 0.3 por cada millón de personas con alergia alimentaria. La muerte por anafilaxia alimentaria es rara y parece haberse mantenido estable, posiblemente por el aumento en el etiquetado de alérgenos alimentarios, los servicios de diagnóstico, las tasas de prescripción de epinefrina intramuscular y la concienciación acerca de alergias alimentarias. Omalizumab es un fármaco aprobado para varias alteraciones (urticaria crónica o asma difícil) y puede ayudar a reducir los síntomas asociados con la alergia alimentaria. La importancia relativa de las tecnologías alternativas, las estrategias de gestión y las políticas para la alergia alimentaria varía de una región a otra, debido a las diferencias en la epidemiología, educación, bienestar socioeconómico y preferencias culturales de la población.

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Anaphylaxis, a potentially life-threatening reaction, is characterized by acute symptoms affecting various systems and requires immediate medical intervention. While the overall mortality rate is low, anaphylaxis induced by foods and drugs has seen an increase. Common triggers include foods, drugs, and Hymenoptera venom. Epidemiology varies by region and age, with a global incidence of 50-112 episodes per 100,000 people annually. Implicated foods vary by age and region, with peanuts and nuts being common triggers. Two mechanisms of anaphylaxis are recognized: IgE-mediated and non-IgE-mediated. Diagnosis is based on clinical criteria and serum tryptase levels. Treatment includes epinephrine, oxygen, and intravenous fluids. Exercise-induced food-dependent anaphylaxis is addressed, where exercise, combined with certain foods, triggers anaphylactic reactions. Proper understanding and management are crucial to mitigate risks.

La anafilaxia, una reacción potencialmente mortal, se caracteriza por la aparición aguda de síntomas que afectan diversos sistemas y requiere intervención médica inmediata. Aunque la tasa de mortalidad general es baja, la anafilaxia inducida por alimentos y fármacos ha experimentado un aumento. Los alimentos, fármacos y veneno de himenópteros son desencadenantes comunes. La epidemiología varía según la región y la edad, con una incidencia global de 50-112 episodios anuales por cada 100,000 personas. Los alimentos más implicados varían según la edad y la región, y los desencadenantes más comunes son cacahuetes y nueces. Se reconocen dos mecanismos de anafilaxia: mediado por IgE y no mediado por IgE. El diagnóstico se basa en criterios clínicos y niveles de triptasa sérica. El tratamiento incluye epinefrina, oxígeno y líquidos intravenosos. Se aborda la anafilaxia inducida por ejercicio dependiente de alimentos, donde el ejercicio, en combinación con ciertos alimentos, desencadena reacciones anafilácticas. La comprensión y el manejo adecuados son cruciales para mitigar riesgos.

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Cold-induced urticaria is considered as a subtype of physical urticaria and also the second most common type of chronic inducible urticaria. Contact with cold surfaces or the environment may cause systemic reactions, especially during aquatic activities. A 22-year-old female patient with a history of sulfa drug allergy began her condition 2 years before the presence of generalized pruritic erythema with hives as well as 2 episodes that had been characterized by facial angioedema and syncope 3-5 minutes after being in contact with cold air or surfaces.  On both events, she had just been outdoors on a cold, winter day. She was suspected to have cold-induced urticaria; thereby she had a positive reaction to the ice cube test. Due to the previous episodes of anaphylaxis, the patient was trained to administer intramuscular epinephrine. After 4 weeks of starting the treatment with antihistamines, no new events or injuries had occurred. Cold-induced urticaria may cause life-threatening reactions. The rate of anaphylaxis in these patients is low however, this case is presented to inform the importance of identifying this type of systemic reaction and preventing strategies.

