Burning Down the House

By Elisabeth Rosenthal|Saturday, May 01, 1993
When Meg Swift first noticed the itchy red blotches erupting on her skin with the regularity of fireworks on the Fourth of July, she didn’t even consider the idea that anything could be terribly wrong. After all, she’d never been seriously ill before. She guessed she must be having an allergic reaction, but she had no idea what she was reacting to--she’d never had allergies before, either. In any case, she figured, it didn’t matter, since allergies are no big deal. She decided to just finish reading the newspaper and wait to see if the itchy hives would go away by themselves.

As the minutes passed, however, the itching didn’t go away; instead it spread to her stomach and legs. It was getting so bad she couldn’t concentrate. Worse still--was it her imagination?--her eyes and lips were beginning to feel puffy. She looked in the mirror. They did look a little swollen, but then again, she hadn’t slept well the night before. After staring intensely at herself for another minute, she turned away, worried that she was becoming a hypochondriac.

An allergy pill should do the trick, she thought. So she rummaged through the medicine chest in the hope of finding the pills her sister had once given her as part of a first-aid kit to take on a camping trip. But when she stepped back from the medicine chest, she caught another glimpse of herself in the mirror. Already her lips and eyelids were growing bigger. They were beginning to resemble water balloons. She called out to Matthew, her husband, to come and see--and noticed that her throat felt clumsy when she tried to swallow or speak.

Since they were new to town and didn’t yet have a doctor, Matthew insisted they take a taxi to the nearest hospital outpatient clinic, just to get her checked out. Meg protested that she felt silly going to a hospital for an allergy attack: after all, her mother and sister had taken pills for hay fever and asthma for as long as she could remember. If only she had found some in the medicine chest--then she could forget about the emergency room.

But by the time they arrived at the hospital, she was feeling a bit woozy and had to lean on her husband’s arm. And her eyes were so itchy and swollen that all she could see was a narrow slit of light. Still, when the guard at the hospital’s front desk asked if she wanted a wheelchair, she waved him off. I’m 25; it’s just allergies, she said. He had her write her name on a registration list and take a seat in the waiting room until the triage nurse got a chance to check her out. It all seemed fairly routine.

So she was startled when the nurse in charge, who had come to the waiting room to speak to the family of another patient, made a big fuss upon seeing her. The nurse asked her a few quick questions and then rushed Meg into the emergency room itself, straight into a treatment bed.

Until this point, I’d been unaware of Meg Swift’s plight; I’d been sitting at the doctor’s desk in the ER, filling in some patients’ charts. But as the nurse passed by with Meg, she said one word to me-- anaphylaxis. My heart started pounding, and I immediately fell in behind her.

Anaphylaxis, the malevolent kingpin of allergic reactions, makes a mockery of a patient’s assertion that it’s just allergies. Anaphylaxis is a misguided attack by the body’s immune system against a generally benign foreign substance--usually a food, drug, or insect venom. In this type of relentless allergic reaction, an overzealous immune system seeks to expel a harmless intruder by burning down the house. It is so overwhelming that it can leave virtually every body system in a state of collapse, and so ferocious that a patient can be dead in minutes despite the best medical treatment.

Anaphylaxis occurs when the body recognizes the presence of a foreign intruder, or antigen, that it has seen before and for some unknown reason has deemed henceforth unwelcome. During the first encounter there is no outward reaction to the antigen. But the body takes an irrational dislike to the substance, creating immune molecules called antibodies that remember its chemical structure. If and when it intrudes again, these scouts detect its presence and sound a chemical alarm. Cells called mast cells release powerful chemical messengers--histamines--that pour into the bloodstream and cause smooth muscle to contract and blood vessels to open wide and become leaky. Tissues become swollen as fluid leaks from the vessels. And this inflammation occurs not only externally--causing hives-- but internally as well.

When I first saw Meg Swift, it was clear she was having a severe attack: her pale, puffy face seemed to be all lips and eyelids. In fact, her eyes were now sealed shut. But that was not what worried me. An allergic reaction that confines itself to the skin can make patients look like monsters and go wild with itching, but it is rarely dangerous. The other symptoms Meg had mentioned to the nurse (with a touch of embarrassment, confessing she was sure they were all in my head) were what caused me concern: terrible cramping in her stomach, a funny tightness in her throat, wooziness, and a weird whistling sound when she breathed.

