The etiology, risk factors, and clinical features of anaphylaxis: The single-center retrospective cohort study of the tertiary university hospital

The etiology, risk factors, and clinical features of anaphylaxis



etiology, frequency, anaphylaxis, hypersensitivity reactions


Background/Aim: Anaphylaxis presents in multiple ways, making its diagnosis challenging. Delayed diagnosis can lead to a postponement in administering crucial adrenaline treatment. The prevalence of anaphylaxis varies by geographical region and gender. However, there has been no comprehensive regional analysis of anaphylaxis data within our country. Despite an increasing incidence, our understanding of anaphylaxis etiology, risk factors, and clinical features remains limited, particularly within our nation. This study aims to assess the frequency, etiology, risk factors, and clinical findings of anaphylaxis among patients seen at the allergy clinic of a tertiary university hospital. Additionally, it seeks to compare regional data with existing literature.

Methods: This retrospective cohort study reviewed the medical records of 8,295 patients who visited the allergy outpatient clinic at Sivas Cumhuriyet University Hospital between July 2, 2018, and December 10, 2019. The hospital’s data system retrospectively analyzed records using the ICD code T78.2 (anaphylaxis). Only cases where patients were prescribed an adrenaline auto-injector were included. The study evaluated anaphylaxis frequency, etiologies, demographics, and clinical features.

Results: The study identified 77 patients (n=77) with a mean age of 40.29 (3.77) years, consisting of 47 females and 30 males. The frequency of anaphylaxis among allergy outpatient admissions was less than 1% (0.009%). Single-type atopic diseases included venom allergy (23%), drug allergy (14%), inhalant allergens (n=6), food allergens (n=4), and skin allergic diseases (n=3). Multiple allergic diseases were present in 40% (n=31) of cases. Prick tests were performed on 56 (72%) patients, with 25 (44%) yielding negative results. Among positive prick test cases, venom was the main cause of anaphylaxis (82%), while drug allergy was more prevalent (68.2%) among negative test results (P=0.016). Inhalant allergen sensitivity and allergen polisensitivity did not significantly influence the anaphylaxis cause (P<0.001). Causes of anaphylaxis included drug allergy (47%), venom allergy (31%), food allergens (16%), food-dependent exercise-induced reactions (n=2), idiopathic cases (n=2), and cold urticaria (n=1). Non-steroidal anti-inflammatory drugs (NSAIDs) (44%) and beta-lactams (10%) were the primary culprits. In cases where neither drugs nor venom were involved, food allergies were the cause (P<0.001). With venom allergy, the cause was venom, and without venom, drug allergy was the cause (P<0.001). Female patients showed significantly higher drug- and food-related anaphylaxis rates than males (P=0.032 and P=0.042, respectively). History of Apis mellifera-related anaphylaxis was significantly more common than Vespula vulgaris-related cases (P=0.028). Anaphylaxis severity included grade 2 (30%), grade 3 (48%), and grade 4 (12%) reactions. Recurrent anaphylaxis episodes occurred in 55% (n=42) of patients. Initial hospital administrations involved epinephrine injections in only 25% (n=19) of cases. Cutaneous symptoms were present in 94%, respiratory symptoms in 88%, cardiovascular symptoms in 63%, neurological symptoms in 57%, and gastrointestinal symptoms in 12% of patients.

Conclusion: This study identified drug allergy as the leading cause of anaphylaxis in the examined cases. Preventable factors contributing to drug-induced anaphylaxis included insufficient patient and physician knowledge and widespread over-the-counter drug use without medical consultation. Despite 55% of patients experiencing recurrent attacks, only a quarter received epinephrine administration. These findings emphasize the need to educate patients with recurrent anaphylaxis about avoidance strategies and to enhance healthcare providers’ understanding of anaphylaxis treatment.


Download data is not yet available.


Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006 Feb;117(2):391-7. doi: 10.1016/j.jaci.2005.12.1303. DOI:

Muraro A, Worm M, Alviani C, Cardona V, Dunn Galvin A, Garvey LH, et al. European Academy of Allergy and Clinical Immunology, Food Allergy, Anaphylaxis Guidelines Group. EAACI guidelines: Anaphylaxis (2021 update). Allergy. 2022 Feb;77(2):357-77. doi: 10.1111/all.15032. DOI:

Vezir E, Erkoçoğlu M, Kaya A, Toyran M, Özcan C, Akan A, et al. Characteristics of anaphylaxis in children referred to a tertiary care center. Allergy Asthma Proc. 2013 May-Jun;34(3):239-46. doi: 10.2500/aap.2013.34.3654. DOI:

Erkoçoğlu M, Civelek E, Azkur D, Özcan C, Öztürk K, Kaya A, et al. Knowledge and attitudes of primary care physicians regarding food allergy and anaphylaxis in Turkey. Allergol Immunopathol (Madr). 2013 Sep-Oct;41(5):292-7. doi: 10.1016/j.aller.2012.05.004. DOI:

Gaspar Â, Santos N, Piedade S, Santa-Marta C, Pires G, Sampaio G, et al. One-year survey of pediatric anaphylaxis in an allergy department. Eur Ann Allergy Clin Immunol. 2015 Nov;47(6):197-205. Erratum in: Eur Ann Allergy Clin Immunol. 2016 Jan;48(1):31.

Hoyos-Bachiloglu R, Ivanovic-Zuvic D, Álvarez J, Linn K, Thöne N, de los Ángeles Paul M, et al. Prevalence of parent-reported immediate hypersensitivity food allergy in Chilean school-aged children. Allergol Immunopathol (Madr). 2014 Nov-Dec;42(6):527-32. doi: 10.1016/j.aller.2013.09.006. DOI:

Simons FE, Peterson S, Black CD. Epinephrine dispensing patterns for an out-of-hospital population: a novel approach to studying the epidemiology of anaphylaxis. J Allergy Clin Immunol. 2002 Oct;110(4):647-51. doi: 10.1067/mai.2002.127860. DOI:

Mueller HL. Diagnosis and treatment of insect sensitivity. J Asthma Res. 1966 Jun;3(4):331-3. doi: 10.3109/02770906609106941. DOI:

Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011 Feb;4(2):13-37. doi: 10.1097/WOX.0b013e318211496c. DOI:

Ye YM, Kim MK, Kang HR, Kim TB, Sohn SW, Koh YI, et al. KAAACI Work Group on Urticaria/Angioedema/Anaphylaxis. Predictors of the severity and serious outcomes of anaphylaxis in Korean adults: a multicenter retrospective case study. Allergy Asthma Immunol Res. 2015 Jan;7(1):22-9. doi: 10.4168/aair.2015.7.1.22. DOI:

Russell S, Monroe K, Losek JD. Anaphylaxis management in the pediatric emergency department: opportunities for improvement. Pediatr Emerg Care. 2010 Feb;26(2):71-6. doi: 10.1097/PEC.0b013e3181ce2e1c. DOI:

Civelek E, Erkoçoğlu M, Akan A, Özcan C, Kaya A, Vezir E, et al. The Etiology and Clinical Features of Anaphylaxis in a developing country: A nationwide survey in Turkey. Asian Pac J Allergy Immunol. 2017 Dec;35(4):212-9. doi: 10.12932/AP0752. DOI:

Alvarez-Perea A, Tomás-Pérez M, Martínez-Lezcano P, Marco G, Pérez D, Zubeldia JM, et al. Anaphylaxis in Adolescent/Adult Patients Treated in the Emergency Department: Differences Between Initial Impressions and the Definitive Diagnosis. J Investig Allergol Clin Immunol. 2015;25(4):288-94.

Yang MS, Lee SH, Kim TW, Kwon JW, Lee SM, Kim SH, et al. Epidemiologic and clinical features of anaphylaxis in Korea. Ann Allergy Asthma Immunol. 2008 Jan;100(1):31-6. doi: 10.1016/S1081-1206(10)60401-2. DOI:

Khan NU, Shakeel N, Makda A, Mallick AS, Ali Memon M, Hashmi SH, et al. Anaphylaxis: incidence, presentation, causes, and Outcome in patients in a tertiary-care hospital in Karachi, Pakistan. QJM. 2013 Dec;106(12):1095-101. doi: 10.1093/qjmed/hct179. DOI:

Tang R, Xu HY, Cao J, Chen S, Sun JL, Hu H, et al. Clinical Characteristics of Inpatients with Anaphylaxis in China. Biomed Res Int. 2015;2015:429534. doi: 10.1155/2015/429534. DOI:

Bilò BM, Bonifazi F. Epidemiology of insect-venom anaphylaxis. Curr Opin Allergy Clin Immunol. 2008 Aug;8(4):330-7. doi: 10.1097/ACI.0b013e32830638c5. DOI:

