A 72-year-old female presented to the allergy clinic as a new patient with a chief complaint of rashes. She has a history of moderate persistent asthma and allergic rhinitis. She was previously on allergen immunotherapy by an outside allergist, Hashimoto’s thyroiditis, and hypertension.
Upon arrival to the allergy clinic, the patient states that although she was presenting for hives, her asthma had worsened that day and she was dyspneic. She took her albuterol inhaler as the nurse was rooming her. She was late to her appointment because she had to keep pulling over due to multiple bouts of diarrhea. She also was itchy during her appointment. Her blood pressure was 72/51 mmHg using an automatic blood pressure cuff, and her manual blood pressure was 85/56 mmHg (she states her normal systolic blood pressure is 120 mmHg). She did feel lightheaded, so she was laid supine. Her physical exam was notable for urticaria, and her pulse oximetry was normal on room air.
She was given intramuscular epinephrine 0.5 mg, prednisone 40 mg orally, and cetirizine 10 mg orally for suspected anaphylaxis. Her symptoms resolved within 20 minutes, and her blood pressure improved to 127/70 mmHg. She had not eaten prior to her appointment, had not taken aspirin or other NSAIDs, and had taken her normal medications (levothyroxine, raloxifene, and escitalopram). She has never experienced symptoms like this before and reported no history of hymenoptera allergy.
A tryptase level was obtained after she was given epinephrine, which was 19 µg/L. She had a repeat level performed 10 days later which showed a tryptase of 5 µg/L. At her follow up visit, she stated that she continued all of her typical home medications without any adverse effects. The patient was eventually started on omalizumab for her chronic idiopathic urticaria, and she has not had a recurrent episode of anaphylaxis since her initial allergy visit. Read more about the case.
