Allergy-Immunology – The Emergency Medical Minute

Podcast #226: Biphasic Anaphylaxis

Author: Sam Killian, M.D.

Educational Pearls

Anaphylaxis is common in the ED. These patients are treated and then usually watched for 4-6 hours.
Biphasic happens in patients that have a complete resolution of their anaphylaxis for at least an hour, but then have a recurrence that requires pharmacologic intervention. Most of the time this happens 3-6 hours later, but can happen more than 10 hours later.
More commonly happens in patients that have a delayed presentation, a wide pulse pressure, need multiple doses of epi, require the use of a beta agonist, or are ages 6-9 years old.
Educate patients about the possibility of Biphasic anaphylaxis before discharge.

Author: Peter Bakes M.D.

Educational Pearls:

Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms
The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis
Reactive arthritis commonly presents with a history of a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
Treatment for reactive arthritis is usually supportive.

References: www.emedicine.medscape.com/article/331347-overview

Run Time: 5 minutes

Author: Peter Bakes M.D.

Educational Pearls:

Case presentation: 18 year old otherwise healthy male presents to the ED complaining of neck stiffness, headache, and right ankle irritation. The patient recently traveled to Italy in an area endemic of Lyme Disease. The patient 2 weeks prior had a viral infection w/ rhinorrhea and diarrhea. The patient was diagnosed the previous day with a “UTI” and is currently taking antibiotics.
Other important information that would be useful for evaluation would be a prior evaluation for lyme, known pre-existing joint processes, and previous rheumatoid history.
The patient had no rash on exam, no associate features of lyme, and no bacteria in the urine, but had noted unilateral conjunctivitis, and a red, inflamed ankle joint.
Possible causes of presentations of one red, warm, inflamed painful joint: Gouty arthritis, pseudogout, septic joint, lyme arthritis, acute on chronic arthritis, and reactive arthritis.
This patient was diagnosed with Reiter’s syndrome now known as a reactive arthritis – an antibody response to an infection. Classically presents as a genitourinary or gastrointestinal infection in a young male with the clinical triad of urethritis, conjunctivitis, and arthritis a few weeks after an infection.

Link to Podcast: http://medicalminute.madewithopinion.com/reiter-s-syndrome/

References: http://www.aafp.org/afp/2003/0701/p83.html

Run Time: 2 minutes

Author: Dr. Nicholas Hatch

Educational Pearls:

Angioedema is usually caused by an allergic reaction and can be induced by ACE inhibitors as well as tissue plasminogen activator (TPA).
Angioedema is caused by the build up of bradykinins resulting in the leaking of capillaries and swelling of tissue.
TPA-induced angioedema is reported to occur in 1.6% of the patients who receive TPA and is more severe than ACE inhibitor-induced angioedema.
Giving solu-medrol to treat ACE inhibitor-induced angioedema is the standard of care, although its actual benefit is limited.
FFP and icatibant (which is a bradykinin receptor antagonist) have been shown to provide more benefit in treatment of angioedema. These are much more expensive options than solu-medrol, with the 30 mg of SubQ icatibant costing the hospital $5000 dollars per dose.
ACE inhibitor-induced angioedema lasts on average 27 hours before the symptoms subside.

Link to Podcast: http://medicalminute.madewithopinion.com/angioedema/

References: http://www.uptodate.com/contents/ace-inhibitor-induced-angioedema

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Run Time: 5 minutes

Author: Dr. Jared Scott

Educational Pearls:

Urticaria means “burning nettles” in Latin.
Lymph nodes release immunoglobulin IgE and IgG, which trigger mast cells located all over the body to release histamines.
Along with the well-known acute urticaria, there are chronic types of urticaria, which last longer than six weeks.
There are many types of urticaria including: dermatographic urticaria, food-induced urticaria, drug-induced urticaria, cholinergic urticaria, solar urticaria, and cold-induced urticaria among others.

References: