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Pediatrics, Anaphylaxis: Differential Diagnoses & Workup

Author: Jeffrey F Linzer Sr, MD, MICP, FAAP, FACEP, Associate Professor of Pediatrics and Emergency Medicine, Emory University School of Medicine; Associate Medical Director for Business Affairs and Compliance and EMS/Pre-Hospital Care Coordinator, Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine; Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston; Co-Medical Director and Consulting Staff, Children's Sedation Service, Children's Healthcare of Atlanta at Egleston
Contributor Information and Disclosures

Updated: Oct 5, 2009

Differential Diagnoses

Angioedema
Shock
Asthma
Shock, Cardiogenic
Bee and Hymenoptera Stings
Shock, Hypovolemic
Carcinoid Tumor
Status Asthmaticus
Exercise-Induced Anaphylaxis
Syncope
Serum Sickness
Toxicity, Seafood

Other Problems to Be Considered

Mastocytosis
Physical urticaria
Red man syndrome (vancomycin related)
Vocal cord dysfunction

Workup

Laboratory Studies

Anaphylaxis is essentially a clinical diagnosis. Laboratory tests generally are not useful for the acute diagnosis of this condition.

  • Serum histamine level rises quickly with the onset of symptoms but does not remain elevated after 30-60 minutes.
  • Serum tryptase level peaks 60-90 minutes after the onset of symptoms and remains elevated for up to 5 hours.
    • β-tryptase is released with degranulation of mast cells, while α-tryptase is secreted constitutively by them.
    • The ratio of total tryptase to β-tryptase can help distinguish systemic mastocytosis from anaphylaxis. A ratio £ 10 implies anaphylaxis, while ³ 20 is consistent with systemic mastocytosis.15 Other tests that may be useful in distinguishing anaphylaxis from other conditions in the differential include C1 inhibitor functional assay (C1INH) (hereditary angioedema) and urine vanillylmandelic acid and serum serotonin levels (carcinoid syndrome).

Imaging Studies

No imaging studies assist in making this diagnosis.

Other Tests

Radioallergosorbent test (RAST) or cutaneous antigen testing (preferably by a specialist) can be used after recovery to try to identify the inciting antigen.

More on Pediatrics, Anaphylaxis

Overview: Pediatrics, Anaphylaxis
Differential Diagnoses & Workup: Pediatrics, Anaphylaxis
Treatment & Medication: Pediatrics, Anaphylaxis
Follow-up: Pediatrics, Anaphylaxis
References
Further Reading
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References

  1. Simons EFR. Advances in H1-antihistamines. N Engl J Med. Nov 2004;351 (21):2203-17. [Medline].

  2. Ogawa Y, Grant JA. Mediators of anaphylaxis. Immunol Allergy Clin North Am. May 2007;27(2):249-60, vii. [Medline].

  3. Vadas P, Gold M, Perelman B, Liss GM, Lack G, Blyth T. Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis. N Engl J Med. Jan 3 2008;358(1):28-35. [Medline].

  4. Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. Jan 8 2001;161(1):15-21. [Medline]. [Full Text].

  5. Lieberman P, Camargo CA Jr, Bohlke K, et al. Epidemiology of anaphylaxis: findings of the American College of Allergy, Asthma and Immunology Epidemiology of Anaphylaxis Working Group. Ann Allergy Asthma Immunol. Nov 2006;97(5):596-602. [Medline].

  6. Yocum MW, Butterfield JH, Klein JS, Volcheck GW, Schroeder DR, Silverstein MD. Epidemiology of anaphylaxis in Olmsted County: A population-based study. J Allergy Clin Immunol. Aug 1999;104(2 Pt 1):452-6. [Medline].

  7. Decker WW, Campbell RL, Manivannan V, Luke A, St Sauver JL, Weaver A, et al. The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin Immunol. Dec 2008;122(6):1161-5. [Medline].

