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Risk Factors in Severe Anaphylaxis: Which Matters the Most, Food or Cofactors?

Casas-Saucedo R1,2,3, de la Cruz C1, Araujo-Sánchez G1,2,3, Gelis S1,2, Jimenez T2,4, Riggioni S1, San Bartolomé C2,3,5, Pascal M2,3,5, Bartra Tomás J1,2,3*, Muñoz-Cano R1,2,3*

1FAllergy Section, Pneumology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
2IRCE – Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
3ARADyAL, Carlos III Health Institute
4Allergy Section, Alicante General University Hospital-ISABIAL, Alicante, Spain
5Immunology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
*These authors contributed equally to this paper

J Investig Allergol Clin Immunol 2022; Vol 32(4) : 282-290
doi: 10.18176/jiaci.0698

Background: The prevalence of anaphylactic shock, the most severe manifestation of anaphylaxis, remains unknown. Risk factors and biomarkers have not been fully identified.
Objective: To identify risk factors in patients who experience anaphylactic shock.
Methods: Using lipid transfer protein (LTP) allergy as a model, we compared the characteristics of patients who developed anaphylaxis and anaphylactic shock. We recorded demographics, pollen sensitization, foods ingested up to 2 hours before onset of the reaction, and the presence of cofactors. Culprit foods were identified through a compatible clinical history and positive allergology work-up (skin prick test and/or sIgE).
Results: We evaluated 150 reactions in 55 patients with anaphylaxis (134 reactions) and 12 with anaphylactic shock (16 reactions). Patients in the anaphylaxis group experienced twice as many reactions (mean [SD], 2.4 [2.5] for anaphylaxis vs 1.3 [1.5] for anaphylactic shock; P<.02). No relationship was found between any food group and severity of the reaction. The most frequent food involved in both groups of patients was the combination of several plant-derived foods (plant food mix), followed by peach and nuts. Indeed, in the reactions caused by plant food mix, the presence of a cofactor was observed more often than in other food groups. On the other hand, cofactors were not present in peach- and nut-related reactions. Exercise was the most frequent cofactor in all groups.
Conclusion: In our series, the severity of the reactions was not determined by the kind of food or presence of a cofactor. Anaphylactic shock seems to be an infrequent presentation that may be associated with other individual-related factors requiring further evaluation.

Key words: Anaphylaxis, Anaphylactic shock, Cofactor, Food allergy

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