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OBJECTIVE: To clinically characterize the events of anaphylaxis in a third-level pediatric hospital. METHODS: 1148 clinical records were reviewed. Eventually, the information of 35 events of anaphylaxis in 20 patients was analyzed; three of them had multiple episodes of anaphylaxis. RESULTS: The median age for the anaphylactic episodes was 11 years (Interquartile range 10 years, Q1 = 5, Q3 = 15), predominantly in adolescents between the ages of 12 and 17 years, and there was a slight predominance in women. The most frequent clinical manifestations were cutaneous (86%), followed by respiratory (83%), cardiovascular (74%), and gastrointestinal (46%) alterations. Cardiac arrest was documented in three episodes; however, no anaphylaxis-related deaths were reported. The main triggers for anaphylaxis were food (34%), medications (29%), allergen-specific immunotherapy (14%), and latex (11%). In patients with perioperative anaphylaxis, the clinical behavior was severe. Epinephrine was administered in 27 out of the 35 events (77%), but only in 11 cases it was the first-line treatment. Systemic corticosteroids were the most frequently used treatment, followed by epinephrine and antihistamines. CONCLUSIONS: The use of epinephrine, which is the mainstay of the treatment, is suboptimal; with a preferred use of second-line medications like corticosteroids. Clear protocols for the diagnosis and treatment of anaphylaxis, as well as continuous education of health personnel, are necessary.

Objetivo: Caracterizar clínicamente los eventos de anafilaxia en un hospital pediátrico de tercer nivel. Métodos: Se revisaron 1148 expedientes clínicos. Finalmente, se analizó la información correspondiente a 35 episodios de anafilaxia en 20 pacientes; tres de ellos con múltiples episodios de anafilaxia. Resultados: La edad mediana de los episodios de anafilaxia fue de 11 años (rango intercuartilar 10 años, Q1 = 5, Q3 = 15), con predomino en adolescentes de 12 a 17 años y del sexo femenino. Las manifestaciones clínicas más frecuentes fueron las cutáneas (86 %), seguidas de las respiratorias (83 %), las cardiovasculares (74 %) y las gastrointestinales (46 %). En tres casos se documentó paro cardiorrespiratorio, pero no hubo casos de mortalidad asociada a anafilaxia. Los principales desencadenantes fueron alimentos (34 %), medicamentos (29 %), inmunoterapia para alérgenos (14 %) y látex (11 %). En los pacientes con anafilaxia perioperatoria el comportamiento clínico fue grave. La adrenalina se utilizó en 27 de los 35 episodios (77 %), en 11 de ellos fue el tratamiento de primera elección. Los corticosteroides sistémicos fueron los medicamentos más frecuentemente utilizados, seguidos de la adrenalina y los antihistamínicos. Conclusiones: El uso de adrenalina, pilar del tratamiento de anafilaxia, es subóptimo; con uso preferente de medicamentos de segunda línea como los corticosteroides. Se requieren protocolos para diagnóstico y tratamiento de anafilaxia, aunado a una educación continua del personal de salud.

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INTRODUCTION: In many cases of drug allergy, it is necessary to do in vitro test, for several reasons. BAT (basophil activation test) is a very useful weapon in these cases. In many iv. or im. depot preparations, the culprit of the allergic reaction is an excipient, and not the main component. CASE REPORT: A 37-year-old male, suffering from a Klinefelter syndrome needed treatment with a preparation of undecanoate of testosterone (Reandron). With the last administered dose, he suffered an anaphylactic shock with Kounis syndrome. The patient declined any in vivo studies, so we thought of BAT as a possibility for the diagnosis. The results were remarkable, showing a very high positivity to castor oil. CONCLUSIONS: This is the second case in the world of anaphylaxis to a preparation of Testosterone, and the first one with the castor oil (also called Cremophor or Kolliphor) as responsible. El BAT was essential for the diagnosis and ulterior treatment of this patient. This is the first time, that this study with BAT, has been done with a Testosterone preparation.

