Title: Mammalian meat allergy (alpha-gal syndrome) following tick bites
Author: Dan Gingold, MD, MPH
Development of IgE antibodies to the oligosaccharide galactose-alpha-1-3-galactose (alpha-gal) appears to be responsible for an acquired allergy to non-primate mammalian meat (i.e., beef and pork) and derived products. Antigen in the salivary apparatus of certain ticks (gross!!) can sensitize an IgE-mediated response to alpha-gal which is present in mammalian meat.
Symptoms are similar to other IgE-mediated hypersensitivity reactions, and can cause a delayed-onset reaction with hives, GI upset, or anaphylaxis after ingestion of red meat. Treatment with standard anti-histamines and epinephrine is effective. Individuals with no prior history of meat sensitivity can develop the syndrome at any age, often after exposure to the outdoors in tick-endemic areas. Skin and blood allergy testing can confirm the diagnosis. Symptoms can persist for years, but can recede over time if not exposed to further tick bites.
In the US, the primary tick responsible is Lone Star Tick (Amblyomma americanum), found primarily in the Eastern, Southeastern, and Midwestern US. Other tick species in Europe, Australia, and Asia have been found to induce the syndrome as well. Interestingly, there is a cross-reactivity with the monoclonal antibody Cetuximab (used to treat colorectal and head and neck cancers), an allergic reaction to which can also induce similar alpha-gal meat sensitivity.
Having first been described in 2009, the syndrome often goes unrecognized; increased physician awareness can inform the evaluation, diagnosis, and education of patients presenting to the ED with undifferentiated allergic reaction.
Khoury JK, Khoury NC, Schaefer D, Chitnis A, Hassen GW. A tick-acquired red meat allergy. Am J Emerg Med. 2018 Feb;36(2):341.e1-341.e3. doi: 10.1016/j.ajem.2017.10.044. Epub 2017 Oct 16. PMID: 29074067.
Crispell G, Commins SP, Archer-Hartman SA, Choudhary S, Dharmarajan G, Azadi P, Karim S. Discovery of Alpha-Gal-Containing Antigens in North American Tick Species Believed to Induce Red Meat Allergy. Front Immunol. 2019 May 17;10:1056. doi: 10.3389/fimmu.2019.01056. PMID: 31156631; PMCID: PMC6533943.
Keywords: CT, head, radiation (PubMed Search)
Most (65%) scans were performed at nonacademic adult centers
Strauss et al., 2019. Radiation Dose for Pediatric CTT: Comparison of Pediatric versus Adult Imaging Facilities
Keywords: dental pain, ibuprofen, acetaminophen (PubMed Search)
Keywords: Neck pain (PubMed Search)
Non-Musculoskeletal Causes of Neck Pain
Neck pain is a common complaint of people presenting to the ED. Most of the cases will be musculoskeleteal in origin and will respond to conservative therapy with NSAIDs or acetominophen. However, other non-musculoskeletal causes of pain could be lurky behind this benign complaint.
Don't forget to consider:
Keywords: Diverticulitis, antibiotics. (PubMed Search)
It seems like the standard treatment course for patients with suspected diverticulitis in the ED is to obtain a CT of the Abdomen and pelvis and then to start antibiotics. A CT scan is really only needed if you suspect that they have an abscess, micro perforation, are not responding to conventional treatment, or you suspect an alternative diagnosis.
However, what should the conventional treatment be? Several recent studies from Sweden, Iceland and the Netherlands have shown that patients treated with antibiotics did not fair any better then patients who were just observed. There was no difference in time to resolution of symptoms, complications, recurrence rate, or duration of hospitalization.
Several national societies (Dutch, Danish, German, and Italian) now recommend withholding antibiotics in patients free of risk factors who have uncomplicated disease, but these patients will need close follow up.
TAKE HOME POINT: Patients with diverticulitis can be treated supportively and probably do not require antibiotics unless you suspect they have complicated disease or are immunosuppressed.
Chabok A, Påhlman L, Hjern F, Haapaniemi S, Smedh K; AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg. 2012;99:532-539.
