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Today I saw a pat who presented in A&E with life-threatening asthma.

MET call. Hypoxic & acidotic & with a hx of asthma. They weren’t compliant with preventative inhalers.

@DrLindaDykes @drrobgreig @jfdwolff @iceman_ex @GongGasGirl @bagheera79 @MDaware
They were treated with back-back nebs, Mg2+, steroids etc.

Hx an hour after eating they had vomited & then went on to an asthma attack. An urticarial rash was also noted. Anaphylaxis was considered but dismissed as a differential. They were reviewed by ICU.
Anaphylaxis & Adrenaline (& this is documented) were discounted as i) No hypotension ii) 1 hour between the ingestion of food & onset of symptoms.

So certain were the teams this was *not* anaphylaxis the pat. was not sent home with Adrenaline. No tryptase was checked.

Hypotension is not essential to diagnose anaphylaxis. Food allergy & asthma go together. Anaphylaxis to foods respiratory symptoms dominate. Audit show pats rarely receive Adrenaline if the presentation of their anaphylaxis is asthma unless they self-administer.
The majority of anaphylactic reactions to foods will occur in under 30 mins of ingestion *but* not always. Some reactions will only manifest when co-factors are present. Common co-factors include exercise, ingestion of NSAIDs & alcohol.
Foods that can commonly present with delayed or co-factor dependent reactions include wheat, prawns & lipid transfer protein (I’ll let @VenterCarina @broughallergy & @FlorinDanPopesc) write the thread on that one!
The point here is about pattern recognition: abdo pain, vomiting, life-threatening asthma & urticaria - an hour after eating in an atopic individual could be/probably is anaphylaxis. It’s about considering it as a differential. And recognising food allergy & airway go together.
Today we identified that this was wheat-dependent exercise induced anaphylaxis. This was not the 1st reaction but it was the most serious. It nearly killed him. In allergy clinic a diagnosis was made, Adrenaline prescribed & we will now look to improve asthma control.

*The end*
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