Orhan F, Canitez Y, Bakirtas A, Yilmaz O, Boz AB, Can D, et al. Anaphylaxis in Turkish children: a multi-center, retrospective, case study. Clin Exp Allergy. 2011 Dec;41(12):1767-76. doi: 10.1111/j.1365-2222.2011.03859.x. DOI:

Jacobs TS, Greenhawt MJ, Hauswirth D, Mitchell L, Green TD. A survey study of index food-related allergic reactions and anaphylaxis management. Pediatr Allergy Immunol. 2012 Sep;23(6):582-9. doi: 10.1111/j.1399-3038.2012.01315.x. DOI:

Lee AJ, Gerez I, Shek LP, Lee BW. Shellfish allergy--an Asia-Pacific perspective. Asian Pac J Allergy Immunol. 2012 Mar;30(1):3-10.

Chen W, Mempel M, Schober W, Behrendt H, Ring J. Gender difference, sex hormones, and immediate type hypersensitivity reactions. Allergy. 2008 Nov;63(11):1418-27. doi: 10.1111/j.1398-9995.2008.01880.x. DOI:

Greenberger PA. Fatal and near-fatal anaphylaxis: factors that can worsen or contribute to fatal outcomes. Immunol Allergy Clin North Am. 2015 May;35(2):375-86. doi: 10.1016/j.iac.2015.01.001. DOI:

Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol. 2009 Feb;123(2):434-42. doi: 10.1016/j.jaci.2008.10.049. DOI:

Pumphrey RS. Fatal anaphylaxis in the UK, 1992-2001. Novartis Found Symp. 2004;257:116-28; discussion 128-32, 157-60, 276-85. DOI:

Tole JW, Lieberman P. Biphasic anaphylaxis: review of incidence, clinical predictors, and observation recommendations. Immunol Allergy Clin North Am. 2007 May;27(2):309-26, viii. doi: 10.1016/j.iac.2007.03.011. DOI:

Rudders SA, Banerji A, Corel B, Clark S, Camargo CA Jr. Multicenter study of repeat epinephrine treatments for food-related anaphylaxis. Pediatrics. 2010 Apr;125(4):e711-8. doi: 10.1542/peds.2009-2832. DOI:

Campbell RL, Luke A, Weaver AL, St Sauver JL, Bergstralh EJ, Li JT, et al. Prescriptions for self-injectable epinephrine and follow-up referral in emergency department patients presenting with anaphylaxis. Ann Allergy Asthma Immunol. 2008 Dec;101(6):631-6. doi: 10.1016/S1081-1206(10)60227-X. DOI:

Valent P, Akin C, Arock M, Brockow K, Butterfield JH, Carter MC, et al. Definitions, criteria and global classification of mast cell disorders with special reference to mast cell activation syndromes: a consensus proposal. Int Arch Allergy Immunol. 2012;157(3):215-25. doi: 10.1159/000328760. DOI:

Brockow K, Jofer C, Behrendt H, Ring J. Anaphylaxis in patients with mastocytosis: a study on history, clinical features, and risk factors in 120 patients. Allergy. 2008;63(2):226-32. doi: 10.1111/j.1398-9995.2007.01569.x. DOI:

Lyons JJ, Yu X, Hughes JD, Le QT, Jamil A, Bai Y, et al. Elevated basal serum tryptase identifies a multisystem disorder associated with increased TPSAB1 copy number. Nat Genet. 2016 Dec;48(12):1564-9. doi: 10.1038/ng.3696. DOI:

Lyons JJ, Chovanec J, O’Connell MP, Liu Y, Šelb J, Zanotti R, et al. Heritable risk for severe anaphylaxis associated with increased α-tryptase-encoding germline copy number at TPSAB1. J Allergy Clin Immunol. 2021 Feb;147(2):622-32. doi: 10.1016/j.jaci.2020.06.035. DOI:

Neugut AI, Ghatak AT, Miller RL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. 2001 January 8;161(1):15-21. doi: 10.1001/archinte.161.1.15. DOI:






Research Article

How to Cite

Tunakan Dalgıç C. The etiology, risk factors, and clinical features of anaphylaxis: The single-center retrospective cohort study of the tertiary university hospital: The etiology, risk factors, and clinical features of anaphylaxis. J Surg Med [Internet]. 2023 Aug. 25 [cited 2024 Jun. 22];7(8):491-7. Available from: