What is the appropriate treatment for an anaphylactic reaction to a bee sting in an 8-year-old female with Crohn’s disease on Remicade (Infliximab)?

Management of Anaphylactic Reaction to Bee Sting in a Child with Crohn's Disease on Remicade

Epinephrine (intramuscular) must be administered immediately as the first-line treatment for this child's anaphylactic reaction, and the addition of Decadron (dexamethasone) and antihistamines should never delay or substitute for this primary management. 1

Immediate Management

1. First-line treatment:

   • Administer epinephrine intramuscularly into the anterolateral thigh
   • Weight-based dosing is appropriate for pediatric patients 2
   • Do not delay administration while waiting for additional medications

2. Supplemental treatments:

   • After epinephrine administration, Decadron (dexamethasone) and antihistamines can be given as adjunctive therapy
   • These medications should not replace epinephrine or delay its administration
   • While high-certainty evidence is lacking regarding the benefit of glucocorticoids and antihistamines as supplemental therapies, they are commonly used 1

Considerations for This Patient

• The patient's history of Crohn's disease and recent Remicade (infliximab) administration does not contraindicate the use of epinephrine, glucocorticoids, or antihistamines for anaphylaxis management
• The fact that she just received Remicade is important to note but does not change the immediate management of anaphylaxis from a bee sting
• Pediatric patients generally respond to anaphylaxis treatment similarly to adults, with similar adverse reaction profiles 2

Monitoring and Follow-up

• Monitor the patient closely for at least 4-6 hours after symptom resolution
• Be alert for potential biphasic reactions, especially since this patient had a severe anaphylactic reaction requiring treatment 1
• Risk factors for biphasic reactions include severe initial anaphylaxis and/or need for >1 dose of epinephrine 1

Important Caveats

• Antihistamines alone are insufficient for treating anaphylaxis as they:

  • Do not relieve all pathophysiological symptoms, particularly serious complications like airway obstruction and hypotension 3
  • Have a delayed onset of action (1-3 hours) compared to epinephrine (<10 minutes) 3

• Patients with a history of systemic reactions to insect stings should:

  • Be prescribed self-injectable epinephrine for future use
  • Be educated on insect avoidance measures
  • Be referred to an allergist-immunologist for evaluation 4

• There is no evidence that the patient's Crohn's disease or Remicade treatment should alter the standard approach to anaphylaxis management

  • While infliximab can itself cause anaphylactic reactions 5, 6, this case involves a reaction to a bee sting, not to the medication

In summary, this child should receive prompt epinephrine as first-line treatment, followed by Decadron and antihistamines as adjunctive therapy. Her Crohn's disease and Remicade treatment do not contraindicate this standard approach to anaphylaxis management.