TABLE V.

Selected clinical findings of 33 vaccine-triggered anaphylaxis cases, VSD, 2009-2011

Case no.	Age (y)/ race/sex	History of atopy	Vaccines	Onset after vaccination	Setting of initial evaluation	Diagnosing provider’s specialty/ attributed trigger	Symptoms	Brighton level	Treatment	Outcome
1	5/B/M	Fish, peanuts, eggs	MMR, DTaP-IPV,  varicella	Onset <30 min	Clinic	Pediatrician/vaccine	General pruritus, wheeze, cough, vomiting	2	Epinephrine, oral antihistamine, antiemetic	Patient recovered
2	26/W/F	Asthma	TIV, PPV23	Onset not documented	ED	ED doctor/vaccine	Wheeze (bilateral), SOB, ↑HR, nasal congestion, nausea	2	Nebulizer	Patient recovered
3	4/?/F	Asthma, atopic dermatitis	TIV	Onset 30 to <60 min	Clinic	FNP/vaccine	Generalized urticaria, wheeze, respiratory distress, vomiting	1	Epinephrine, oral antihistamine, O2, albuterol nebulizer	Patient recovered
4	15/W/F	Asthma, other allergy (DTaP)	Tdap, HPV4	Onset 2 h	Clinic	Pediatrician/vaccine	Angioedema, generalized urticaria, erythema  and pruritus, SOB, abdominal pain	2	Oral antihistamine, bronchodilators	Patient recovered
5	12/W/F	Allergy to penicillin	TIV	Onset 1 d after vaccine	Inpatient  (overnight)	ED doctor/vaccine	Generalized urticaria, pruritus and rash, ↑HR, syncope,  BP 117/72 mm Hg, “lump in throat”	2	Epinephrine, parenteral antihistamine, parenteral  H2-blocker, oral steroid, O2, other (antiemetic,  lidocaine cream)	Patient recovered, referred to allergist  (patient’s skin test and RAST results  both negative for latex), prescribed  epinephrine autoinjector
6	62/W/F	Hives after sulfa and cephalexin	Hepatitis, Tdap	Onset 30 to <60 min	Clinic	ED doctor/vaccine	Flushing, SOB, nausea, vomiting, abdominal pain	2	Parenteral antihistamine, parenteral H2-blocker,  parenteral steroid, O2, other (ASA, nitroglycerin, MS)	Patient recovered
7	17/W/F	Other (latex gloves)	HPV4, MMR, MCV4	Onset 2 h	ED	ED doctor/vaccine (latex  in Sanofi stopper)	Generalized “prickle” sensation, dizziness,  ↑HR, wheeze, throat closure, dry cough	2	Epinephrine, oral antihistamine, oral steroid	Patient recovered, referred to allergist,  prescribed epinephrine autoinjector
8	65/W/M	Asthma, allergic rhinitis, other (allergy shots)	HZV and allergy shot  (received before event)	Onset <30 min	Clinic	LPN and INT doctor/  allergy shot	Generalized pruritus, wheeze, SOB, cough	2	Epinephrine, parenteral antihistamine, albuterol  nebulizer	Patient recovered
9	56/W/M	Other (amoxicillin)	TIV, Tdap	Onset 60 to <90 min	Clinic	FP doctor/vaccine	Angioedema, SOB, vomiting, fatigue	2	Oral antihistamine	Patient recovered
10	36/W/F	Contact dermatitis, allergic rhinitis	TIV, Tdap	Onset 3 h	Clinic	Urgent care doctor/  vaccine	Angioedema, “choking” cough, ↑HR, nausea	2	Oral antihistamine, oral steroid, other (cool compress)	Patient recovered
11	14/W/F	Asthma, allergic conjunctivitis and rhinitis	TIV	Onset 2 h	Clinic	Pediatrician/vaccine	Wheeze, vomiting	2	Oral antihistamine, bronchodilators	Patient recovered
12	5/W/M	Asthma, other (cashew, pistachio nuts)	TIV	Onset 3 h	ED	ED doctor/vaccine	Generalized urticaria, pruritus and rash, SOB	2	Oral antihistamine, oral steroid	Patient recovered
