Multiphasic Anaphylaxis: An Uncommon Event in the Emergency Department

Abstract

Objective:To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. Methods: Retrospective chart review of out-of-hospital, ED, and hospital records over a 4.5-year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with 2 2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths. Results: The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throatkhest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using P-adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria. Conclusion: Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition. Key words: anaphylaxis; allergic reaction; multiphasic allergic reaction; multiphasic anaphylaxis.Acad. Emerg. Med. 1996; 4:193-197. I Anaphylaxis is an immediate, life-threatening, multisystem allergic reaction, representing a true medical emergency. Most often, the initial manifestations are respiratory, cardiovascular, cutaneous, and/or gastrointestinal (GI); occasionally, fulminant cardiovascular collapse may be the only presentation. Reactions range widely in severity from mild pruritus and urticaria to shock and death. The clinical manifestations result from the sudden release of histamine and other mediators from the mast cell and the basophil. Common triggers include food, Hymenop-

Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium

“…The occurrence of biphasic reactions has been established in the literature and appears to occur in 1% to 20% of anaphylactic reactions (as depicted in Table II). 8,11,27,[29][30][31][32][33][34] In a study evaluating patients with fatal or near-fatal food reactions, approximately 20% of patients experienced a biphasic reaction, indicating that biphasic reactions might be more likely in patients who present initially with severe symptoms. 11 The reported time intervals between the initial reaction Adapted from Smit et al 8 and the onset of the second phase ranged from 1 to 72 hours.…”

“…11 The reported time intervals between the initial reaction Adapted from Smit et al 8 and the onset of the second phase ranged from 1 to 72 hours. 11,27,[30][31][32][33][34] Unfortunately, no reliable clinical predictors have been identified to enable the identification of patients at increased risk of a biphasic reaction, although some studies have suggested that patients requiring higher doses of epinephrine to control initial symptoms or delayed administration of epinephrine might be associated with increased risk of a biphasic reaction. 11,15,33,34 Generally, the same organ systems are involved in the initial and secondary reaction.…”

Biphasic Anaphylaxis: A Review of the Incidence, Characteristics and Predictors

“…A delayed onset to the development of symptoms after the initial exposure to the antigen [4,17], and oral ingestion of antigen [4,13] have been noted as potential predisposing factors in two reports thus far, however, many studies that specifically looked for these risk factors were unable to confirm the same [15,16,[18][19][20]. Scranton et al reported biphasic reactions after immunotherapy-induced anaphylaxis [21] further confirming that the route of antigen delivery need not be oral to experience a biphasic response.…”

“…They described an overall incidence rate for these reactions of 5.8%. Subsequent retrospective analyses continued to report relatively low incidence rates, such as 2% (from Cianferoni et al's review of 113 inpatients [14]), 3% (from Brady et al's ED review [15]), and 6% (from Lee and Greenes pediatric inpatient series [16]). The most recently published retrospective analyses further suggests relatively low incidence rates of 5.3% and 11% for biphasic responses [17,18].…”

“…Importantly, 13 of the 19 patients who experienced biphasic reactions (68%) developed recurrent symptoms after they had been discharged from the ED. The study by Brady et al included patients who experienced recurrences as late as 26 and 40 hours after discharge from the ED [15]. Many other isolated case reports emphasize this potential for very late onset biphasic reactivity [25][26][27].…”