Results
There was a total of 8,569 OFCs, and 2,231 (26.0%) positive results
from March 2015 to February 2021. Of the 2,231 positive OFCs, 214
(9.6%) patients received adrenaline. Among these patients, 41 (19.2%)
patients were given more than 2 doses of adrenaline, and 7 (3.3%)
patients required continuous adrenaline infusion. We present the OFC
records of these 7 patients.
The onset time represents the period from completion of the first intake
of the allergen. Adverse events associated with continuous adrenaline
infusion were also evaluated, including tachycardia, tremor, and pallor
with increased blood pressure.
Case 1
A 5-year-old boy underwent an OFC with 3 g udon noodle (wheat). He had
completely eliminated wheat because of a history of generalized rash and
wheezing. Fourteen minutes after consuming the full amount of the
allergenic food, he presented with a runny nose and mild cough. At 28
min, the cough worsened, accompanied by oxygen desaturation
(SpO2 91%), therefore short-acting β2-agonist (SABA)
was administered. However, the symptoms persisted, and
SpO2 did not improve from 91–94%; IM adrenaline and
oxygen was administered at 39 min. Despite these treatments, respiratory
symptoms persisted; therefore, SABA and IM adrenaline were
re-administered at 46 min and 54 min. Respiratory symptoms improved,
followed by extensive urticaria and erythema at 105 min. During
observation of the skin symptoms after administration of an
antihistamine agent, he suddenly became pale, with tachycardia, and
hypotension (systolic blood pressure, 60 mmHg) at 136 min. A third IM
adrenaline injection was administered with a fluid bolus at 142 min, and
continuous adrenaline infusion was immediately started at a dose of 0.03
µg/kg/min. Although he needed a fluid bolus again for tachycardia and
hypotension at 240 min, the symptoms abated 15 min later and did not
require an increase in the infusion rate of adrenaline. The vital signs
and general condition stabilized; therefore, adrenaline infusion was
stopped at 330 min.
Case 2
A 6-year-old girl who had eliminated wheat because of a history of
respiratory symptoms due to udon noodle (wheat) retried the OFC with 1 g
udon noodles. Twenty-four minutes after ingestion of 1 g of udon, she
reported discomfort around her throat, and wheezing. The respiratory
symptoms worsened; therefore, we administered inhaled SABA twice,
followed by IM adrenaline at 37 min because the respiratory condition
had failed to improve. At 47 min, she showed obvious dyspnea and
decreased SpO2 to 92%, so a second IM adrenaline
injection was administered. Although these symptoms temporarily
improved, systemic urticaria and desaturation flared up at 84 min, and
systolic blood pressure decreased to 72 mmHg. We administered the third
and fourth IM adrenaline doses at 87 and 88 minutes, respectively. Soon
after administration of fluid bolus and the fourth IM adrenaline
injection, continuous adrenaline infusion (0.04 µg/kg/min) was started
(89 minutes). The rate was raised to 0.06 µg/kg/min 14 minutes later due
to inadequate effect on hypotension. The vital signs and general
condition stabilized, and the infusion rate was tapered and discontinued
145 min later.
Case 3
A 6-year-old boy underwent an OFC with peanuts. He had completely
eliminated peanuts because of acute symptoms after consumption of nut
cake. After consuming 3 g of peanuts, he experienced discomfort in the
mouth and throat. After 42 min, erythema spread to the neck and abdomen,
and antihistamine agents were administered. At 56 minutes, he presented
with a wheeze and oxygen desaturation (SpO2 93%), so
SABA was administered. The symptoms did not abate, and the erythema
spread to the entire body. IM adrenaline and oxygen were given at 65
min. Although his condition stabilized at 95 min, he suddenly presented
with decreased consciousness during urination and fainted. Secondary
adrenaline was immediately administered, but the systolic blood pressure
decreased to a low of 48 mmHg. A third IM adrenaline injection and fluid
bolus were administered, and a continuous adrenaline infusion was also
prepared. After initiation of continuous adrenaline infusion at 0.03
µg/kg/min, his vital signs and condition stabilized, and infusion was
discontinued after 155 minutes.
