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Factors That Trigger Anaphylaxis

Question:

Discuss about the Drug Induced Anaphylaxis.

Anaphylaxis is a life threatening reaction experienced by some people when they are exposed to any sort of allergen. When they are exposed to something they are allergic to, the immune cells of the body releases certain chemicals which can give rise to anaphylactic reactions (Torres & Blanca, 2010). Anaphylaxis is life threatening and requires an immediate action. Triggering factors for anaphylactic shock includes food, insect stings, medicines, anesthetics, latex, allergens like pollen grains from plants, mold spores, dusts, and chemicals found in cosmetics. In some cases it can be some blood products (Harper et al., 2009).

Anaphylactic agents may enter the body through direct skin contact, ingestion, and inhalation. The antigens identify the allergens as foreign body. Immune cells like the mast cells release chemicals that bind to the IgE antibody to give rise to an inflammatory response (vultaggio, 2010). Anaphylactic shocks causes vasodilatation and increases the permeability of the capillaries leading to poor transfusion of the tissues. Poor tissue perfusion leads to shock (Adkinson et al., 2013).

This essay focuses on the anaphylactic reactions due to the administration of the broad spectrum of antibiotic Flucloxacillin (Jenkins et al., 2009).

Each and every person reacts to medicines differently. A drug suitable for one may not be suitable for the other person. A person may develop rashes or develop more serious adverse reactions; o the other hand another person may not show any such adverse reactions. Immune reactions are due to the chain reaction that starts in the immune reaction. The immune system of the body controls how a body defends itself from infections. The immune system of the body reacts to drugs in many ways. For instance, if a body is allergic to a particular medicine, then the body identifies that particular drug as an allergen or an antigen.

The immune system protects the body from disease. The body is so designed to fight with the infections and diseases. During a hypersensitivity reaction the immune system reacts with the drugs, thinking it as a foreign invader. This immune response leads to inflammation causing rashes, troubled breathing, wheeziness and many more symptoms.

Hypersensitivity reactions due to drugs are mediated mainly by the IgE antibodies or T cells. The reaction mechanism of IgE is well investigated, but the mechanisms of T-cell-mediated drug hypersensitivity are not well understood (Lieberman, 2008). Recent studies have described 2 concepts: the hapten/prohapten concept and the concept of interactions of the antibiotics with immune receptors (Adam, Pichler & Yerly, 2011). In allergic drug reactions, mediated by the T cells, the specificity of the T-cell receptor that has been stimulated by the antibiotic may be directed to a cross-reactive major histocompatibility complex-peptide compound. Therefore, previous contact with the medicine is not obligatory, and an immune mechanism should be considered as the major cause of hypersensitivity (Aun et al.,2014). Indeed, hypersensitive reactions to xenobiotics in patients without any prior exposure to the agent have been described for the neuromuscular blocking agents and radio contrast media. Therefore, the “allergenic” characteristics of a drug under development should be assessed not only by detecting its hapten like characteristics but also by detecting its potential to give rise to an immune reaction (Dona et al., 2011). Recent findings have suggested that previous contact with the drug is not always needed for a drug allergic reaction, but the reactions can be explained by the cross reactivity. Cross reactivity mediated drug allergy may occur in the IgE, IgG and T cell mediated reactions.

Immune Response Mechanisms to Drug Hypersensitivity

The following case study describes about a drug induced anaphylactic reactions. The patient was suffering from Cellulitis. On administration of the drug flucloxacillin, the patient suffered from hypersensitivity reactions (Pichler et al., 2010). This indicates that the antibiotic administered to the patient must have acted like an antigen towards the immune cells of the body, and thus the body might have generated a heightened immune response. The patient has also developed the symptoms that are common in an anaphylactic shock.

Vomiting, Dizziness, Weak or rapid pulse, tightening of the throat, Unconsciousness, Wheezing, Rashes all over the body.

The symptoms given in the given case study is also similar to these general signs caused by the drug induced anaphylaxis (Liew, Williamson & Tang, 2009).

The case study provides information with a person having cellulitis. Cellulitis is a bacterial infection that occurs beneath the skin. Cellulitis can occur on any part of the skin, mostly in legs, which leads to swelling and redness. The person is reported to go to the hospital where he was administered with Flucloxacillin, after which he had an anaphylaxis shock.  Flucloxacillin is an antibiotic that is normally administered to treat bacterial infections like Cellulitis.

