Diagnostic Considerations

The clinical diagnosis of anaphylaxis is based on probability and pattern recognition. Anaphylaxis is considered likely to be present if any 1 of the 3 following clinical criteria is satisfied within minutes to hours:

Acute symptoms involving skin, mucosal surface, or both, as well as at least one of the following: respiratory compromise, hypotension, or end-organ dysfunction
Two or more of the following occur rapidly after exposure to a likely allergen: hypotension, respiratory compromise, persistent gastrointestinal symptoms, or involvement of skin or mucosal surface
Hypotension develops after exposure to an allergen known to cause symptoms for that patient: age-specific low blood pressure or decline of systolic blood pressure of more than 30% compared to baseline

However, anaphylaxis occurs as part of a clinical continuum that can begin with relatively mild features and rapidly progress to life-endangering respiratory or cardiovascular manifestations. Delaying the diagnosis until multiorgan manifestations of anaphylaxis are present is risky because the severity of a reaction is difficult or impossible to predict at the time of symptom onset.

Other problems to be considered in diagnosing potential anaphylaxis include the following:

Vasodepressor (vasovagal) reaction (probably the most common masquerader)
Globus hystericus
Hereditary angioedema
Other forms of shock (ie, hypovolemic, cardiogenic, septic)
Flushing syndrome, including red man syndrome (vancomycin), pancreatic polypeptide tumors, postmenopausal patient, ethanol-induced, autonomic epilepsy
Monosodium glutamate poisoning
Scombroid fish poisoning
Capillary leak syndrome
Pulmonary embolism
Myocardial dysfunction
Foreign body aspiration (young children, especially)
Poisoning, acute
Neurologic (stroke, seizure)

Nonorganic disease, including panic attack, hyperventilation, vocal cord dysfunction syndrome, somatoform anaphylaxis

Differential Diagnoses

Workup

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Author

S Shahzad Mustafa, MD Physician in Allergy, Immunology, and Rheumatology, Rochester General Medical Group; Clinical Assistant Professor of Medicine, University of Rochester School of Medicine and Dentistry

S Shahzad Mustafa, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, Finger Lakes Allergy Society

Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD Clinical Professor of Medicine, George Washington University School of Medicine; 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, Association of American Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Roy Alson, MD, PhD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine, Wake Forest University School of Medicine; Medical Director, Forsyth County EMS; Deputy Medical Advisor, North Carolina Office of EMS; Associate Medical Director, North Carolina Baptist AirCare

Roy Alson, MD, PhD, FACEP, FAAEM is a member of the following medical societies: Air Medical Physician Association, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, North Carolina Medical Society, Society for Academic Emergency Medicine, and World Association for Disaster and Emergency Medicine