Case 4
An 8-year-old boy underwent an OFC with raw Chinese yam. He had
developed facial swelling and a cough after ingestion of Chinese yam
when he was 6 years old. Soon after ingesting a few grams of Chinese
yam, he experienced discomfort in his mouth and presented with a mild
cough. At 3 min, the cough appeared to be significant. At 20 minutes, he
showed moderate abdominal pain and declining activity; therefore, IM
adrenaline and oxygen were administered. After treatment, the symptoms
disappeared, but urticaria occurred at 65 min and spread systemically.
Almost simultaneously, he presented with tachycardia and remarkable
hypotension (sBP 30 mmHg), and finally lost consciousness. IM adrenaline
was immediately administered at 75 min, but hypotension persisted (BP
65/30 mmHg). At 80 min, a third dose of IM adrenaline and fluid bolus
were administered. For persistent hypotension, continuous adrenaline
infusion was administered at 0.03 µg/kg/min at 95 minutes. Shortly after
we confirmed that his systolic blood pressure had improved to 90 mmHg,
he was hospitalized. The vital signs and general condition were
stabilized, so the infusion rate was gradually decreased over a period
of 120 min and discontinued.
Case 5
The patient was a 10-year-old boy who was able to consume raw eggs
without problems at rest, but anaphylaxis was observed immediately after
exercise, in accordance with ingestion. Therefore, food-dependent
exercise-induced anaphylaxis (FDEIA) was suspected. In line with our
protocol for the diagnosis of FDEIA, he was administered aspirin 10
mg/kg, and three raw eggs. During the bed stay after ingestion, the
patient did not display any symptoms. After 60 min of observation, he
ran for 15 min while maintaining a heart rate of over 180/min.
Immediately after exercise, he developed severe eyelid swelling,
urticaria on his abdomen, and wheezing, successively within a few
minutes. While preparing the SABA inhaler, he suddenly showed decreased
consciousness and restlessness; therefore, IM adrenaline was immediately
administered 4 minutes after exercise. However, his systolic blood
pressure decreased to 60 mmHg, and he showed signs of airway obstruction
and dyspnea; therefore, IM adrenaline was repeatedly administered a
total of 4 times every few minutes. Twenty minutes after exercise, a
fluid bolus (10 ml/kg) and adrenaline intravenous infusion were started
at 0.02 µg/kg/min. Since the low blood pressure persisted, we increased
the rate to 0.04 µg/kg/min 5 minutes later. His condition gradually
improved, except for temporary mild wheezing, and the infusion rate was
decreased and discontinued at 164 min.
Case 6
An 11-year-old boy underwent an OFC with milk. At the age of 5 months,
he had immediate symptoms after ingestion of formula, but subsequent
OFCs were negative; therefore, he had ingested 3 ml of milk. At the OFC,
soon after ingestion of 8 ml, the patient vomited and developed a severe
urticaria. After 5 min, the patient suddenly became pale and lost
consciousness. IM adrenaline was administered three times for shock
symptoms at 6, 8, and 11 min. However, his cardiovascular symptoms did
not improve, and he finally developed respiratory failure. At 15
minutes, continuous adrenaline infusion (0.03 μg/kg/min) and fluid bolus
were started. Despite treatment, respiratory failure progressed, and he
finally required intubation at 61 minutes. His condition gradually
improved without increasing the rate of adrenaline infusion. Continuous
adrenaline infusion was discontinued 190 min later and the intubation
tube was removed the next day. The patient was discharged on the
following day.
Case 7
A 17-year-old boy underwent an OFC with multiple nuts. He consumed 3 g
of cashews, walnuts, and macadamias simultaneously. He had never eaten
these nuts before because his immunoglobulin E (IgE) levels were
positive. At 21 minutes after ingestion, he presented with erythema of
the face and discomfort of the throat. Urticaria gradually spread to the
whole body at 54 min, and he presented with tachycardia (heart rate
[HR], 133/min) and oxygen desaturation (SpO2 94%)
at 67 minutes, so IM adrenaline, oxygen, and fluid bolus (10 mL/kg) were
administered. As the shock symptoms did not improve, a second IM
adrenaline injection was administered at 94 min. The symptoms improved
for a while, but at 132 min, tachycardia (HR 140/min) and hypotension
(blood pressure, 85/38 mmHg) recurred. Even after the third adrenaline
administration at 153 min, significant tachycardia and hypotension
persisted, so fluid bolus was administered again, and continuous
adrenaline infusion was started at 160 min. Six minutes after starting
the continuous infusion, vital signs and general condition stabilized.
Continuous adrenaline infusion was discontinued 151 minutes later.