Daniels L, Ünlü Ç, de Korte N, et al; A randomized clinical trial of observational versus antibiotic treatment for a first episode of uncomplicated acute diverticulitis. BMC Surg. 2010 Jul 20;10:23
Keywords: app pearls apple google (PubMed Search)
We are proud to announce the release of our new UMEM Pearls App, now available in the Apple App Store and the Google Play Marketplace! You will now be able to pull down pearl content for offline viewing, in addition to having all of the pearls in searchable format available on your mobile devices.
Click either of the following links on your mobile device to download your Pearls App today!
Keywords: Drowning, rescue (PubMed Search)
Happy Memorial Day! With all the recent attention in the news about swimming and drowning I thought I would share this article
The Instinctive Drowning Response—so named by Francesco A. Pia, Ph.D., is what people do to avoid actual or perceived suffocation in the water. And it does not look like most people expect. There is very little splashing, no waving, and no yelling or calls for help of any kind. To get an idea of just how quiet and undramatic from the surface drowning can be, consider this: It is the No. 2 cause of accidental death in children, ages 15 and under (just behind vehicle accidents)—of the approximately 750 children who will drown next year, about 375 of them will do so within 25 yards of a parent or other adult. In some of those drownings, the adult will actually watch the child do it, having no idea it is happening.* Drowning does not look like drowning—Dr. Pia, in an article in the Coast Guard’s On Scenemagazine, described the Instinctive Drowning Response like this:
This doesn’t mean that a person that is yelling for help and thrashing isn’t in real trouble—they are experiencing aquatic distress. Not always present before the Instinctive Drowning Response, aquatic distress doesn’t last long—but unlike true drowning, these victims can still assist in their own rescue. They can grab lifelines, throw rings, etc.
Look for these other signs of drowning when persons are in the water:
So if a crew member falls overboard and everything looks OK—don’t be too sure. Sometimes the most common indication that someone is drowning is that they don’t look like they’re drowning. They may just look like they are treading water and looking up at the deck. One way to be sure? Ask them, “Are you all right?” If they can answer at all—they probably are. If they return a blank stare, you may have less than 30 seconds to get to them. And parents—children playing in the water make noise. When they get quiet, you get to them and find out why.
Keywords: Postoperative, fever, cause (PubMed Search)
Post Operative Fever is extremely common, and with the increase in same day surgery this is a common complaint presenting to the ED. The mnemonic "5Ws" are often taught to remember the causes. They are:
Though many surgical textbooks report that atelectasis is the most common cause of early post-operative fever, some even claiming that it is responsible for over 90% of febrile episodes in the first 48 hours after surgery; a recent review in CHEST (reference below) showed that there is no evidence to support this. We often see atelectasis in medical patients too, and few if any of them have fever. The CHEST review found that there was no clear evidence that atelectasis causes fever at all.
Pearl: Temperature >38.9C should raise concern for a true infection, where lower temperatures can be due to pulmonary embolism, DVT, drug fever, etc….
Mavros MN, Velmahos GC, Falagas ME.Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest. 2011 Aug;140(2):418-24. doi: 10.1378/chest.11-0127. Epub 2011 Apr 28. Review. PMID: 21527508
Keywords: Frostbite (PubMed Search)
Keywords: CSF, lactate (PubMed Search)
Lactate levels help to confirm septic arthritis but what about bacterial meningitis. As reported in the daily electronic ACEP newsletter a small study of 45 patients showed that all patients with a confirmed diagnosis of bacterial meningitis had a CSF lactate level > 3.5 mmol/L. Therefore, it might be true that viral meningitis will only have CSF lactate levels < 3.5 mmol/L.
With only 45 patients, this finding is clearly not ready for Prime Time but consider adding it to your next CSF study so more data can be collected on the utility of this test.
The story as seen in ACEP eNews on September 14th, 2012 is:
MedPage Today (9/14, Gever) reports, "Cerebrospinal fluid (CSF) levels of lactate were a perfect marker of viral versus bacterial meningitis in a small study, a researcher reported" at the Interscience Conference on Antimicrobial Agents and Chemotherapy. Researchers found that, "among 45 adults in whom the etiology of meningitis was microbiologically confirmed, all those with CSF lactate levels above 3.5 mmol/L had the bacterial form, whereas every patient with lower levels had viral meningitis."
Keywords: jet lag, sleep, athletic performance (PubMed Search)
Apologies for the long pearl, I did not want to split this into 3 parts)
Disruptions in sleep and circadian rhythms (from travel across time zones and jet lag) are known to alter cognitive functions. Mood and complex mental performance tasks deteriorate faster than do simpler mental performance tasks.
An athlete’s circadian rhythms are believed to be optimal for performance in the early evening (reaction time to light and sound in the fastest). Interestingly, the evening is the time of day when most world records have been broken. However, activities that require fine motor control and accuracy (hand steadiness and balance) are best in the morning.
In the normal population, travel effects are seen in inattention and an increase in errors and injuries in the workplace.
Athletes who perform in international competitions immediately after time zone transitions demonstrate a decline in performance involving complex mental activities, with an associated feeling of lethargy and a general loss of motivation.
British Olympic athletes demonstrated a decrease in leg and back strength in addition to reaction time when traveling westward across 4 time zones. In the NFL, west coast teams consistently beat east coast teams in evening games.
Of course, this type of outcome data is multifactorial and travel effects likely are only one of many complex factors.
Full adaptation to the new time zone is NOT recommended for short trips (1 – 2 days), only for longer stays (> 3 days).
Preadaptation and bright light therapy: Remember that exposure to light is the primary cue for circadian rhythms. Bright light exposure in the mornings (after eastward travel) will advance the body clock, while exposure in the evenings (after westward travel) will delay it (Level B).
Shifting the sleep schedule 1 - 2 hours towards the destination time zone in the days preceding departure may shorten the duration of jet lag (Level B).
Strategic napping: Napping in the new time zone during typical sleep times in the destination time zone will delay adaptation. Power naps (20 minutes) may be helpful in decreasing daytime sleepiness in those with jet lag (Level B). The best time to nap (in flight or post flight) is nighttime in the destination time zone (Level B).
Melatonin: Cochrane review concludes that it is safe and effective in both treating and preventing jet lag. It is recommended for adults traveling across 5 or more times zones; and may be effective for travel across 2 to 4 time zones. Take melatonin in the morning when traveling westward, and at the local bedtime when traveling eastward (Level B). Doses of 0.5 to 5mg were similarly effective. Melatonin taken in the evening and at higher doses are effective at inducing sleep (Level A).
Sleep aids: Hypnotic sleep aids reliably induce insomnia secondary to jet lag. Benzodiazepines improve sleep quality but may cause a “hangover” effect the next day, possibly impairing performance.
Ambien (zolpidem) and Lunesta (zopiclone) can be effective while limiting the hangover effect especially in those who have previosly tolerated the medication (Level A). Zolpidem may be more effective than melatonin and placebo at countering jet lag symptoms. Note: the use of both medicines together was not more effective than zolpidem alone but did cause daytime somnolence.
Stimulants: Care should be used in the athlete as most of these medications are banned in competition. There is a potential off label use for Provigil (modafinil) for improving daytime sleepiness associated with jet lag (currently approved for narcolepsy).
Caffeine, while not banned for the World Anti-Doping Agency, is a monitored substance. It increases daytime alertness and may accelerate entrainment in new time zones when consumed in the morning (later ingestion may interfere with sleep induction) (Level A).
Aaron Lee and Juan Carlos Galvez. Jet lag in athletes.Sports Health. 2012,211 - 216.
Keywords: Travel, jet lag, circadian (PubMed Search)
Travel across time zones is regularly required of profession and collegiate athletes (in addition to the some of us professionally)
Jet lag is defined as insomnia or excessive daytime sleepiness/malaise following travel across at least 2 time zones
Symptoms usually persist 1 day for each time zone crossed
The sleep schedule is primarily modulated by light and melatonin
Secretion of melatonin helps induce sleep
Exposure to light stimulates arousal and inhibits melatonin secretion
Who is at risk?
Those with more rigid sleep habits have more symptoms
“Morning” people have less difficulty flying eastward
“Evening” people have less difficulty flying west
However, overall, eastward travel causes the most severe symptoms which persist for up to 7 days (versus <3 days with westward travel)
(The length of the day gets shortened and the circadian system must shorten to reestablish a normal rhythm. The human body demonstrates a natural tendency toward periods longer than 24 hours)
Those with higher levels of physical fitness adjust more quickly
Effects similar in men and women
Midday arrivals experience fewer symptoms than morning arrivals
Symptoms are less in those who have traveled the journey previously
Symptoms are less in those who had a shorter interval their last full nocturnal sleep in the departure city and their first full nocturnal sleep in the destination city
Keywords: contrast media, iodine, shellfish (PubMed Search)
Many patients will report that they have a allergy to iodinated contrast by saying that they are allergic to iodine
Iodine, itself, is not an allergen and is a required element for thyroid homrone production. Plus could you imagine the hordes of people that would be having allergic reactions everyday when they add salt to their french fries. Our EDs would be completely swamped.