She was definitely not imagining things. Even from the foot of her stretcher I could hear the wheezes and see the saliva running from the corner of her mouth. I knew she needed treatment right away and that niceties like taking a history and performing an exam would have to wait.

As the nurse and I each hooked up an IV line to give her fluids, I began to order medicines: Hydrocortisone, a steroid to reduce further inflammation, 100 mg, through the IV. Diphenhydramine, an antihistamine, 50 mg, also through the IV. Zantac, a drug that would help calm her crampy intestine, 50 mg, again through the IV.

But the most crucial drug was to be injected under the skin: .3 cc’s of epinephrine. Epinephrine is another name for adrenaline, the fight or flight hormone that can also counteract many of the dangerous effects histamine has throughout the body; it raises blood pressure, relaxes spasms in the airways, and quiets the stomach and bowel. It also puts great stress on the heart, and in an older person or someone with hypertension or a heart condition, it can do more harm than good. So as the nurse prepared the epinephrine injection I asked Meg if she had any heart problems. She shook her head no.

Okay, then, I told her. I’m going to give you a shot of adrenaline, which will make your heart pound and make you feel really jumpy, but you need it to break the attack.’’ I stuck the needle into her arm. I remembered, from my childhood bouts with asthma, the blessed relief such shots could bring, but also the hours of jitters and sleeplessness that followed them. It’s in, I said, withdrawing the syringe.

Good, she answered in a voice that was raspy and barely audible. Uh-oh.

Is that how you normally speak? I asked.

No, she answered with difficulty. I started to get hoarse in the waiting room.’’ It was obvious that the swelling that had started on her skin had now moved down to her vocal cords.

The quick exam that followed confirmed my initial impression that her reaction was widespread and serious. Her blood pressure was extremely low--only 78/50, compared with a normal pressure of 120/80--because of the fluid leaking out of her blood vessels and the widening of those vessels. This meant that she was in danger of going into shock--or even dying-- because less oxygen was reaching her brain and other vital organs. Her lungs were in trouble, too: with my stethoscope I could hear the wheezes even more precisely. Her belly was tender. And as she was being helped into a gown she started vomiting.

It was obvious that quite a few of Meg’s organs were involved in the reaction, and that worried me. I was relieved to note, however, that no single system in her body had reached the point of total collapse.

So after giving her the first dose of epinephrine, the nurse and I held vigil at her bedside, peppering her with questions. It was no easy task, since the antihistamine she had received--used to block the further release of histamine from mast cells--can make even the heartiest of souls profoundly sleepy.

I’m going to be a pest, I told her, trying to keep her awake. How’s your breathing feel?

Better, she said, her eyelids dropping. But her voice seemed even raspier than before.

Suddenly she sat bolt upright and grabbed her neck. I feel like I’m choking. Like it’s closing off.

Another epinephrine, right now, I said to the nurse at my side.

A battle was being waged between her body’s own aberrant immune chemicals and the ones we had given her to block their way. All I could do was watch the nurse give the second round of epinephrine and pray our side would win.

After a few minutes I looked at Meg’s arms and noticed that her hives were fading. Through her boggy eyelids I could see slivers of green. Her blood pressure was up to 110/70. When she spoke, I heard a more resonant voice.

The immediate crisis had been averted, but now came the hard work: we had to figure out what had provoked this life-threatening episode. Anaphylactic reactions tend to get worse each time they occur, so it’s crucial to know what caused the first one and to prevent any subsequent exposure to that antigen.

People who develop an allergy--to a specific drug, for instance-- frequently react with disbelief. Allergic to Bactrim? Couldn’t be. I took that last year. But that’s just the point: in allergies, the immune system only reacts to vanquish foes it has already met.

The meeting may be brief, however, so brief that the patient is not even aware of it. A person may become sensitized to penicillin, for instance, from trace quantities of the drug in cow’s milk. At other times, the encounter is not with the allergenic substance itself but with a different, though chemically related, substance. For instance, a person may become allergic to insect venom after being pricked by a sea urchin spine.

In Meg’s case, I probed and probed to find a culprit, any culprit, but with each line of questioning I ran into a dead end. She and her husband, who joined us once the crisis had passed, insisted that she was taking no medicines. I asked about new shampoos, new soaps, new powders--anything that could be absorbed through the skin. Nothing. She had no history of allergies and had had no insect bites.

It’s not always this difficult to track down the reason for a severe allergic reaction. I took care of one man who knew he was allergic to peanuts but thought he might be able to get away with eating a few on his birthday. He survived, but 24 hours on a breathing machine in the intensive care unit was the price of his little snack.

Although the severity of a reaction is loosely related to the amount of a substance that enters the bloodstream (the man who ate the peanuts had gotten away with eating a few on special occasions before), in people who are sensitized, even a minuscule portion can be perilous. And the reaction each time is unpredictable.

The medical journals contain reports of a man allergic to fish who died after eating french fries that had been cooked in oil used to fry cod earlier in the day. Likewise, they tell of a woman with a peanut allergy who succumbed to anaphylaxis after eating a turkey sandwich cut with a knife that had previously been used to slice a peanut butter and jelly sandwich. A friend of mine, who is allergic to celery, has had several severe reactions after eating dishes that she was assured by waiters were celery-free; she now carries epinephrine with her everywhere. For people allergic to foods that restaurants commonly use as minor ingredients for texture or flavor, eating out can be like walking through a minefield.

Having tried everything else I could think of, I had to assume that Meg’s attack was caused by a food allergy as well. So we started to go through the foods she’d eaten for breakfast, since anaphylactic reactions tend to start within several hours of exposure to the offending substance.

I was hoping Meg would tell me that she’d had an unusual meal that morning, one that included a type of food commonly associated with severe allergic reactions--nuts (an apple walnut muffin?), chocolate (a chocolate croissant?), berries (strawberries on her cereal?). But no luck. She told me she was a creature of extreme habit. Every morning she had coffee, orange juice, and a bagel with cream cheese or grape jam.

Still, I pushed her to go over every last spoonful of food. And it was worth it, because we sparked something in Matthew Swift’s memory.

Wait! he suddenly exclaimed. We did have grape jam, but it wasn’t the one we usually eat. It was from that gift basket we got for Christmas. It was not a very satisfying lead, but I clung to it nonetheless. Who knew what substance had been dumped into the vat to make the jam sweeter or purpler or stickier?

But I was still left with a problem. Meg would soon be ready to leave the emergency room--her voice was already back to normal and the hives had disappeared--and I had to give her instructions about what foods to avoid. I would have loved to be able to tell her right there and then that she had developed an allergy to grapes or to grape jam. But the only way to tell for sure would be to do some kind of allergy testing, and the devastating internal aftermath of an anaphylactic attack made that an impossibility. The body’s exhausted immune system needs time to rebuild and replenish itself so that it can react normally when challenged with a suspect antigen. The drugs that we used to suppress the near-fatal reaction would skew any test results as well.

The best I could do was to warn Meg to avoid anything and everything she had eaten that morning--including coffee and bagels. And since allergy attacks sometimes rebound, even after successful treatment, I explained that she would have to continue taking the antihistamines and the steroids to break the cycle of inflammation. After all, some of the substance that had precipitated this near disaster might still be in her blood, so it was wise not to drop our defenses.

I arranged for Meg to see an allergist two weeks later--by which time her system would have recovered. The allergist would use one of two methods to find her nemesis: he might mix small samples of her blood with a wide variety of potential antigens to see which caused the cells in her blood to release histamine, or he might simply perform a prick test, dropping a minute amount of each chemical onto the skin, making a tiny pinprick beneath it, and looking for a local reaction.

In the end, the allergist--using the first of the two methods-- found that Meg had indeed reacted to something from that gift basket. But the culprit wasn’t the grape jam she’d told me about. She’d forgotten that she had also taken a tiny taste of papaya jelly that morning. Her body, however, had remembered.

The day she left the ER, though, I still could not name her enemy. So instead I gave her a prescription and a piece of advice. The prescription was for an EpiPen--a syringe of epinephrine that injects automatically when pressed into the flesh of the thigh. I told her to use it if she felt an attack coming on and felt that she couldn’t breathe--and then to return to the hospital immediately. And my piece of advice was this: Remember, though I knew she would, anaphylaxis is not ‘just allergies.’
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