13	29/W/F	None	TIV (administered 1 d before)	Onset 8 h	ED	ED doctor/vaccine	Angioedema, swelling (lips, uvula, mouth), generalized  urticaria, pruritus and rash, SOB, cough	1	Oral antihistamine, oral H2-blocker, oral steroid	Patient recovered, referred to PCP
14	55/W/F	None	TIV	Onset 6 h	ED	ED doctor/vaccine	Wheeze, SOB, red and itchy eyes	2	Oral antihistamine, oral steroid, bronchodilators,  other (fluids and rest)	Patient recovered, referred to PCP
15	7/?/M	Anaphylaxis, atopic dermatitis, other (egg, gelatin,  TIV and other vaccines)	Hepatitis A, varicella	Onset 30 to <60 min	Clinic	ED doctor/vaccine	Angioedema, swelling (lips), throat closure, red itchy  eyes, cough, erythema and rash, vomiting	1	Epinephrine, oral antihistamine, oral H2-blocker,  parenteral steroid, IVT, bronchodilator	Patient recovered, referred to allergist
16	64/?/F	Asthma, other (multiple medications)	PPV23	Onset not documented	Clinic	INT doctor/vaccine	Wheeze (bilateral), dizziness, nausea	2	Bronchodilators	Patient recovered
17	9/?/F	None	TIV	Onset <30 min	Clinic	ED doctor and  pediatrician/vaccine	Angioedema (eyelid), cough	2	Epinephrine, oral antihistamine, oral steroid,  bronchodilators, other (icepack)	Patient recovered, referred to  pediatrician
18	44/W/F	Anaphylaxis, asthma, allergic rhinitis,  other (ASA)	TIV	Onset <30 min	ED	ED doctor/vaccine	Generalized pruritus and rash, wheeze, SOB, throat  tightening, hoarse voice, cough, vomiting and diarrhea	2	Parenteral antihistamine, oral steroid, O2, bronchodilators	Patient recovered
19	12/W/M	Asthma, atopic dermatitis, allergic rhinitis, other (egg)	MCV4, MMRV, Tdap	Onset <3 h	Clinic	Pediatrician/vaccine	Generalized urticaria, pruritus and rash, cough	2	Oral antihistamine, other (cool compress)	Patient recovered
20	8/W/M	Contact dermatitis, allergic rhinitis	MIV	Onset <30 min	ED	ED doctor/vaccine	Angioedema (periorbital), wheeze, SOB	1	Oral antihistamine, oral steroid, bronchodilators	Patient recovered
21	6/W/F	Anaphylaxis, allergic rhinitis, reactive  airway disease, other (TIV)	TIV	Onset 60 to <90 min afte  5 test doses vaccine	Clinic	Allergist/vaccine	Erythema (throat), generalized pruritus and rash, cough	2	Epinephrine, oral antihistamine	Patient recovered
22	4/?/M	None	DTaP, IPV, MMR	Onset <60 min	Clinic	ED doctor and  pediatrician/vaccine	Angioedema, generalized urticaria, erythema, rash, red  itchy eyes, wheeze, ↑RR, cough	1	Oral antihistamine, parenteral steroids	Patient recovered, referred to allergist  and pediatrician, prescribed  epinephrine autoinjector
23	62/?/F	Other (penicillin class medications)	HZV (administered at  work same day)	Onset not documented	Clinic	Physician’s assistant/  vaccine	Generalized pruritus, erythema, tongue swelling, chest tightness	1	Parenteral antihistamine, oral H2-blocker	Patient recovered
24	4/W/M	Asthma, allergic conjunctivitis and rhinitis	DTaP, MMR, IPV, varicella	Onset <30 min	Clinic	Allergist/vaccine	Facial swelling, erythema and pruritus, wheeze (bilateral),  swelling (posterior oropharynx), rhinorrhea, cough, vomiting	1	Epinephrine, bronchodilators	Patient recovered, referred to allergist
