Q:

8/27/2013
HPI: 22 yo M presents with c/o Acute hand and face numbness progressing to acute hand and facial swelling within 1-2 minutes along with itchy skin but absence of hives. The hand swelling prevented him to make a fist, and as the reaction progressed he started wheezing but denies chest tightness, throat tightness, throat swelling or dyspnea. He was taken to the ED where he was treated with epinephrine, prednisone, benadryl which caused sedation and woke up 2 hours later feeling fine. He denies any history of allergic rhinitis and has no such symptoms. He denies a childhood history of atopic dermatitis, asthma and food allergies. He eats peanuts, tree nuts, shellfish, dairy, eggs, and wheat without any adverse reactions. Previous honeybee sting/yellow jacket sting have only resulted in a localized reaction. He admits he took Motrin 9 hours prior to the reaction. He takes Motrin on a regular basis and has never had any symptoms. Specific IgE levels done by PCP showed a total IgE level of 2047 with multiple environmental and food allergies as well as IgE level to bumble bee. No systemic reaction when he was stung once. Admits to frequent NSAIDs but had it 9 hours before reaction.

Our labs: Repeat IgE 1205 (one month later); normal CBC, LFTs, ESR, C3, C4, Lyme screen, thyroid antibodies, TSH, IgE and IgG Apergillus fum, ANA, C1 inhbitor level, H pylori. Skin testing to environmental and foods were all normal; CXR normal.

Pending labs- tryptase, SPEP, UPEP to r/o IgE myeloma

Summary: pt with very high IgE and normal eosinophils (I see a lot of posted Q/A with both elevated but not seeing a differential with only very high IGE level), with seeming anaphylaxia and angioedema episode. Please recommend any additional workup or differential.

A:

Thank you for your inquiry.

I think that you have done due diligence and doubt that any further evaluation would be of help to you in determining the cause of your patient's episode of angioedema/anaphylaxis. I think it is important to remember that up to 60% of the cases of anaphylaxis in adults, and even a higher percentage of cases of angioedema will be idiopathic. In these instances, extensive workups are often not helpful. It is doubtful that anything will turn up on the tests that are still pending. If this is the case, I would simply equip him with an automatic epinephrine injector and be available to him should an event occur.

The other important consideration is whether or not the ibuprofen he ingested was the trigger. The fact that he took the ibuprofen 9 hours prior makes this highly unlikely, but if he has not taken it since, it may still be advisable to avoid it.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology