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Inhaled onion associated anaphylaxis

Question:

2/3/2016
I saw this nurse who is working in the ER of our local hospital. Her first reaction was on 1/31/16. She was home and her husband was cutting onion. She reports that she felt that she was getting her throat swollen so we ask for opening the window and went to the basement. While there she got in more discomfort and asked for her Epipen and Benadryl but nothing was available at home. Her 20 YO daughter drove her to the Pharmacy and she got worse and called 911. She used the Epipen. While the daughter asked the EMT to use epi they would not do that until they checked her BP and it was high and she was having more trouble breathing. She was given Epi and Benadryl on her way to the hospital.

She arrived to the ER with severe shortness of breath, pain across her mid to upper back. (she had normal stress echo in 2008 and no history of HTN, heart disease or problem). She was in severe distress on arrival with inability to talk or move air.

PE
Hypervigilant with obvious difficulty moving air and stridor with inability to talk. Posterior throat shows swollen tonsillar pillars with a narrow opening. Patient refused intubation. Use of accessory muscles. Retractions, moving air bilaterally with no wheezing. With medications taking effect she started to speak.

Lab
Troponin <0.02
EKG: normal sinus rhythm QRS normal. ST segment ST_T wave segment depression in II, III, and F aVF new compared with prior EKG dated 10/29/15. Abnormal EKG with ST-T wave changes in inferior leads.

CXR Hypoventilation otherwise unremarkable

ED course
patient had an acute anaphylactic reaction to onions. Received Epi; Benadryl, Zantac, Solu Medrol.

Second reaction on 2/1/16
While at work, she smelled onion again and felt SOB, and felt like back of tongue swelling and throat swelling, Chest and back heaviness. Used her EpiPen immediately. She was then placed in an exam room and IV were established. Patient complained of inability to breathe. She felt like her throat was closing off. She had trouble moving air but no stridor. PE: She did not have any rash. She was using accessory muscles to breathe and had retractions. She had a rapid rate and rhythm. She had chest pain and her EKG showed tachycardia with strain then the second EKG was back to normal. She has had anaphylaxis to latex and to Flonase smell. She is having anaphylaxis without question but is it onion? What do you suggest for her work up beside RAST to latex and onion? There is cross reaction with lilies and major spices. No Tryptase or Histamine were drawn.

Answer:


I was skeptical that your patient was experiencing anaphylaxis but difficult to discount the evidence of swelling in the throat with the first episode associated with onion. My reasons for skepticism are the lack of urticaria and the peculiar attributed triggers (fluticasone nasal spray odor and onion odor). I suspect this is idiopathic anaphylaxis and not related to specific-IgE since odors are not of sufficient molecular size to provoke an immunologic response. I have concern about the use of epinephrine for suspected asthma without a specific trigger since there have been documented EKG changes either due to epinephrine or the acute reactions.

My suggestion would be to prescribe epinephrine, although you may want to consider a pediatric dose for self-administration since she has not experienced hypotension and has had EKG changes with the events. I would recommend cardiac assessment including a stress test in light of the EKG changes. I do not think specific-IgE to onion or antigens that cross-react with onion will be particularly helpful but I certainly understand you’re pursuing. I would be more convinced if she had eaten onion rather than been in room with onion being prepared by her husband. I would also carefully review the history to be sure you do not think mammalian meat ingestion (lamb, beef, pork) preceded the reactions by 3-8 hours. If so would measure specific-IgE to alpha-gal oligosaccharide (Commins). Idiopathic anaphylaxis by definition is unpredictable but odor may be a neurogenic trigger but not an antigenic trigger. I would obtain a baseline tryptase and repeat if and when she experiences another episode to evaluate for possible mast cell disorders. I would start daily H1 and H2 antihistamine as you would treat a patient with mast cell activation syndrome or idiopathic anaphylaxis until you have longer follow up and more data. If another episode occurs with odor exposure, I would treat as idiopathic anaphylaxis with odor as neurogenic trigger (Wiggins). The 2015 practice parameter Anaphylaxis has suggestions for treatment of idiopathic anaphylaxis, recognizing it is difficult to develop evidence based recommendations.

1. Commins, Scott P., and Thomas AE Platts-Mills. "Delayed anaphylaxis to red meat in patients with IgE specific for galactose alpha-1, 3-galactose (alpha-gal)." Current Allergy and Asthma Reports 13.1 (2013): 72-77.
2. Wiggins, Carol Ann, Mark S. Dykewicz, and Roy Patterson. "Idiopathic anaphylaxis: classification, evaluation, and treatment of 123 patients" Journal of Allergy and Clinical Immunology 82.5 (1988): 849-855.

I hope this information is of help to you and your patient.

All my best.
Dennis K. Ledford, MD, FAAAAI