Introducción: En muchos casos de alergia a medicamentos, es necesario realizar pruebas in vitro por diversos motivos. La PAB (prueba de activación de basófilos) es un arma útil en estos casos. Reporte de caso: Se trata de un hombre de 37 años en tratamiento con undecanoato de testosterona relacionado a síndrome de Klinefelter; que al momento de la última minsitración de la dosis, el paciente sufrió un choque anafiláctico acompañado de síndrome de Kounis. Por la necesidad de seguir con el tratamiento con testosterona, decidimos recurrir a la PAB para el diagnóstico, y los resultados fueron concluyentes, se documentó positividad al aceite de ricino. Conclusiones: A nivel mundial, este es el segundo caso de anafilaxia asociado a undecanoato de testosterona y el primero donde el aceite de ricino ha sido el responsable. La PAB se hizo necesaria para el diagnóstico y el posterior tratamiento de este paciente.

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INTRODUCTION: The European Network of Drug Allergy and the European Academy of Allergy and Clinical Immunology have classified hypersensitivity reactions induced by nonsteroidal anti-inflammatory drugs (NSAIDs) into 5 phenotypes according to the pathophysiology, clinical manifestations, number of drugs involved, and the presence of underlying diseases. This classification does not include anaphylaxis as part of NSAID cross-reactivity. The objective of this study was to characterize a group of patients with anaphylactic NSAID cross-reactivity. METHOD: This was a retrospective, descriptive, observational study. Patients who developed anaphylaxis to one NSAID plus another acute reaction (anaphylactic or not) to at least one other NSAID of a different chemical group were included. Demographic and clinical characteristics and the diagnostic approach were studied. RESULTS: A total of 38 patients were included, 28 (73.7%) of whom were women. The mean age was 40 ± 17.7 years. The main organs affected in the anaphylactic reaction were the skin and the respiratory system, occurring in 35 (92.1%) and 33 (86.8%) patients, respectively. Thirty-two (84.3%) patients presented with cutaneous and respiratory involvement simultaneously. The main anti-inflammatory agent involved in anaphylactic reactions was acetylsalicylic acid in 9 (23.7%) patients, followed by dipyrone in 8 (21.1%). The most frequent allergic comorbidity was rhinitis in 20 (52%) patients. Skin tests were performed in 15 (39.5%) patients, showing positivity in 12 (80%), mainly to mites. A total of 36 of 38 patients were challenged with alternative drugs, and 35 (97.2%) tolerated meloxicam and/or etoricoxib. CONCLUSION: In the present study, NSAID cross-anaphylaxis was more frequent in women, and acetylsalicylic acid and dipyrone were the main triggers. Rhinitis was the main allergic comorbidity, and there was a high incidence of atopy. The majority tolerated selective COX-2 NSAIDs.

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INTRODUCTION: Hypersensitivity reactions (HSRs) to rituximab occur during the first infusion in 29% to 40% of patients. Commonly, these hypersensitivity reactions are the result of a release of cytokines, although IgE mediated reactions have also been reported. CASE REPORT: A 7-year-old female patient with diagnosis of CD-20 positive acute lymphoblastic B-cell leukemia was included in a pilot study that consisted of two doses of rituximab treatment in the induction to remission phase by the pediatric hematology service; 30 minutes after the first administration of 300 mg of rituximab the patient started with generalized rash, nausea, vomiting, tachycardia, dyspnea, foreign body sensation in throat, oxygen desaturation until 89% and hypotension; therefore, the infusion of rituximab was suspended, and intramuscular epinephrine was administered as well as intravenous hydrocortisone and chlorphenamine and supplemental oxygen supply with adequate resolution of symptoms. MANAGEMENT & OUTCOME: Intradermal skin testing with rituximab at the concentration 1 mg/ml (dilution 1:10), was positive. Desensitization to rituximab was indicated by our service with 4 bags - 16 steps protocol with an initial concentration dose of 1/1,000 of the total dose. The patient was premedicated 1 hour prior with intravenous chlorphenamine, methylprednisolone and ondansetron. Intravenous prophylactic fluids with normal saline solution were administered during the infusion. The procedure was carried out with close monitoring of vital signs in a course of 6.67 hours, without presenting hypersensitivity reactions. DISCUSSION: HSR to rituximab may be induced by the activation of mast cells and basophils. Desensitization protocols are developed when there is no alternative drug for the underlying condition.

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