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The Role of Peanut Allergy in Anaphylaxis

The Role of Peanut Allergy in Anaphylaxis

Otterbein University Digital Commons @ Otterbein

Nursing Student Class Projects (Formerly MSN) Student Research & Creative Work

7-2018

The Role of in

Jessica Schmelzer Otterbein Univerisity, [email protected]

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Recommended Citation Schmelzer, Jessica, "The Role of Peanut Allergy in Anaphylaxis" (2018). Nursing Student Class Projects (Formerly MSN). 305. https://digitalcommons.otterbein.edu/stu_msn/305

This Project is brought to you for free and open access by the Student Research & Creative Work at Digital Commons @ Otterbein. It has been accepted for inclusion in Nursing Student Class Projects (Formerly MSN) by an authorized administrator of Digital Commons @ Otterbein. For more information, please contact [email protected]. The role of peanut allergy in anaphylaxis Jessica Schmelzer, RN, BSN, FNP student Otterbein University, Westerville, Ohio

Introduction Diagnosis of food Signs and Pathophysiology Significance of Implications for References allergy Symptoms Valenta et al., describe allergic sensitization as the ”first induction of an allergic pathophysiology Nursing Practice Brasted, I., Ruppel, M. (2016). Anaphylaxis upon encounter” (Valenta et al., 2015). Sensitization to food allergen can occur in the and its treatment. EMS World, 45, 31- The rise of food in the • of conjunctiva, The significance of the • Early diagnosis and treatment for United States and the authors personal has been gastrointestinal tract, oral cavity, skin or sometimes in the respiratory tract (Sampson et al., 2017). In 37. face, lips, mouth, tongue, or aforementioned pathophysiology is anaphylaxis is key to decreasing Duke University Medical Center. (2018). experience with her child’s food allergies defined by the expert panel of the addition, according to Sampson et al, skin barrier disruptions, likely caused by inflammation or filaggrin throat related to the amount of children (and mortality Animal study shows how to retrain National Institute of Allergy and gene mutation, are associated with increased risk of food sensitization in humans and are therefore has led to a need to understand the • Tachycardia, adults) affected by peanut allergies. • The gold standard for treatment of the to ease food Infections Disease (NIAID) as “an predictive of food allergy (Sampson et al., 2017). Specific functional variants in ”IL-2 b1, toll-like pathological process behind an allergic • Loss of consciousness, Anaphylaxis from peanut allergy is anaphylaxis is , usually allergies. Retrieved from: adverse health effect arising from a receptor 9, thymic stromal lymphopoietin genes and IL-4 gene polymorphism” have all been associated with reaction. Anaphylaxis is defined as a confusion, headache, attributed to 100-200 deaths each year through an auto-injector (Brasted & https://medicalxpress.com/news/201 specific immune response that an increased risk of food sensitization (Fiocchi & Fierro, 2017). “serious allergic reaction that is rapid in anxiety in the United States (Zhou et al., 2013). Ruppel, 2016) 8-02-animal-retrain-immune-ease- occurs reproducibly on exposure to IgE is a fundamental in those with atopic diseases (such as eczema) and is considered the onset and may cause death” (Jones & • Urticaria, pruritis, flushing Only 10% of children are lucky enough • Knowledge regarding the mechanism food.html a given food” (Valenta et al., 2015). hallmark of allergic sensitization (Sampson et al., 2017). According to Valenta et al., upon initial encounter Fiocchi, A., Fierro, V. (2017). Food allergy. Burks, 2017). In the United States, an (common in adults) to outgrow their allergy to peanut, of epinephrine (potent alpha-1 Diagnosis of a food allergy is a of a potential allergen (such as a food), the antigen-presenting cells (APC), such as dendritic or B cells, Retrieved from: estimated 50% of anaphylactic reactions • , , causing the potential for anaphylaxis to adrenergic agonist, causing multi step process that involves a presents the antigens to the T-helper 2 (Th2) cells. This, in turn, causes a production of such as http://www.worldallergy.org/educati are caused by food allergies (Fiocchi & (common in last their entire lives, impairing quality vasoconstriction and peripheral thorough history to establish a interleukin (IL 4 and IL 12). These B cells then proliferate and “induce class switching and production of on-and-programs/education/allergic- Fierro, 2017). The top 8 in the children) of life (Zhou et al., 2013). vascular resistance) will allow for United States are: causal relationship between the allergen-specific IgE” (Sampson et al., 2017). This initial allergic sensitization typically occurs early in life disease-resource- • Nasal rhinorrhea In addition, anaphylaxis can understanding of potential side effects center/professionals/food-allergy • peanut, offending allergen and the reaction, and leads to memory of T-cells and IgE. A pictorial depiction of this process can be seen below. • Coughing, shortness of present with great variations and the for the patient after administration (n.d.). Retrieved from: • as well as combined results of the When a sensitized individual is exposed to an allergen, the allergen activates (allergen-specific) IgE tree , breath, wheezing, dysphagia key to increased survival rates are quick (Brasted & Ruppel, 2016) https://lumenlearning.com/microbio skin prick test (SPT) and IgE total and nearby mast cells and bind to the allergen (Brasted & Ruppel, 2016). If the exposure is • milk, • Urinary incontinence clinical judgement, leading to the correct • Education should be provided to the logy/chapter/hypersensitivities/ and specific (Fiocchi & ”sufficiently noxious” and degranulation will occur releasing multiple inflammatory • egg, (Rance & Goldberg, 2013). diagnosis (Brasted & Ruppel, 2016). The family or patient regarding: Jones, S., Burks, W. (2017). Food allergy. The Fierro, 2017). A double blind, mediators, such as , prostaglandin, platelet-activating factors (PAF), tumor necrosis factors (TNF), • wheat, The most life threatening clinical manifestations of anaphylaxis (as o Strict avoidance of the allergen New England Journal of Medicine, 377, placebo-controlled food challenge is and proteases (Sampson et al., 2018). • soy, effects occur in the respiratory noted on this poster) include a vast oSigns and symptoms of anaphylaxis 1168-1176. DOI: the preferred diagnostic test, The major allergenic component in foods is protein. In the case of a peanut allergy, there are 13 10.1056/NEJMcp1611971. • fish and cardiac systems. This is array of symptoms, therefore increasing oUnderstanding food labels however is rarely used in clinical different peanut allergens (Ara h1-Ara h13) that have been recognized by the Allergen Nomenclature Sub- National Institute of Allergy and Infectious • shellfish. due to the ”fluid shift from the potential for missed diagnosis. Skin oNutritional counselling to avoid practice as they require specialized Committee of the International Union of Immunological Societies (Zhou et al., 2013). The combined Disease (NIAID). (2006). Guidelines Food allergies can be divided into intravascular to extravascular and mucosal involvement are often the deficiencies due to food allergies resuscitative centers that have the allergens come from seven different protein families, however, Aha 1-Aha 3 have been accepted as the major for the Diagnosis and Management of three subsets; IgE-mediated (which space resulting in edema, most common symptoms, however, are generally have a sudden onset of ability for overnight admission, in peanut allergens (Zhou et al., 2013). The allergenicity of these particular allergens as described by Zhou et Food Allergy in the United States. respiratory arrest and absent in 10% of cases (Brasted & Retrieved from: symptoms), non-IgE-mediated and the event of anaphylaxis (Fiocchi & al., is as follows: circulatory collapse” (Brasted & Ruppel, 2016). Conclusion https://www.niaid.nih.gov/sites/defa Fierro, 2017). • Ara h 1 is a glycoprotein and belongs in the vicilin family. It comprises approximately 12-16% of the mixed IgE (which both have delayed Ruppel, 2016). A thorough knowledge of the ult/files/faguidelinespatient.pdf total peanut protein and affects a vast number of peanut allergic patients (35-95%). One of the most important onset of symptoms) (Fiocchi & Fierro, pathophysiological process behind Rance, K., Goldberg, P. (2013). Food allergy • Ara h 2 is also known as “glycoprotein” and accounts for 5.9-9.3% of the total peanut protein. It is implications for nursing practice is the 2017). Of these three types of allergic Diagnosis of anaphylaxis anaphylaxis will help the practitioner to in clinical practice. The Journal for considered more potent than Ara h1 and more than 95% of peanut allergic individuals have specific understanding that food allergy research responses, IgE-mediated allergies have Diagnostic criteria as