Hot Seat Case #116: 12 yo female with an allergic reaction
Posted on: September 7, 2018, by : Sarah Isbey
Sarah Isbey, MD Children’s National Medical Center
with Kristen Breslin, MD Children’s National Medical Center
12 yo female with a history of severe seasonal allergies. The morning of arrival, she received an allergy shot from her allergist and was observed in clinic without issues. On the way home, she started having coughing and wheezing in the car. On arrival home, her father gave her Cetirizine and a single albuterol nebulizer treatment. Her wheezing improved but she then developed hives. The allergist was contacted, who suggested a dose of Benadryl and a 2nd dose Cetirizine (which was not given), as well as an ED evaluation. Denied recent fevers, cough, congestion, nausea, vomiting, or diarrhea.
PMHx: Allergy shots x2 years, no prior issues
PSHx: None
Fam hx: mother with asthma, father without allergies
T 37.2 RR 20 HR 95 SpO2 98% on RA BP 110/70
Gen: awake, alert, talkative, and interactive. Itching her skin
Skin: diffuse urticarial rash on trunk, arms, and legs
HEENT: No perioral edema. Oropharynx clear without signs of erythema or swelling. TMs pearly. Neck supple.
Resp: RR20, no respiratory distress. Scattered end-expiratory wheeze that clears with coughing
CV: RRR no murmur, 2+ pulses, cap refill 2 sec
Abd: Soft, non-tender, non-distended
Neuro: Alert, oriented. Speaking in full sentences. Playing on iPad
MSK: Moves all extremities equally
You decide to give IM epinephrine and plan to observe the patient for 4 hours. On repeat exam 1 hour after epinephrine, her father is asking for a sandwich for her. The patient’s hives have completely resolved, she is no longer itching, and she has no wheezing. He is demanding that she eat lunch. You and the resident make several attempts to discuss why she isn’t allowed a full lunch, but he states he will leave AMA if she cannot eat lunch.
Two hours after her epinephrine, her father states he must leave to get to work or he will be fired. You discuss the dangers of leaving and why you are concerned. Dad calls his manager, who is yelling at him over the phone to come to work. The patient will be home alone while dad is working, and there is no one else to care for her.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
Interesting case, because ten years ago I would have tried really hard to treat this patient as someone with seasonal allergies triggering urticaria and an mild asthma exacerbation – give albuterol, give oral steroids, continue anithistamines. I would have gone to IM epi immediately if there was angioedema, facial swelling, or intraoral symptoms (tongue, mouth or throat tingling or scratching, etc), in a younger child where I couldn’t assess intraoral symptoms, or if she sounded very tight or had severe respiratory distress. I also would have given IM epi if she wasn’t improving as expected with albuterol/steroids.
Clearly more modern guidelines encourage us to treat more patients with IM epi – to recognize anaphylaxis and severe allergic reaction earlier and treat with epi earlier. If I use the ED Severe Allergy Diagnostic Criteria, this patient meets criteria for anaphylaxis if she had “sudden onset of symptoms” because she has two systems involved – skin and respiratory. So I would want to ask about the timing of symptoms and if she’s actually been having intermittent symptoms of an asthma exacerbation (SOB with exertion, cough, etc) for a few days. But my threshold for giving IM epi in this situation is lower than it was years ago. IM epi can be uncomfortable for the patient (needle, tachycardia, flushing), but it may help her bronchospasm. The rationale for giving epi early is retrospective studies showing length of time to first epi dose was associated with greater risk of mortality, and it makes sense that in many cases the potential benefits outweigh the discomforts. I’m still waiting to hear of evidence that earlier administration of epi improves outcomes for patients who have had waxing and waning urticaria and mild bronchospasm for hours before they came in to be seen, but it could be true.
So, I think it’s reasonable to treat her with either albuterol/steroids or IM epi, and depending on the details of presentation, probably more consistent with current guidelines to give the epi. She improves, and now we’re wondering about her risk of biphasic reaction. There are quite a few retrospective reviews looking at the incidence of biphasic reaction; the one I’m most familiar with is Lee, et. al. from the early 2000s, that looked at 106 children admitted after receiving IM epi for anaphylaxis over a period of several years (5? 10?). This was back when I was in residency, and it was standard to admit anyone requiring IM epi for a 23 hour observation period. (Yes. Really.) Lee et.al. found 6/106 had biphasic reactions; in 3 cases it was less severe than their initial presenting symptoms and required minimal intervention. Three cases were more severe, including one patient who required intubation for their biphasic reaction – but for that patient, the biphasic reaction occurred more than 48 hours after the initial presentation. This was one piece of evidence that a 23 hour observation period was not helpful for most patients. In fact, studies have shown that biphasic reactions can occur up to 5 days after the initial reaction. Should you watch someone for a period of time after giving epi? Of course. But how long – 2 hours, 4 hours, 6 hours, 8 hours, 23 hours, 5 days, is really a little arbitrary. Long enough for the effects of epi and any albuterol to wear off, to see if the symptoms return immediately. Longer if you suspect the family might not be able to recognize, respond with epi pen, or return for recurrent symptoms. I don’t like the idea of a 12 year old monitoring herself , alone, for recurrent symptoms, but if there’s another adult who can stay with her and they understand what to watch for, I’d probably be comfortable with that. Similarly, the risk the patient is going to require intubation during her observation period is vanishingly low, but not 0. I’m fine if she eats although I would discourage starting with pizza and fries. Maybe clears and crackers and advance as tolerated.
The patient has 2 systems involved (skin and respiratory) after known allergen, therefore she meets criteria for anaphylaxis and should receive IM epinephrine. Whether or not to give other medications is less clear from my understanding of the literature, but it’s still is the practical standard of care. With a well-appearing child with normal vital signs who is experiencing signs of anaphylaxis without vomiting or diarrhea I would administer PO medications after IM epi. That being said, I typically give PO prednisolone not PO dex (not familiar with the literature on PO dex for anaphylaxis, and I was trained to use PO pred and to give Rx upon discharge for 2-3 days of pred). I also give PO zantac in addition to PO benadryl and inhaled albuterol.
I would allow a well-appearing asymptomatic 12 year old without any original GI symptoms to eat at least a snack, but I don’t have actual data to back-up my gut instinct.
I would want to observe the patient for long enough that the effects of epinephrine and albuterol have worn off. If the father is not able to stay, there should be another adult who can stay with her. Otherwise I would consider and admission for observation.