Adventures in Anaphylaxis

tldr: Don't eat blackberries off the bush.

So I had some excitement with a yellow jacket nest Monday.

Didn't get stung in the process of getting rid of the nest, luckily.

I've gotten lots of stings during my life, especially from yellow jackets, but also from bees.

I’ve never had a hint of an issue, other than the obvious effects of the venom. (They hurt like heck, for starters...)

Well, yesterday afternoon I was eating blackberries from a bush in our yard, and something flew around my head and then stung me in the jaw.

Hello anaphylaxis!

Never had that kind of response before. It is not pleasant, especially when your entire body breaks out in super-itchy hives.

Luckily my wife and I are both trained, but it pretty much boils down to get to the emergency room as quickly as possible. It's three miles from our house, so we didn't bother with calling an ambulance which would have to drive three miles to get to our house—we just got in the car and drove.

Pro-tip: Don't try applying an epi-pen when you are driving! Especially when your vision goes while reading the instructions, and your loving wife is emulating a rally-car driver.

I passed out on the way to the hospital... A nice IV feed, a drug cocktail, and a couple of hours of observation later and I was back home with a swollen head—literally!

Karma is a bitch, it seems.

P.S. 10/30/2024

So the leaves on the shrub I was standing by when I got stung finally dropped, revealing this. It’s apparently a bald face hornet nest, which is a type of yellowjacket.

“Their aggressive defensive nature, though, makes them a threat to humans who wander too close to a nest or when a nest is constructed too close to human habitation. They vigorously defend the nest…”

Indeed they do.

I’m curious.

I didn’t argue with the physician in the ER about what he was treating me with. He said epinephrine (adrenalin) and I knew that’s the primary treatment for anaphylaxis, so I let it go. Plus I was in no state to do some research and determine if he was doing the best treatment.

But, the next morning when I got up I was of course curious about what he had done.

When I got into the ER, trucked in in a wheelchair barely-conscious from the car, they slapped an IV into me and started injecting things.

I got a saline drip (water), and the following medications:

1. Epinephrine (Adrenaline), the flight-or-fight hormone.

2. Diphenhydramine (Benadryl), an antihistamine.

3. Famotidine (Pepcid), the anti-ulcer drug which is also an antihistamine.

4. Methylprednisolone (Solu-MEDROL), a steroid (corticosteroid—prednisone, a synthetic cortisol).

So this morning I read the guidelines and research on treating anaphylaxis. It’s quite enlightening about the actual practice of medicine, as opposed to the theoretical, evidence-based practice of medicine.

The ‘Evidence’.

Evidence-based medicine has a hierarchy of evidence (actually, they have like 82 hierarchies of evidence, but they do have some consistency.)

At the bottom, generally, are animal studies and clinical experience. At the top is randomly-controlled trials and, maybe, meta-analyses.

Nevertheless:

“As anaphylaxis is a medical emergency, there are no randomized controlled clinical trials on its emergency management. Therefore, current guidelines are mostly based on data from observational studies, animal and laboratory studies.” (Liyanage, 2017)

The “observational studies” are of clinical experiences. The bottom of the barrel?

1. Adrenaline

Treatment of anaphylaxis is quite successful. So successful that if you have an epi-pen (a dispenser of adrenaline/epinephrine given to patients for self administration) that you may be in need of no medical care.

“If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response.” (Golden, 2023)

And:

“The cardinal treatment of anaphylaxis is prompt epinephrine injection.” (Golden, 2023)

Sadly, by the time we found my wife’s epi-pens (not “prompt”), I was in a pretty bad state, and we both thought it best to visit the emergency room.

All of this clinical experience has led to the conclusion that epinephrine is the primary treatment for anaphylaxis, that’s what the guidelines say, anyway (Shaker, 2020; Golden, 2023). And if it doesn’t work, you give another shot (after five minutes). Only if that doesn’t work are you really in trouble, and you’re probably going to get yet another shot…

Luckily, my ER doc gave me epinephrine first, while I was unconscious. Why is that lucky?