A recent meta-analysis by Drs. Schabelman and Witting also showed the following:
As we enter Crab eating season in Maryland, lets stop giving shellfish a bad name. A patent with any allergy is at increased risk, but shellfish is no higher a risk than those allergic to Strawberries.
Schabelman E, Witting M. The relationship of radiocontrast, iodine, and seafood allergies: a medical myth exposed.J Emerg Med. 2010 Nov;39(5):701-7. Epub 2010 Jan 4.
Keywords: Triage, Mass Causality (PubMed Search)
START triage is a simple system to implement that does not require any special equipment in order to determine who needs immediate, delayed or non-urgent care during a mass causality.
START stands for Simple Triage And Rapid Treatment. Patients are triaged based on 4 factors:
The steps are:
So those that can leave are green, those that do not meet any of the START criteria are YELLOW, and those with any of the four factors are RED or DEAD.
Weird and Unusual Symptoms
Bet you didn't know that severe and intense pruritus of the nostrils, known as Wartenberg's symptom, is an uncommon but characteristic symptom of a brain tumor.
Etiologies include astrocytoma, glioblastoma, oligodendroglioma, medulloblastoma, and metastatic tumors.
1. Andreev VC, Petkov. Skin manifestations associated with tumors of the brain. Br J Dermatol 1975;92:675
2. Mark Marinella, Pocket Brain of 50 Unusual Symptoms. Blackwell Publishing
Keywords: Wound, Repair (PubMed Search)
A pearl last year addressed the irrigation of wound and the fact that the type of fluid (sterile versus tap water) does not affect infection rates but rather the volume of irrigation is most important.
Sterile versus unsterile gloves have also been studied, and it turns out that clean unsterile gloves have the same rate of infection as sterile gloves but come with a substantial cost savings.
When caring for a contaminated wound it is most important to remove any gross contamination, and then irrigate the wound as much as possible. A 20 mL syringe with an 18G angio-catheter provides the proper pressure to remove debris without causing tissue damage. The wound can then be closed wearing the gloves that are most comfortable or accessible to you.
Finally, from a medicolegal standpoint it is always best to inform the patient that you have tried to remove all of the contamination but there is still a chance that the wound can get infected.
Keywords: Epinephrine (PubMed Search)
Dose of Epinephrine for Patients with Anaphylaxis
Many of us are familiar with 0.3-0.5 mg IM of 1:1,000. Important to give IM and not SC.
In severe cases, consider IV Epinephrine:
Corey Slovis, Vanderbilt University
Hans House, University of Iowa Emergency Medicine Residency,
USC Essentials Course 2010 (Mel Herbert and USC Faculty)
Keywords: Pneumoperitoneum, CXR, CT (PubMed Search)
Submitted on behalf of Dr. Michael Abraham
1. Spencer CA, Takeuchi M, Kazarosyan M. Current status and performance goals for serum thyrotropin (TSH) assays. Clin Chem. Jan 1996;42(1):140-145.
2. Liebert M. Thyrotropin/Thyroid Stimulating Hormone (TSH) Measurement. Http://www.medscape.com/
Keywords: Billing, Critical Care (PubMed Search)
Critical Care billing is time dependent and includes all time spent caring for and coordinating (i.e.: reviewing records, talking to consultants or family) the care of the patient except for the time spent doing separately billable procedures (i.e. central line, CPR, etc). The following procedures taken from the ACEP website are included in the Critical Care code so the time spent doing these procedures should BE included in your total Critical Care time .
They are :
ACADEMIC MEDICINE CAVEAT: For the reporting of time-based services, such as critical care or moderate sedation, the teaching physician must be directly present during the entire reported time period.
ACEP Coding and Reimburshment Website http://www.acep.org/practres.aspx?LinkIdentifier=id&id=33484&fid=910&Mo=No&taxid=117956#critcare