eMedicine Specialties > Allergy and Immunology > Allergy Pathogenesis

Hypersensitivity Reactions, Immediate: Differential Diagnoses & Workup

Author: Miriam K Anand, MD, Consulting Staff, Department of Allergy/Immunology, Allergy Associates and Lab, Ltd
Coauthor(s): John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
Contributor Information and Disclosures

Updated: Jun 16, 2009

Differential Diagnoses

Allergic and Environmental Asthma
Hereditary Angioedema
Anaphylaxis
Hypersensitivity Pneumonitis
Angioedema
Irritable Bowel Syndrome
Asthma
Pulmonary Embolism
Bronchitis
Shock, Distributive
Carcinoid Lung Tumors
Sinusitis, Acute
Cardiogenic Shock
Sinusitis, Chronic
Chronic Obstructive Pulmonary Disease
Syncope
Emphysema
Upper Respiratory Tract Infection
Farmer's Lung
Urticaria
Food Allergies
Food Poisoning
Heart Failure

Other Problems to Be Considered

Aspergillosis
Nonallergic Rhinitis

Workup

Laboratory Studies

  • Some laboratory tests may be helpful in determining whether a reaction is truly allergic in nature.

    • Obtaining a tryptase level soon after the onset of symptoms can be helpful in differentiating anaphylaxis from other forms of shock and from other symptom complexes that may be confused with anaphylaxis. The tryptase level can be elevated, which is indicative of mast cell degranulation. False-negative results can occur. Ideally, the tryptase level should be drawn within 4 hours after the event, but it can be drawn up to 15 hours later. Measurement of urinary histamine may also be useful.
    • An elevated eosinophil count may be observed in patients with atopic disease.
    • IgE levels may be elevated in patients who are atopic, but the level does not necessarily correlate with clinical symptoms.
    • The radioallergosorbent test (RAST) and other in vitro IgE assays measure antigen-specific IgE and can be useful in identifying which allergens are causing symptoms for the patient. A more sensitive type of RAST is known as the CAP-RAST (Pharmacia; Uppsala, Sweden) and has a greater positive predictive value for foods.

Other Tests

  • Skin tests
    • Skin tests can be performed in the outpatient setting in the allergist's office and are very useful in the evaluation and management of allergic rhinitis and allergic asthma.
    • Skin prick tests involve pricking the skin where diagnostic allergen has been dropped. A positive reaction consists of a wheal and flare that occurs within 15-20 minutes.
    • Intradermal (ID) tests involve injecting allergen into the superficial dermis. ID tests have many more false positive reactions, and the clinical significance of a positive ID test is questionable.
    • Food skin tests have a higher false-positive rate than skin tests for aeroallergens, but negative food skin test results can be helpful in excluding IgE-mediated allergies.
    • For the most part, standardized diagnostic allergens are not available for drugs. Penicillin is the only drug for which a standardized diagnostic allergen exists, but even this is only available for the major determinant, one of many possible allergens in the penicillins. While nonstandardized skin tests can be performed for the minor determinants in penicillin or for other drugs (ie, by pricking the skin where drug solution has been placed), these tests are only useful if findings are positive.
  • Spirometry/pulmonary function tests
    • Spirometry or pulmonary function tests offer an objective means of assessing asthma.
    • Peak-flow meters can also be used for this and can be used by patients at home to monitor their status.
    • Inhalation challenge with histamine, methacholine, and specific allergen can be used to confirm airway hypersensitivity or allergen sensitivity.
  • Nasal smear tests
    • A nasal smear can be performed to look for eosinophils.
    • Elevated eosinophil levels can be consistent with allergic rhinitis.

More on Hypersensitivity Reactions, Immediate

Overview: Hypersensitivity Reactions, Immediate
Differential Diagnoses & Workup: Hypersensitivity Reactions, Immediate
Treatment & Medication: Hypersensitivity Reactions, Immediate
Follow-up: Hypersensitivity Reactions, Immediate
Multimedia: Hypersensitivity Reactions, Immediate
References
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Further Reading

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Keywords

type I hypersensitivity reactions, allergic reactions, IgE-mediated reactions, immunoglobulin E-mediated reactions, atopy, immunopathology, immediate hypersensitivity reactions, cytotoxic hypersensitivity reactions, delayed hypersensitivity reactions, anaphylaxis, allergic asthma, urticaria, angioedema, allergic rhinitis, drug reaction, atopic dermatitis, inactivation antibody reactions, activation antibody reactions, cytotoxic antibody reactions, cytolytic antibody reactions, immune-complex reactions, T-cell cytotoxic reactions, granulomatous reactions

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Contributor Information and Disclosures

Author

Miriam K Anand, MD, Consulting Staff, Department of Allergy/Immunology, Allergy Associates and Lab, Ltd
Miriam K Anand, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians-American Society of Internal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
John M Routes, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Microbiology, American Society for Virology, Clinical Immunology Society, and Federation of American Societies for Experimental Biology
Disclosure: Nothing to disclose.

Medical Editor

Stephen Rosenfeld, MD, Professor Emeritus, Department of Medicine, Allergy, Immunology and Rheumatology Unit, University of Rochester School of Medicine and Dentistry
Stephen Rosenfeld, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American Federation for Clinical Research, Clinical Immunology Society, and Medical Society of the State of New York
Disclosure: Elan Ownership interest None; Invitrogen Ownership interest None; Merck Ownership interest None; Pfizer Ownership interest None; Medco Health Ownership interest None; Millipore Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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