“Epinephrine is the cornerstone of anaphylaxis management but continues to be underutilized.” (Shaker, 2020)

Sigh. Nevertheless:

“Despite underuse of rapidly acting epinephrine as first-line treatment, fatal anaphylaxis is a rare outcome, with population prevalence rates between 0.47 and 0.69 per million persons (0.25%-0.33% of anaphylaxis hospitalizations or ED visits).” (Shaker, 2020)

Anaphylaxis is a lot less serious than I had thought, but those are still pretty high risks compared to a normal day. (That’s 1 death for every 333-400 days, which is a lot higher than your lifetime risk of dying, but still.)

2 and 3. Benadryl and Pepcid (Antihistamines)

“Unlike epinephrine, antihistamines will not effectively treat cardiovascular and respiratory symptoms such as hypotension or bronchospasm.” (Shaker, 2020)

While the itchy hives that happen in anaphylaxis are certainly miserable, they’re not going to kill you. Shutdown of your cardiovascular and respiratory systems during anaphylactic shock will, of course. I had a very low pulse of 40 beats per minute, a high blood pressure of 156/96 (as I recall), and no pulse in my extremities. Not good, in other words.

Antihistamines are great for alleviating that skin response, but will not save your life.

4. Solu-MEDROL (Steroids)

“Although glucocorticoids [steroids] are frequently used as an adjunctive therapy for anaphylaxis, evidence is lacking to support clinical benefit, and they should not be administered in place of epinephrine in the treatment of acute anaphylaxis.” (Shaker, 2020)

While steroids are very effective at suppressing the immune system, they don’t do so in the short-term, unlike adrenaline, which works within five minutes, typically.

There was some thought that steroids were helpful for two-stage (biphasic) anaphylaxis, but this seems not to have born out under further study. That and the following quotes are from (Liyanage, 2017), “Corticosteroids in Management of Anaphylaxis; a Systematic Review of Evidence”.

“The rate of corticosteroid use in emergency treatment of anaphylaxis varied from 48% to 100% with an average of 67.99%.”

Compared to epinephrine:

“Although epinephrine is clearly recommended as the first line treatment for management of anaphylaxis, human studies reviewed here revealed that usage of epinephrine either during pre-hospital or emergency care varies widely from 7-70%.”

So you are more likely to get steroids than epinephrine in the emergency room. Despite the fact that there is no evidence supporting steroids’ efficacy.

“Corticosteroids are often used in the management of anaphylaxis and sometimes used as a first-line therapy instead of adrenaline, despite the lack of compelling evidence and guidelines recommending their use only as an adjuvant therapy. There are no randomised or quasi-randomised trials providing support to this practice.”

And the use of steroids is not a factor of the type of anaphylaxis.

“Irrespective of the trigger, management of anaphylaxis is the same for all patients.”

Nevertheless,

“Some multicenter trials have demonstrated that corticosteroids are still being administered as the first-line therapy instead of epinephrine.”

So yes, I was lucky that I got that shot of epinephrine.

Practice vs. Evidence.

Clinical experience is often rated poorly as a source of evidence because, in part, physicians are often reluctant to change practice in light of scientific evidence or the lack thereof.

“Antihistamines and glucocorticoids are common medications used to treat and prevent allergic reactions. While these treatments should not interfere with prompt administration of epinephrine in anaphylaxis treatment, they are often administered as first-line drugs with a wait-and-see approach before epinephrine is administered. It has been shown that epinephrine is often omitted in the ED [emergency department] setting while antihistamines and glucocorticoids are administered for a diagnosis of anaphylaxis.” (Shaker, 2020)

Physicians can be very reluctant, as Shaker et. al., point out.

