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Case Reports
. 2020 Dec;50(12):1400-1405.
doi: 10.1111/cea.13749. Epub 2020 Oct 25.

Anaphylaxis Refractory to intramuscular adrenaline during in-hospital food challenges: A case series and proposed management

Cherry Alviani  1   2 , Sarah Burrell  3 , Abigail Macleod  4 , Susan Edees  4 , Graham Roberts  1   2 , Paul J Turner  3 , Michel Erlewyn-Lajeunesse  1   2
Affiliations
Case Reports

Anaphylaxis Refractory to intramuscular adrenaline during in-hospital food challenges: A case series and proposed management

Cherry Alviani et al. Clin Exp Allergy. 2020 Dec.

Abstract

Background: Anaphylaxis is a severe, systemic hypersensitivity reaction that can be potentially life-threatening. Anaphylaxis during oral food challenge is not uncommon and can usually be effectively managed with intramuscular adrenaline as first line treatment. Although very rare, fatal anaphylaxis during in-hospital food challenge has been reported.

Objective: We describe our experience of cases of refractory anaphylaxis at in-hospital challenge and propose a framework for escalation of treatment in such cases using intravenous infusion of adrenaline which has been adopted for widespread use elsewhere.

Methods: We present four patients who all experienced severe life-threatening anaphylaxis, refractory to intramuscular adrenaline treatment, during supervised oral food challenges. Patient data were collected from contemporaneous notes, and patient consent was obtained.

Results: In all four cases, the anaphylaxis reactions were amenable to treatment with low-dose intravenous adrenaline, with no reported adverse effects.

Conclusion and clinical relevance: These cases demonstrate the need for clinicians undertaking higher risk allergen challenges to be able to manage cases of severe anaphylaxis refractory to intramuscular adrenaline, and to consider a framework for managing these reactions. While peripheral intravenous adrenaline infusions should always be initiated only in conjunction with expert input, the protocol suggested is simple enough to be undertaken within the hospital environment while more experienced support is obtained.

Keywords: adrenaline; allergy; anaphylaxis; food allergy; oral food challenge.

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References

REFERENCES

    1. Turner PJ, Worm M, Ansotegui IJ, et al. Time to revisit the definition and clinical criteria for anaphylaxis? World Allergy Organ J. 2019;12(10):100066.
    1. Panesar SS, Javad S, de Silva D, et al. The epidemiology of anaphylaxis in Europe: a systematic review. Allergy. 2013;68(11):1353-1361.
    1. Turner PJ, Campbell DE, Motosue MS, Campbell RL. Global trends in anaphylaxis epidemiology and clinical implications. J Allergy Clin Immunol Pract. 2020;8(4):1169-1176.
    1. Bird JA, Leonard S, Groetch M, et al. Conducting an oral food challenge: an update to the 2009 adverse reactions to foods committee work group report. J Allergy Clin Immunol Pract. 2020;8(1):75-90.e17.
    1. Roberts G, Allen K, Ballmer-Weber B, et al. Identifying and managing patients at risk of severe allergic reactions to food: Report from two iFAAM workshops. Clin Exp Allergy. 2019;49(12):1558-1566.

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