As per the symptoms indicated in the given case study it could be understood that the person’s airway has narrowed causing troubled breathing and the blood vessels might have widened, making the blood pressure fall. All these symptoms align with the general symptoms of a drug induced anaphylaxis.

Laboratory procedures are always not found to be reliable in the detection of the anaphylactic reactions. A patient suffering from drug induced anaphylaxis should have elevated plasma histamine at least within one hour of onset of the symptoms. Serum or plasma tryptase levels greater than 15ng/ml, within 12 hours of onset is normally used as a confirmatory test but usually negative in food-induced anaphylaxis (Rueff et al., 2009). Plasma tryptase measurements are more reliable that single measurement. Elevated level of IgE in the serum and skin tests for the allergen is not always reliable for understanding the drug induced hypersensitivity reactions. Mast cell tryptase is the laboratory procedure that confirms an anaphylactic reaction.

It is recommended to remove the causative agent of the reaction, although it is not always possible. The initial treatment if treating anaphylaxis is the administration of epinephrine (Kemp, Lockey & Simons, 2008). Epinephrine IV is given in case of severe reactions. In case of severe shock, the skin and the muscle may not be per fused properly in such a case subcutaneous or intramuscular epinephrine will not be properly absorbed in to the circulation that is why type IV is given. Epinephrine has many lethal side effects. It can cause severe palpitations and dyrrhythmias if it too fast application is done. One should calculate the sub-cutanous or the intramuscular dose and should give only dose IV between 2 to 10 minutes, as per the seriousness of the condition (Soar et al., 2008).

Case Study: Anaphylactic Reactions Due to Flucloxacillin

Identification

Name of the patient- Jim Palmer

Situation

Jim Palmer is a farmer of 53 years old He was admitted in the morning with a case of severe cellulitis in his left lower leg.

Background

Jim Palmer is a farmer of 53 years old He was admitted in the morning with a case of severe cellulites in his left lower leg. He was brought to the clinic where he got one dose of flucloxacillin as a slow bolus. Ten minutes after the administration of the medicine he was found breathless, throat congestion, feeling of lightheadedness, and dizziness. On further assessment it was found that the level of unconsciousness is gradually increasing. It was found that Jim had a bilateral chest movement, depth of his breathing is shallow, and some audible wheezing can be heard with some central cyanosis. He is feeling extremely drowsy and is responding to voices.

Diagnosis

Presence of Urticarial rashes along with swelling in his lips, fingers and toes indicating acute anaphylaxis reactions.

Past medical history

Past medical history does not show any such allergic reactions.

Assessment

Vital signs- Resps 26 bpm, B.P- 99 mm Hg systolic on palpitation, body temperature- 37.4?, SaO2 91% on RA, cool  and clammy peripherals, Capillary refill timing is greater than 4 secs, Urticarial red rashes, swelling of lips, toes, Blood glucose- 5.3 mmols/litres.

Current medication

The patient is administered with two doses of Flucloxacillin 1gram IV is given.

The patient is showing gradual signs of deterioration. His visibilities and response to voices are decreasing gradually. So will be better that an immediate action is taken. It is recommended to start the initial treatment with a low dose of Epinephrine. It is recommended to check the Serum or plasma tryptase levels. A level greater than 15ng/ml, within 12 hours of onset is normally used as a confirmatory test for the anaphylaxis reactions.

Conclusions

Anaphylactic reactions because of the usage of antibiotics have increased in frequency because of the widespread use of the pharmaceuticals. Anaphylaxis is hypersensitive reactions caused due to the release of the mediators of basophils and mast cells by the IgE. Anaphylactic reactions differ from patient to patient, so sensitivity of one patient to a particular allergen might not match with the other patient. Anaphylactic reactions are life threatening in some cases. Therefore few things must be kept into mind to avoid anaphylaxis. It is very importan to be acquainted with the patient’s medical history. Care should be taken by the nurses and the healthcare providers to provide medicines like β-lactams, non steroidal anti inflammatory drugs, anasthetics, radio contrast media, latex and some more. Simple strategies help in preventing anaphylaxis, which involves the route through which the drug has been administered, patient identification with previously known history of anaphylaxis and the knowledge that some medicines can cross react and give rise to hypersensitive reactions. Thus it can be concluded that the most important requirements for the detection of anaphylactic shock are the early detection, diagnosis and prompt interventions without any delay.