  8. Sheikh A, Alves B. Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clin Exp Allergy. Oct 2001;31(10):1571-6. [Medline].

  9. Simons FE, Peterson S, Black CD. Epinephrine dispensing patterns for an out-of-hospital population: a novel approach to studying the epidemiology of anaphylaxis. J Allergy Clin Immunol. Oct 2002;110(4):647-51. [Medline].

  10. Bohlke K, Davis RL, DeStefano F, Marcy SM, Braun MM, Thompson RS. Epidemiology of anaphylaxis among children and adolescents enrolled in a health maintenance organization. J Allergy Clin Immunol. Mar 2004;113(3):536-42. [Medline].

  11. [Guideline] Joint Task Force on Practice Parameters, American Academy of Allergy, Asthma and Immunology; American College of Allergy,Asthma and Immunology and Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. Mar 2005;115(3 Suppl 2):S483-523. [Medline].

  12. Sampson HA, Munoz-Furlong A, Campbell RL, et al. 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. J Allergy Clin Immunol. Feb 2006;117(2):391-7. [Medline]. [Full Text].

  13. Kobrynski LJ. Anaphylaxis. Clin Ped Emerg Med. 2007;8:110-16. [Full Text].

  14. Sicherer SH, Sampson HA. Peanut allergy: emerging concepts and approaches for an apparent epidemic. J Allergy Clin Immunol. Sep 2007;120(3):491-503. [Medline].

  15. Schwartz LB, Irani AM. Serum tryptase and the laboratory diagnosis of systemic mastocytosis. Hematol Oncol Clin North Am. Jun 2000;14(3):641-57. [Medline].

  16. Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock. Cochrane Database Syst Rev. Oct 8 2008;CD006312. [Medline]. [Full Text].

  17. Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. Jan 1998;101(1 Pt 1):33-7. [Medline].

  18. Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. Nov 2001;108(5):871-3. [Medline].

  19. [Guideline] Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy. Aug 2007;62(8):857-71. [Medline]. [Full Text].

  20. American Heart Association. Part 12: Pediatric Advanced Life Support. Circulation. 2005;112(Suppl 1):IV-167-87. [Full Text].

  21. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med. Nov 2000;36(5):462-8. [Medline].

  22. Lieberman P. Biphasic anaphylactic reactions. Ann Allergy Asthma Immunol. Sep 2005;95(3):217-26. [Medline].

  23. Kemp SF, Lockey RF, Simons FE. Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization. Allergy. Aug 2008;63(8):1061-70. [Medline].

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Further Reading

AAAAI Board of Directors. Position Statement: Anaphylaxis in schools and other child-care settings. American Academy of Allergy Asthma & Immunology. Available at http://www.aaaai.org/media/resources/academy_statements/position_statements/ps34.asp. Accessed August 19, 2007.

AAAAI School Tools: Allergy & Asthma Resources for Professionals. Available at http://www.aaaai.org/professionals/school_tools.stm. Accessed April 30, 2009.

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Keywords

anaphylaxis, anaphylaxis symptoms, anaphylaxis in children, allergic reaction, treating anaphylaxis, anaphylaxis syndrome, bee sting, drug allergy, food allergens, food allergy, latex allergy, peanut anaphylaxis, severe allergic reaction, venomous sting/bite

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Contributor Information and Disclosures

Author

Jeffrey F Linzer Sr, MD, MICP, FAAP, FACEP, Associate Professor of Pediatrics and Emergency Medicine, Emory University School of Medicine; Associate Medical Director for Business Affairs and Compliance and EMS/Pre-Hospital Care Coordinator, Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine; Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston; Co-Medical Director and Consulting Staff, Children's Sedation Service, Children's Healthcare of Atlanta at Egleston
Jeffrey F Linzer Sr, MD, MICP, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, American College of Emergency Physicians, and Medical Association of Georgia
Disclosure: Nothing to disclose.

Medical Editor

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, 
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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