Q:

12/20/2013
I have a 34 year old lady who has adverse reaction after eating eggs or exposed to "smell" of eggs and vapor of freshly baked food with eggs. The symptoms are significant and includes itchy palms, soles, throat, nausea, cramping abdominal pain and mild breathing difficulty. She has had to use her Epipen on a few occasions. Both Skin test and RAST negative on 3 occasions each. Only pertinent findings Is Dermagraphism for the last 7 years since birth of last child.

A:

Thank you for your inquiry.

Several features of your patient's history and manifestations are suggestive of individuals reported by Patterson, et al. Below you will find the abstracts of these reports. In view of this fact, I think that it is important for you to try and obtain objective confirmation of anaphylaxis in your patient. If possible, a serum tryptase and/or 24-hour urinary histamine and prostaglandin D2 obtained at the time of the event would be very helpful. In addition, a blinded challenge (either double or single-blinded) might help clarify the issue as well. If you cannot confirm the history with objective measurements, then this of course, as best we can, establishes a diagnosis of the condition described by Patterson and colleagues. In the articles, you will find suggested means of managing these very challenging patients.

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

J Allergy Clin Immunol. 1995 Dec;96(6 Pt 1):893-900.
Undifferentiated somatoform idiopathic anaphylaxis: nonorganic symptoms mimicking idiopathic anaphylaxis.
Choy AC, Patterson R, Patterson DR, Grammer LC, Greenberger PA, McGrath KG, Harris KE.
Author information
Department of Medicine, Northwestern University Medical School, Chicago, IL 60611, USA.
Abstract
Background: Northwestern University's Division of Allergy and Immunology has had experience with the diagnosis and treatment of more than 350 patients with idiopathic anaphylaxis (IA). In 1992 we reported a group of patients with IA whose presentations mimicked IA, but IA and other organic causes were later excluded. Psychologic factors were suspected as the underlying problem. These patients were classified as IA-variant. Management of these cases was extremely difficult. There was significant morbidity and high and unnecessary costs.
Objective: We aim to distinguish the nature of this disease and to highlight the evaluation and treatment of this group of patients.
Methods: Their cases are reviewed and reported.
Results: Common features included (1) presenting symptoms mimicking IA, (2) no objective findings that correlated with 1, (3) no response to the therapeutic regimen for IA, (4) meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for undifferentiated somatoform disorder, and (5) significant wasted health care expenditure.
Conclusions: This group of patients were better defined as having undifferentiated somatoform-IA. An algorithm was proposed to expedite the diagnosis of the disease so that with early recognition of the disease, unwarranted repetitive consultations, tests, and inappropriate therapy can be avoided.

Allergy Asthma Proc. 2000 May-Jun;21(3):141-4.
Idiopathic anaphylaxis: variants as diagnostic and therapeutic problems.
Patterson R, Tripathi A, Saltoun C, Harris KE.
Author information
Department of Medicine, Northwestern University Medical School, Chicago, Illinois 60611-3008, USA.
Abstract
Idiopathic anaphylaxis presents a problem requiring rapid diagnosis and initiation of therapy. Some cases are complex and difficult to assess. We present four cases of unusual complexity to illustrate diagnostic and therapeutic problems. Two cases were found not to be idiopathic anaphylaxis, one being undifferentiated somatoform idiopathic anaphylaxis and the other very severe urticaria. Various conditions can be or mimic idiopathic anaphylaxis, and patience and observation can result in reasonable outcomes.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology