Morning Case report

October 4th 2011

IDENTITY
Name : NU
Age : 23 years old
Sex : Male
Address : Renon, Denpasar
Ethnicity : Balinese
Religion : Hindu
No. RM : 01482569
Time of coming : 16.00 pm
 ANAMNESIS
Chief Complaint : Shortness of breath

Present History :
 Patient came with chief complaint of shortness of breath since 1
hour BATH. 2 hours BATH the patient got sting by a bee. The
shortness of breath worsened and it didn’t get better by changing of
position.
 He also complained about swollen and watery eyes which began 15
minutes after he got sting by a bee. There were no factor that could
worsened or relieved this complain.
 And he complained about itchiness all over his body since 30 minutes
BATH. This complain was so bad that he felt he couldn’t do his daily
activity. He felt like there was a lot needle, pricking all over his skin.
There were no factor that could worsened or relieved this complain.
ANAMNESIS
Present History :
History of nausea, vomitting, abdominal discomfort or
collapse was denied by the patient.
Anamnesis : Past History
History of drug or food allergy was denied by the patient
History of asthma, dermatitis atopic or rhinitis allergic was
denied by the patient.
Anamnesis : Family history
There was no one from patient’s family who have had the same
complaints and problems.
His father has a history of asthma since he was a teenager.
There were no history of DM, hypertension, in his family
member.
Anamnesis: social history
Patient was a student.
History of alcohol consumption and smoking was denied by the
patient
Physical examination
General app. : Mild ill
Consc. : Compos mentis
GCS : E4V5M6
BP : 120/80 mmHg
Pulse rate : 80x / minute
Respi. rate : 25x/ minute
Axillary temp. : 36.5 ̊c
 Physical Exam. ..
Status Present
Eyes : pale conj.(-/-), yellowish sclera (-/-), pupil reflex (+/+) isochoric, Oedem
palpebrae (++/++). watery (+/+)
ENT : Tonsil, Pharynx, tongue WNL
Neck : JVP PR + 0 cmH2O
Thorax : Symmetry
HEART
• Insp : ictus cordis not visible
• Palp : ictus cordis not palpable
• Perc : UB: ICS II, RB: PSL D, LB: 1 cm lateral to left MCL
• Ausc : S1S2 single regular murmur (-)

LUNG
• Insp : symmetrical (static and dinamic)
• Palp : tactile fremitus N/N
• Perc : sonor/sonor
• Ausc : Vesicular +/+; ronchi -/-; wheezing +/+
Abdomen: Insp : distensi (-)
Ausc : Bowel sound (+) normal
Palp : H/L not palpable
tenderness(-)
Ballotment (-)
Perc: Tympani (+)

Extremity: pitting edema - - , warm + +

- - + +
Others : macula erytematous all over his body with various size (+)
Assessment
Anapylatic reaction ec. Bee’s sting
THERAPY
 Hospitalized (but the patient didnt give his consent)
 O2 4Lpm
 IVFD NS 0.9% 20dpm
 Adrenaline 0.3cc IM 1x
 Diphenhydramine 3 x 10mg IV  2 X 8 mg (po)
 Methylprednisolone 2 x 62.5mg IV
 Cetirizine 1 x 10 mg (po)
THERAPY
 Diagnostic Planning :
 IgE total

 Monitoring:
 Vital Signs
 Complaints
THANK YOU
Clinical Criteria for Diagnosing Anaphylaxis
(Sampson HA, et al. JACI 2006)

• Acute onset of an illness ( minutes to several hours) with

involvement of the skin, mucosal tissues, or both ( eg,
generalized hives, pruritus or flushing, swollen lips-tongue-
uvula)
• AND AT LEAST ONE OF THE FOLLOWING
– Respiratory compromise (eg, dyspnea, wheeze-bronchospasm,
stridor, reduced PEF, hypoxemia)
– Reduced BP or associated symptoms of end-organ dysfunction (eg,
hypotonia /collapse, syncope, incontinence)
2. Two or more of the following that occur rapidly after
exposure to a likely allergen for that patient (minutes to
several hours) :
• Involvement of the skin-mucosal tissue (eg, generalized hives,
itch-flush, swollen lips-tongue-uvula)
• Respiratory compromise (eg, dyspnea, wheeze-bronchospasm,
stridor, reduced PEF, hypoxemia)
• Reduced BP or associated symptoms (eg, hypotonia collapse,
syncope, incontinence)
• Persistent gastrointestinal symptoms (eg, crampy abdominal
pain, vomiting)
3. Reduced BP after exposure to known allergen for that
patient
( minutes to several hours ) :
• Infants and children: low systolic BP (age specific) or greater
than 30% decrease in systolic BP
• Adults: systolic BP of less than 90 mm Hg or greater than 30%
decrease from that person's baseline
MANAGEMENT OF ANAPHYLAXIS
History of severe allergic reaction with respiratory difficulty or
hypotension, especially if skin changes present

Stop administration of precipitant

Oxygen high flow

Adrenalin / epinephrine (1 : 1000) 0,3 – 0,5 ml IM (0,01 mg/kg BW)

Repeat in 5-15 minutes if no clinical improvement

Antihistamine 10-20 mg IM or slowly Intravenously

In addition
 Give 1-2 l of fluid intravenously if clinical manifestation of shock do not respond
to drug treatment
 Corticosteroid for all severe or recurrent reactions & patients with asthma.
- Methyl prednisolone 125-250 mg IV
- Dexamethasone 20 mg IV
- Hydrocortisone 100-500 mg IV slowly
continue by maintenance dose
 Inhaled short acting -2 agonist may used if bronchospasm severe
 Vasopressor (dopamine, dobutamine) with titration dose
Observation for 2 - 3 x 24 horus, for mild case just need 6 hours
Give Corticosteroid and antihistamine orally for 3 x 24 horus
Elderly ( 60 y.o), CVD  adrenalin dose 0,1-0,2cc IM with interval 5-10 mnt
Epinephrine

1-receptor 2-receptor 1-adrenergic 2-adrenergic

receptor receptor

•  vasoconstriction •  insulin release •  inotropic •  bronchodilator

•  peripheral •  noreepinephrine •  chronotropic •  vasodilatation
vascular resistance release
•  glycogenolysis
•  mucosal edema
•  mediator release

Pharmacology of epinephrine
The epinephrine injection vs oral H1antihistamine
controversy
• H1 anti-histamines are commonly used to relieve cutaneous signs &
symptoms ( eg, itching, flushing, urtica)
• H1 anti-histamines :
• play little in relief of bronchospasm,
gastrointestinal symptoms
• fail to relieve upper airway edema or hypotention
• in usual doses, do not reduced the explosive release of
histamine and other mediators inflammation
(mast cells & basophils )
• Epinephrine injection would need to be given immediately after
exposure by correct doses and route; decreased morbidity &
mortality
PATHOPHYSIOLOGY
• Anaphylactic reaction (IgE mediated reaction)

Figure 2. Anaphylactic reaction / IgE mediated reaction3

• Anaphylactoid reaction (Non IgE mediated)
- Complement activation - Physical factors
- Substance for Histamine released - Idiopathic
- Arachidonic acid modulation
Adanya alergen pada kontak pertama menstimulasi sel B
untuk memproduksi antibodi, yaitu IgE  IgE masuk ke
aliran darah dan berikatan dengan reseptor di sel mastosit
dan basofil sehingga sel mastosit atau basofil menjadi
tersensitisasi.
Pada saat kontak ulang dengan alergen, maka alergen akan
berikatan dengan IgE yang berikatan dengan antibody di sel
mastosit atau basofil dan menyebabkan terjadinya granulasi.