ANAPHYLACTIC SHOCK CAUSED BY SUBCUTANEOUS IMMUNOTHERAPY WITH THE ALLERGEN AMBROSIA ELATIOR – CASE REPORT
Abstract
Introduction: Sensitization to ragweed pollen can lead to symptoms of allergic rhinitis, conjunctivitis, and allergic asthma. Allergen immunotherapy (AIT) is an immunomodulatory therapeutic procedure that, in addition to short-term curative effect (reduction of disease symptoms), also has a long-term preventive effect (preventing the progression of allergic rhinitis into allergic asthma and/or preventing the development of a more severe form of the disease). The two main AIT administration modalities used in clinical practice are subcutaneous allergen immunotherapy (SCIT) and sublingual allergen immunotherapy (SLIT). Both modalities are equally effective in reducing disease symptoms, but the use of SCIT is associated with a higher risk of local and systemic adverse reactions.
Case report: A patient who developed a clinical picture of anaphylactic shock during the induction phase of SCIT with Ambrosia elatior pollen extract is presented in this article. The clinical course is described as well as the quick and effective therapeutic management of this life-threatening condition.
Conclusion: When properly dosed, in a medical facility and under medical supervision, SCIT with Ambrosia elatior is a very safe and well-tolerated treatment option for allergic rhinitis. Local reactions at the site of subcutaneous administration occur more often than systemic adverse reactions. Anaphylactic shock is the most severe form of a systemic allergic reaction that affects multiple organ systems and can end in death, usually due to airway obstruction and cardiovascular collapse. It is necessary to educate the medical staff as well as the patients regarding the proper treatment of this difficult condition. Based on the assessment of risk factors in each patient, severe reactions to SCIT can be predicted and avoided with appropriate precautions and prophylactic measures. Future innovations in AIT are expected to further improve the efficacy and safety of this form of treatment for allergic diseases.
References
Ihler F, Canis M. Ragweed-induced allergic rhinoconjunctivitis: current and emerging treatment options. J Asthma Allergy. 2015 Feb 16;8:15-24. doi: 10.2147/JAA.S47789.
Florincescu-Gheorghe NA, Popescu F, Alexandru DO, Popescu FD. The prevalence of allergic rhinitis to Ambrosia elatior in Oltenia area and the association with allergic conjunctivitis or asthma. Curr Health Sci J. 2019 Jan-Mar;45(1):66-72. doi: 10.12865/CHSJ.45.01.09.
James C, Bernstein DI. Allergen immunotherapy: an updated review of safety. Curr Opin Allergy Clin Immunol. 2017 Feb;17(1):55-9. doi: 10.1097/ACI.0000000000000335.
Janwitayanujit S. Anaphylaxis. J Med Assoc Thai. 2007 Jan;90(1):195-200.
Arnold JJ, Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011 Nov 15;84(10):1111-8.
Drazdauskaitė G, Layhadi JA, Shamji MH. Mechanisms of allergen immunotherapy in allergic rhinitis. Curr Allergy Asthma Rep. 2020 Dec 12;21(1):2. doi: 10.1007/s11882-020-00977-7.
Klimek L, Brehler R, Hamelmann E, Kopp M, Ring J, Treudler R, et al. Evolution of subcutaneous allergen immunotherapy (part 1): from first developments to mechanism-driven therapy concepts. Allergo J Int. 2019 Apr 15;28(3):78-95. doi: 10.1007/s40629-019-0092-4.
Turkalj M, Banic I, Anzic SA. A review of clinical efficacy, safety, new developments and adherence to allergen-specific immunotherapy in patients with allergic rhinitis caused by allergy to ragweed pollen (Ambrosia artemisiifolia). Patient Prefer Adherence. 2017 Feb 14;11:247-57. doi: 10.2147/PPA.S70411.
Klimek L, Brehler R, Hamelmann E, Kopp M, Ring J, Treudler R, et al. Development of subcutaneous allergen immunotherapy (part 2): preventive aspects and innovations. Allergo J Int. 2019 May 13;28(4):107-19. doi: 10.1007/s40629-019-0097-z.
Aue A, Ho J, Zhu R, Kim H, Jeimy S. Systemic reactions to subcutaneous allergen immunotherapy: real-world cause and effect modelling. Allergy Asthma Clin Immunol. 2021 Jul 6;17(1):65. doi: 10.1186/s13223-021-00566-x.
Sánchez-Borges M, Bernstein DI, Calabria C. Subcutaneous immunotherapy safety: incidence per surveys and risk factors. Immunol Allergy Clin North Am. 2020 Feb;40(1):25-39. doi: 10.1016/j.iac.2019.09.001.
Pitsios C, Demoly P, Bilò MB, Gerth van Wijk R, Pfaar O, Sturm GJ, et al. Clinical contraindications to allergen immunotherapy: an EAACI position paper. Allergy. 2015 Aug;70(8):897-909. doi: 10.1111/all.12638.
Passalacqua G, Nowak-Węgrzyn A, Canonica GW. Local Side Effects of Sublingual and Oral Immunotherapy. J Allergy Clin Immunol Pract. 2017 Jan-Feb;5(1):13-21. doi: 10.1016/j.jaip.2016.06.020.
Cox L, Larenas-Linnemann D, Lockey RF, Passalacqua G. Speaking the same language: The World Allergy Organization subcutaneous immunotherapy systemic reaction grading system. J Allergy Clin Immunol. 2010 Mar;125(3):569-74, 574.e1-574.e7. doi: 10.1016/j.jaci.2009.10.060.
Epstein TG, Liss GM, Murphy-Berendts K, Bernstein DI. Risk factors for fatal and nonfatal reactions to subcutaneous immunotherapy: National surveillance study on allergen immunotherapy (2008-2013). Ann Allergy Asthma Immunol. 2016 Apr;116(4):354-9.e2. doi: 10.1016/j.anai.2016.02.001.
Pflipsen MC, Vega Colon KM. Anaphylaxis: Recognition and Management. Am Fam Physician. 2020 Sep 15;102(6):355-62.
Rutkowski K, Dua S, Nasser S. Anaphylaxis: current state of knowledge for the modern physician. Postgrad Med J. 2012 Aug;88(1042):458-64. doi: 10.1136/postgradmedj-2011-130634.
Fineman SM. Optimal treatment of anaphylaxis: antihistamines versus epinephrine. Postgrad Med. 2014 Jul;126(4):73-81. doi: 10.3810/pgm.2014.07.2785.
