Food, drug, insect sting allergy, and anaphylaxis
Anaphylaxis epidemic: Fact or fiction?

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Anaphylaxis definition and clinical criteria for diagnosis

In the past, low blood pressure or shock were often prominent components of the definition of anaphylaxis; however, a new broader definition has recently evolved.10, 11 The modern definition does not mandate that reduced blood pressure or shock need to be present; indeed, evidence suggests that initial signs and symptoms in patients dying of anaphylaxis are more likely to involve respiratory distress than circulatory collapse, particularly in fatal food-induced anaphylaxis.12, 13, 14, 15, 16

Role of laboratory tests in diagnosis

The clinical diagnosis of anaphylaxis is not necessarily corroborated by an increased serum or plasma total tryptase concentration or an increased plasma histamine concentration,17 and these tests are not routinely performed in anaphylaxis. In the study of Decker et al,8 a serum total tryptase level was obtained in only 14 of the 211 patients and was increased in only 5 of these 14 patients (Decker et al, personal communication). Total tryptase and histamine tests have clinically relevant

Is anaphylaxis overdiagnosed?

If the definition of anaphylaxis used to make the diagnosis in an individual patient or used in an epidemiologic study is not stringent enough, anaphylaxis might be overdiagnosed, and this might contribute to the increased incidence reported during the past few years.1, 2, 3, 4, 5, 6, 8 It is unlikely that this happened in studies in which all the International Classification of Diseases, 9th Revision (ICD-9), codes and most of the ICD-10 codes used to identify admissions to the hospital for

Is anaphylaxis underdiagnosed?

Despite the previous comments, it is also possible that anaphylaxis has been underrecognized and underdiagnosed in recent epidemiologic studies,2, 3, 4, 5, 8 as it is in real life.7 Lack of recognition and diagnosis of anaphylaxis potentially occurs in a variety of clinical situations and for a variety of reasons (Table II). It can be difficult to recognize and diagnose if it is the first episode, if symptoms are mild or fleeting, or if the trigger is not apparent, hidden, or previously

Issues with ICD-9 and ICD-10 coding for anaphylaxis

Patients with multiple-organ system involvement after exposure to a known allergen are often given diagnoses of an allergic reaction or an acute allergic reaction when the correct diagnosis is in fact anaphylaxis. A study of the emergency department management of food-induced acute allergic reactions found that among 678 patients identified based on ICD-9 codes, 51% should actually have been classified as having anaphylaxis. A similar study of insect sting–induced acute allergic reactions found

Summary

If one compares the average annual incidence of anaphylaxis in the 5 years from 1993 through 1997 in the Decker et al8 study (48/100,000 person-years) with the 5 years from 1983 to 1987 in the Yocum et al9 study (21/100,000 person-years), the rate of occurrence has more than doubled. Correcting for the 25% of cases identified in the Decker et al8 study because of the broader search methods used compared with the Yocum et al9 study, there is still a 71% increase in the average annual incidence

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    Disclosure of potential conflict of interest: F. E. R. Simons received grant support from the Canadian Institutes of Health Research and serves on the advisory boards for Dey, Intelliject, and ALK-Abelló. H. A. Sampson is a consultant for and shareholder in Allertein Therapeutics, LLC; received grant support from the Food Allergy Initiative, the National Institutes of Health, and the National Institute of Allergy and Infectious Diseases; is a consultant/scientific advisor for the Food Allergy Initiative; and is President of the American Academy of Allergy, Asthma & Immunology.

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