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Scenario 1: A 16-year-old boy comes to clinic with chief complaint of sore throat for 3 days. Denies fever or chills. PMH negative for recurrent colds, influenza, ear infections or pneumonias. NKDA or food allergies. Physical exam reveals temp of 99.6 F, pulse 78 and regular with respirations of 18. HEENT normal with exception of reddened posterior pharynx with white exudate on tonsils that are enlarged to 3+. Positive anterior and posterior cervical adenopathy. Rapid strep test performed in office was positive. His HCP wrote a prescription for amoxicillin 500 mg po q 12 hours x 10 days disp #20. He took the first capsule when he got home and immediately complained of swelling of his tongue and lips, difficulty breathing with audible wheezing. 911 was called and he was taken to the hospital, where he received emergency treatment for his allergic reaction.

                                                        Anaphylaxis as an Immune Response

An allergic reaction occurs when an external stimuli causes an inflammatory response in the body (McCance & Huether, 2019). In fact, allergies are the most common type of hypersensitivity reaction (McCance & Huether, 2019). In this case study, the patient is experiencing an anaphylactic reaction which is the most severe type of allergic reaction (Justiz-Vaillant & Zito, 2019). An anaphylactic reaction is the result of a massive histamine release in response to a stimulant that causes inflammation and may result in bronchospasm, laryngeal edema, hypotension, and if left untreated can result in shock (Justiz-Vaillant & Zito, 2019). This explains the patient’s symptoms of swelling, dyspnea, and wheezing.

There is a plethora of evidence showing that allergies are genetic in nature. When one parent possesses an allergy, the offspring are 40% more likely to develop the same allergy, while families in which both parents have the allergy increases the risk to 80% (McCance & Huether, 2019). Individuals with a genetic predisposition to a certain allergy are referred to as atopic (McCance & Huether, 2019). Atopic patients possess higher IgE levels and receptors on their mast cells which increases their risk for allergic reactions (McCance & Huether, 2019). In addition, atopic patients’ airways and skin are more reactive to external stimulants which may increase their risk of an anaphylactic reaction (McCance & Huether, 2019).

When the body encounters an allergen, the immune system produces IgE antibodies (Justiz-Vaillant & Zito, 2019). These antibodies bind to mast cells and basophils which contain histamine granules (Justiz-Vaillant & Zito, 2019). As this binding occurs, the cells release large amounts of histamine which leads to an inflammatory response in the body. Penicillin derivatives, such as the amoxicillin in this case study, may be subject to the processes of sensitization (McCance & Huether, 2019). Sensitization occurs when the immune system is introduced to trace amounts of the stimulant until there are enough antibodies to elicit a full-blown allergic reaction (McCance & Huether, 2019). Penicillin is found in trace amounts in some dairy products so this patient may have experienced some sensitization leading up to the anaphylactic reaction at age sixteen. 

The penicillin drug group is one of the largest drug allergy groups. Studies have shown that women are more likely to have a penicillin group reaction than men (Healio, 2019). In a study of more than 30,000 patients who underwent skin testing after taking penicillin, women were found to be four times more likely to develop an allergic reaction to the drug (Healio, 2019). Of the group, only1% of patients had a drug reaction at all (Healio, 2019). The patient in this case study defied the odds by being in the minority of patients to develop a drug allergy to a penicillin derivative. In addition, taking the genetic nature of allergies into consideration, it may be beneficial to evaluate the patient’s family history of penicillin allergy before prescribing amoxicillin for strep throat.