25	12/W/M	None	Rabies IM (history of cat  bite in Mexico)	Onset 30 to <60 min	ED	ED doctor/vaccine	Angioedema (eyelids, lips), generalized rash, facial erythema  and urticaria, wheeze, swelling (lips, throat)	1	Epinephrine, parenteral antihistamine, parenteral  H2-blocker, parenteral steroid, O2, other  (continued antibiotic)	Patient recovered, referred to  pediatrician
26	11/?/M	None	MCV4, Tdap, varicella,  hepatitis A	Onset not documented	Clinic	Pediatrician/vaccine	Injection site urticaria & erythema, measured ↓BP	2	Oral antihistamine	Patient recovered
27	44/B/M	Allergic rhinitis, other (penicillin class medications)	Hepatitis A	Onset 2 h	ED	ED/vaccine	Generalized erythema and rash, red itchy eyes, ↑HR,  palpitations, swelling (throat), “chest heaviness”	1	Oral antihistamine, acetaminophen	Patient recovered, referred to PCP
28	27/W/F	None	MIV, TIV	Onset 2 h	ED	ED doctor/vaccine	Generalized urticaria, pruritus and rash, angioedema,  swelling (tonsils)	1	Epinephrine, parenteral steroid	Patient recovered
29*	11/W/M	Asthma, other (fluconazole, penicillins)	Varicella, Tdap, MCV4	Onset immediate	Clinic	FPP/vaccine	Angioedema (lips), swelling (tongue)	2	Epinephrine, oral antihistamine, oral steroid	Patient recovered
30*	15/W/F	Allergic rhinitis, other (shellfish, methylprednisolone)	Tdap, varicella	Onset 30 to <60 min	Clinic	FPP/vaccine	Angioedema (lips), swelling (tongue)	2	Epinephrine, oral antihistamine, oral steroid	Patient recovered
31*	37/W/F	Asthma, other (codeine and cephalexin)	MIV	Onset 2 h	ED	ED doctor/vaccine	Generalized “prickle” sensation, SOB, swelling (throat),  “tingling” lips	2	Epinephrine, parenteral antihistamine, other (lorazepam)	Patient recovered, referred to PCP
32*	35/W/F	Other (shellfish, latex, amoxicillin, ciprofloxacin, gentamicin)	TIV	Onset <30 min	Clinic	FP doctor/  vaccine	Generalized pruritus, swelling (tongue), SOB, throat closure	2	Epinephrine, parenteral antihistamine, IVT,  bronchodilator (albuterol)	Patient recovered
33*	44/W/F	Asthma, allergic rhinitis, other (eggs, sulfonamides)	Tdap	Onset 2 h	ED	ED doctor and INT/  vaccine	Generalized urticaria, erythema and rash, measured ↓BP,  LOC, nausea, diaphoretic	1	Epinephrine, oral antihistamine, parenteral H2-blocker,  parenteral steroid, IVT, bronchodilators	Patient recovered, referred to PCP

ASA, Aspirin; B, black; BP, blood pressure; F, female; FNP, family nurse practitioner; FPP, family practice provider; HR, heart rate; IM, intramuscular; INT, internist; IPV, inactivated polio vaccine; IVT, intravenous therapy; LOC, loss of consciousness; LPN, licensed practical nurse; M, male; MCV4, meningococcal conjugate vaccine; MMRV, measles, mumps, rubella, and varicella vaccine; MS, morphine sulfate controlled-release; NSAID, nonsteroidal anti-inflammatory drug; PCP, primary care physician; RR, respiratory rate; SOB, shortness of breath; W, white.

^*Identified by means of screening for epinephrine administration.