Is unrecognized anaphylaxis a cause of sudden unexpected death?

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Abstract
Summary: Background: Serum tryptase levels reflect mast cell activation and correlate with anaphylactic reactions. Elevated post‐mortem serum tryptase levels have been found in witnessed fatal anaphylaxis.Objective: This study was designed to examine whether or not unwitnessed anaphylaxis may be a hitherto unrecognized cause of sudden unexplained death.Methods: Mast cell tryptase was measured by immunoassay in 68 post‐mortem sera remaining from a previous study which reported elevated venom‐specific IgE antibodies in 22 (23%) of 94 victims of sudden unexpected death. Autopsies were performed in all cases. The cause of death was independently reported by pathologists unfamiliar with the nature of this study.Results: Serum tryptase levels were elevated (> 10ng/mL) in nine of 68 cases. The levels could not be predicted from the clinical circumstances surrounding death. Sera from four individuals contained both elevated tryptase and previously reported elevated venom‐specific IgE.Conlusions: We conclude that mast cell activation may accompany up to 13% of sudden unexpected deaths in adults. Measurement of both tryptase and specific IgE antibody levels in post‐mortem sera from persons experiencing sudden, unexpected death may identify a small subset of cases due to clinically unrecognized fatal anaphylaxis, including those due to insect stings.

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