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.