set by the NIAID understand: Nurse Practitioners, 9(4) 187-196. IgE to this allergen likely due to the 10 epitopes it has available on the molecular surface. is constantly changing, as is the the greatest potential for anaphylactic Anaphylaxis is likely when any one of these three criteria is • Increased vascular permeability DOI: • Ara h 3 is described as a seed storage protein and belongs in the legumin family. It is recognized in knowledge of the pathophysiology. It is http://dx.doi.org.ezproxy.otterbein.ed reaction and will therefore be the focus fulfilled: causes a fluid shift from only 50% of peanut allergic individuals (Zhou et al., 2013). crucial that all health care professionals u/10.1016/j.nurpra.2013.01.007 of this poster. Factors that contribute to 1. Acute onset of illness (minutes to several hours) with intravascular to extravascular, The remainder of the allergenic components in the peanut come from various other families and their stay up to date on the current Sampson, H., O’Mahony, L., Burks, W., Plaut, the severity of the reaction include: involvement of the skin, mucosal tissue, or both (e.g., generalized leading to edema pathogenicity related to peanut allergy are not fully understood at this time (Zhou et al., 2013). recommendations, as well as new M., Lack, G., & Akdis, C. (2018). • Amount of allergen ingested, , pruritus or flushing, swollen lips, tongue, or uvula) • release of histamine will increase • Stability of the allergen against research such as this recent discovery Mechanism of food allergy. Journal of and at least one of the following: the heart rate, lower the diastolic Allergy and Clinical Immunology, 141, digestion, from Duke Health, as seen below. (a) Respiratory compromise (e.g., dyspnea, wheeze or blood pressure and therefore 11-19. • And permeability of the epithelial , stridor, reduced peak expiratory flow, hypoxemia) increase the pulse pressure Valenta, R., Hochwallner, H., Linhart, B., & barrier (b) Reduced blood pressure or associated symptoms of end- (Brasted & Ruppel, 2016). Pahr, S. (2015). Food allergies: the (Valenta, Hochwallner, Linhart & Pahr, organ dysfunction (e.g., hypotonia [collapse], syncope, • release of other inflammatory basics. Gastroenterology, 148(6), 2015). incontinence) mediators can lead to edema of the 1120-1131. face and airway that will Zhou, Y., Wang, J., Yang, X., Lin, D., Gao, Y., Su, Y.,…Zheng, J. (2013). Peanut exacerbate breathing difficulties Risk factors for 2. Two or more of the following that occur rapidly after exposure to allergy, allergen composition, and a likely allergen for that patient (minutes to several hours): (Brasted & Ruppel, 2016). methods of reducing allergenicity: a anaphylaxis (a) Involvement of the skin or mucosal tissue (e.g., • The loss of intravascular volume as review. International Journal of Food generalized hives, or flush, swollen lips, tongue, or uvula) described above can lead to • Delayed treatment with Epinephrine Science, Article ID 909140, 8 pages. (b) Respiratory compromise (e.g., dyspnea, wheeze or circulatory collapse and shock DOI: • Allergy to peanut, tree nuts, fish or bronchospasm, stridor, reduced peak expiratory flow, hypoxemia) (anaphylactic shock) (Brasted & https://doi.org/10.1155/2013/9091 shellfish (c) Reduced blood pressure or associated symptoms (e.g., Ruppel, 2016) 40. • Adolescence hypotonia [collapse], syncope, incontinence) • Anaphylaxis can occur in biphasic • History of (d) Persistent gastrointestinal tract symptoms (e.g., crampy reactions (due to the short half-life • Chronic lung disease abdominal pain, vomiting) of epinephrine), which occurs • Cardiovascular disease when a second reaction happens • Pregnancy anywhere from 1-30 hours after 3. Reduced blood pressure after exposure to known allergen for • Systemic mastocytosis the initial reaction (Brasted & that patient (minutes to several hours): • Use of a beta-adrenergic blocker, Ruppel, 2016). angiotension-converting-enzyme (a) Infants and children: low systolic blood pressure (age inhibitor, or alpha-adrenergic blocker specific) or >30% decrease in systolic blood pressure (b) Adults: systolic blood pressure <90 mmHg or >30% Image retrieved from: (Jones & Burks, 2017) decrease from that person’s baseline Image retrieved from: https://medicalxpress.com/news/2018-02-animal- National Institute of Allergy and Infectious Disease, 2006 https://courses.lumenlearning.com/microbiology/chapter/hypersensitivities/ retrain-immune-ease-food.html

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