Diagnosis and Treatment of Anaphylactic Shock

References

Adam, J., Pichler, W. J., & Yerly, D. (2011). Delayed drug hypersensitivity: models of T?cell stimulation. British journal of clinical pharmacology, 71(5), 701-707.

Adkinson Jr, N. F., Bochner, B. S., Burks, A. W., Busse, W. W., Holgate, S. T., Lemanske, R. F., & O'Hehir, R. E. (2013). Middleton's Allergy E-Book: Principles and Practice. Elsevier Health Sciences.

Aun, M. V., Blanca, M., Garro, L. S., Ribeiro, M. R., Kalil, J., Motta, A. A., ... & Giavina-Bianchi, P. (2014). Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis. The Journal of Allergy and Clinical Immunology: In Practice, 2(4), 414-420.

Doña, I., Blanca?López, N., Cornejo?García, J. A., Torres, M. J., Laguna, J. J., Fernández, J., ... & Blanca, M. (2011). Characteristics of subjects experiencing hypersensitivity to non?steroidal anti?inflammatory drugs: patterns of response. Clinical & Experimental Allergy, 41(1), 86-95.

Harper, N. J. N., Dixon, T., Dugue, P., Edgar, D. M., Fay, A., Gooi, H. C., ... & Pumphrey, R. S. H. (2009). Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia, 64(2), 199-211.

Jenkins, R. E., Meng, X., Elliott, V. L., Kitteringham, N. R., Pirmohamed, M., & Park, B. K. (2009). Characterisation of flucloxacillin and 5?hydroxymethyl flucloxacillin haptenated HSA in vitro and in vivo. PROTEOMICS-Clinical Applications, 3(6), 720-729.

Kemp, S. F., Lockey, R. F., & Simons, F. E. R. (2008). Epinephrine: the drug of choice for anaphylaxis--a statement of the World Allergy Organization. World Allergy Organization Journal, 1(2), S18.

Lieberman, P. (2008). Epidemiology of anaphylaxis. Current opinion in allergy and clinical immunology, 8(4), 316-320.

Liew, W. K., Williamson, E., & Tang, M. L. (2009). Anaphylaxis fatalities and admissions in Australia. Journal of Allergy and Clinical Immunology, 123(2), 434-442.

Pichler, W. J., Adam, J., Daubner, B., Gentinetta, T., Keller, M., & Yerly, D. (2010). Drug hypersensitivity reactions: pathomechanism and clinical symptoms. Medical Clinics of North America, 94(4), 645-664.

Ruëff, F., Przybilla, B., Biló, M. B., Müller, U., Scheipl, F., Aberer, W., ... & Campi, P. (2009). Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase—a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. Journal of Allergy and Clinical Immunology, 124(5), 1047-1054.

Soar, J., Pumphrey, R., Cant, A., Clarke, S., Corbett, A., Dawson, P., ... & Hall, J. (2008). Emergency treatment of anaphylactic reactions—guidelines for healthcare providers. Resuscitation, 77(2), 157-169.

Soar, J., Pumphrey, R., Cant, A., Clarke, S., Corbett, A., Dawson, P., ... & Hall, J. (2008). Emergency treatment of anaphylactic reactions—guidelines for healthcare providers. Resuscitation, 77(2), 157-169.

Thong, B. Y. H., & Tan, T. C. (2011). Epidemiology and risk factors for drug allergy. British journal of clinical pharmacology, 71(5), 684-700.

Torres, M. J., & Blanca, M. (2010). The complex clinical picture of β-lactam hypersensitivity: penicillins, cephalosporins, monobactams, carbapenems, and clavams. Medical Clinics of North America, 94(4), 805-820.

Torres, M. J., Mayorga, C., & Blanca, M. (2009). 1 Nonimmediate Allergic Reactions Induced by Drugs: Pathogenesis and Diagnostic Tests. Journal of investigational allergology & clinical immunology, 19(2), 80.

Vultaggio, A., Matucci, A., Nencini, F., Pratesi, S., Parronchi, P., Rossi, O., ... & Maggi, E. (2010). Anti?infliximab IgE and non?IgE antibodies and induction of infusion?related severe anaphylactic reactions. Allergy, 65(5), 657-661.

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