Panel test for Anaphylaxis
Tryptase (serum)
- Increased serum levels may confirm diagnosis.
- Specific but not sensitive for diagnosis
- Testing most informative 15-180 minutes after symptom onset
- Increased concentration may persist for 4-6 hours
- Normal levels do not rule out anaphylaxis
- More common to have normal levels in food allergy anaphylaxis
- Postmortem femoral vein sampling may be useful to confirm anaphylaxis as cause of death – must be within ≤1 hour of death
- Not definitive, as myocardial infarction, trauma, or asphyxia may also cause increased tryptase level
Histamine
- Serum or plasma
- Levels peak 5 minutes after onset of anaphylaxis and return to baseline within 30-60 minutes
- Testing may not be feasible, as levels must be obtained at symptom onset
- Basophil activation during clotting may cause artifactual elevation
- Levels peak 5 minutes after onset of anaphylaxis and return to baseline within 30-60 minutes
- Urine
- Histamine metabolite (N-methylhistamine) is measured
- Remains elevated in urine for many hours after anaphylaxis
- Preferred specimen is 24-hour urine
- Reflects overall levels of released histamine
- Histamine metabolite (N-methylhistamine) is measured
IgE allergen serum testing
- Used to identify potential allergens to enable allergen avoidance or desensitization
- Multiple allergen IgE testing (based on suspected allergens) may be appropriate
- IgE panel tests include insect and bee venom, food, inhalant, and other allergens
CD63 and CD203 expression by flow cytometry
- Newer tests
- Markers of basophil activation
Testing to rule out mastocytosis
- Mastocytosis should be considered and ruled out in severe anaphylaxis
- Flow cytometry, serum IgE, baseline tryptase (ie, not during acute event), and KITD816V mutation testing should be considered in addition to clinical evaluation
References
Guideline
- Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol 2002; 110:341.
- Muraro A, Roberts G, Simons ER. New visions for anaphylaxis: an iPAC summary and future trends. Pediatr Allergy Immunol. 2008; 19 Suppl 19: 40-50. PubMed
- Simons ER, Ardusso LR, Bilò B, Dimov V, Ebisawa M, El-Gamal YM, Ledford DK, Lockey RF, Ring J, Sanchez-Borges M, Senna GE, Sheikh A, Thong BY, Worm M, World Allergy Organization. 2012 Update: World Allergy Organization Guidelines for the assessment and management of anaphylaxis. Curr Opin Allergy Clin Immunol. 2012; 12(4): 389-99. PubMed
- Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Rivas F, Santos AF, Zolkipli ZQ, Bellou A, Beyer K, Bindslev-Jensen C, Cardona V, Clark AT, Demoly P, Dubois AE, DunnGalvin A, Eigenmann P, Halken S, Harada L, Lack G, Jutel M, Niggemann B, Ruëff F, Timmermans F, Vlieg-Boerstra BJ, Werfel T, Dhami S, Panesar S, Akdis CA, Sheikh A, EAACI Food Allergy and Anaphylaxis Guidelines Group. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. 2014; 69(8): 1026-45. PubMed
- Bonadonna P, Pagani M, Aberer W, Bilò MB, Brockow K, Elberink O, Garvey L, Mosbech H, Romano A, Zanotti R, Torres MJ. Drug hypersensitivity in clonal mast cell disorders: ENDA/EAACI position paper. Allergy. 2015; 70(7): 755-63. PubMed
- Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks W, Feldweg AM, Fink JN, Greenberger PA, Golden DB, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010; 126(3): 477-80.e1-42. PubMed
- Simons ER, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park H, Sheikh A. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J. 2015; 8(1): 32. PubMed