“Therefore, the administration of epinephrine for all patients with anaphylaxis and the withholding of antihistamines and corticosteroids for some patients will not be acceptable to all professional stakeholders.” (Shaker, 2020)

I noted in an old post about the mis-treatment of fever:

“So people are scared of fevers because their doctors are scaring them. That's logical, at least, even if it's incorrect. Amusingly, the doctors are the ones blaming the patients they've scared for being scared.” (Goodrich, 2012)

According to Shaker, et al., the same problem exists here:

“Patients may feel ‘‘safer’’ with the use of antihistamines and/or glucocorticoids, but this preference is likely to be highly influenced by counseling and education they receive from health care providers. The patient will need education and reeducation on the signs and symptoms of anaphylaxis and on the use of epinephrine as the only first-line medication for the treatment of anaphylaxis. Providers cannot allow the patient to ‘prefer’ an antihistamine over epinephrine for the treatment of anaphylaxis. Patient preference may be a consideration in the use of antihistamines and glucocorticoids as second-line medications following epinephrine administration. Antihistamines and glucocorticoids may provide some role in treating the urticaria [hives/rash] and pruritus [itching] occurring during anaphylaxis.” (Shaker, 2020)

Both barrels.

So the ER hit me with both barrels of the shotgun, effectively, to relieve me of the signs and symptoms of anaphylaxis. I can’t really fault the physician for that.

But I won’t be continuing the course of steroids or the benadryl he prescribed to me now that I am home. I’m not a fan of them, as I’m legally blind in my left eye due to a course of prednisone. And at this point it’s well-known that impairing inflammation impairs the healing process, and I would like to get over this as quickly as possible.

But if you wind up with a case of anaphylaxis, make sure you get a shot of adrenaline first, before you get some shots to deal with the minor, non-life-threatening symptoms.

My remaining questions.

So why did this happen? When I fixed my diet all of my allergies went away, and it’s been 15 years now (Goodrich, 2011).

I’ve had some minor symptoms like this previously, but never anything severe enough to require treatment.

I really don’t know. I suspect it’s likely because of the position of the bite, as my neck is still quite sore and swollen. I look like I have a goiter.

It may be just age, unfortunately, but who really knows.

I’ll probably carry an epi-pen on my adventures for a while, as directed by the ER physician. My wife, a nurse, will see to that.

I wouldn’t mind getting stung again so I can see what happens, although my wife has forbidden me from conducting this experiment intentionally.

We shall see what happens.

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References

Golden, D. B. K., Wang, J., Waserman, S., Akin, C., Campbell, R. L., Ellis, A. K., Greenhawt, M., Lang, D. M., Ledford, D. K., Lieberman, J., Oppenheimer, J., Shaker, M. S., Wallace, D. V., Abrams, E. M., Bernstein, J. A., Chu, D. K., Horner, C. C., Rank, M. A., Stukus, D. R., … Wang, J. (2024). Anaphylaxis: A 2023 Practice Parameter Update. Annals of Allergy, Asthma & Immunology, 132(2), 124–176. https://doi.org/10.1016/j.anai.2023.09.015

Goodrich, T. D. (2011, May 7). Wheat, Allergies, and Asthma [Blog]. Yelling Stop. https://tuckergoodrich.substack.com/p/wheat-allergies-and-asthma

Goodrich, T. D. (2012, April 27). Yelling Stop: Are Fevers Paleo? [Blog]. Yelling Stop. https://yelling-stop.blogspot.com/2012/04/are-fevers-paleo.html

Liyanage, C. K., Galappatthy, P., & Seneviratne, S. L. (2017). Corticosteroids in Management of Anaphylaxis; a Systematic Review of Evidence. European Annals of Allergy and Clinical Immunology, 49(05), 196. https://doi.org/10.23822/EurAnnACI.1764-1489.15

Shaker, M. S., Wallace, D. V., Golden, D. B. K., Oppenheimer, J., Bernstein, J. A., Campbell, R. L., Dinakar, C., Ellis, A., Greenhawt, M., Khan, D. A., Lang, D. M., Lang, E. S., Lieberman, J. A., Portnoy, J., Rank, M. A., Stukus, D. R., Wang, J., Riblet, N., Bobrownicki, A. M. P., … Wang, J. (2020). Anaphylaxis—A 2020 Practice Parameter Update, Systematic Review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Analysis. Journal of Allergy and Clinical Immunology, 145(4), 1082–1123. https://doi.org/10.1016/j.jaci.2020.01.017