What is the management for an anaphylactic reaction to cheese?

Management of Anaphylactic Reaction to Cheese

Administer intramuscular epinephrine immediately as first-line treatment (0.3 mg for adults >25 kg, 0.15 mg for children 10-25 kg in the anterolateral thigh), call 911, and position the patient recumbent with legs elevated—all other treatments are adjunctive and should never delay epinephrine. 1

Immediate Acute Management

First-Line Treatment (Do These Simultaneously)

• Eliminate further allergen exposure by removing any remaining cheese from the patient's environment 1
• Give intramuscular epinephrine immediately using either auto-injector or 1:1,000 solution at 0.01 mg/kg (maximum 0.5 mg per dose) in the anterolateral thigh 1, 2
• Call for emergency help (911 or equivalent) immediately after epinephrine administration—do not delay epinephrine to summon help 1
• Position patient recumbent with lower extremities elevated if tolerated 1

Critical Timing Considerations

• Repeat epinephrine every 5-15 minutes if symptoms persist or progress—repeated epinephrine remains first-line over any adjunctive treatment 1
• The more rapidly anaphylaxis develops, the more likely it is to be severe and life-threatening 1
• Most severe food reactions occur within 30 minutes to 2 hours of exposure 3

Adjunctive Treatments (Only After Epinephrine)

• Supplemental oxygen should be provided 1
• IV fluid resuscitation with large volumes for orthostasis, hypotension, or incomplete response to epinephrine 1
• H1-antihistamine (diphenhydramine): 1-2 mg/kg (maximum 50 mg) IV or oral—oral liquid absorbs faster than tablets 1
• Bronchodilator (albuterol): 4-8 puffs via MDI for children, 8 puffs for adults, or nebulized solution every 20 minutes as needed 1

Critical pitfall: Antihistamines are the most common reason for not using epinephrine and significantly increase risk of progression to life-threatening reaction—they cannot reverse anaphylaxis and delay in epinephrine increases mortality 1, 3, 4

Observation Period

• Observe for minimum 4-6 hours after treatment in an emergency facility 1, 4
• Biphasic reactions occur in 1-20% of cases and can develop up to 72 hours after initial resolution, requiring extended observation for high-risk patients 3, 4
• Risk factors warranting longer observation include: severe initial reaction, delayed epinephrine administration, history of biphasic reactions, or need for multiple epinephrine doses 1

Discharge Management

Prescriptions and Equipment

• Provide two epinephrine auto-injectors with prescription and hands-on training before discharge 1, 4
• Instruct patient to check expiration dates routinely 1
• Prescribe post-discharge medications for 2-3 days: 1
  • H1-antihistamine (diphenhydramine every 6 hours or non-sedating alternative)
  • H2-antihistamine (ranitidine twice daily)
  • Corticosteroid (prednisone daily)

Patient Education Requirements

• At first sign of symptom recurrence, self-administer epinephrine immediately, then call 911 1
• Patients are at risk for repeat episodes in the future 1
• Provide written anaphylaxis emergency action plan 1, 4
• Recommend medical identification jewelry or wallet card 1

Allergen Identification and Follow-Up

Immediate Diagnostic Steps

• Identify the specific trigger through detailed history before discharge—in this case, determine if reaction was to cow's milk protein, sheep's milk, goat's milk, or other cheese components 1
• Note that sheep's milk cheese can cause severe reactions even in patients without cow's milk allergy, as cross-reactivity is unpredictable 5

Specialty Referral

• Refer to allergist-immunologist for comprehensive evaluation within days to weeks of the reaction 1, 4
• Allergist will perform skin prick testing and serum-specific IgE testing to identify specific milk proteins and cross-reactivities 3, 4
• Supervised oral food challenges may be necessary in controlled medical settings to confirm specific triggers and assess tolerance to related foods 3, 4

Avoidance Strategy

• Strict elimination of confirmed allergens is the cornerstone of long-term management 3
• Provide education on reading food labels and identifying hidden sources of milk proteins in processed foods 3
• Do not implement broad dietary restrictions without objective confirmation through testing 3

Special Considerations for Cheese Allergy

• Cheese contains concentrated milk proteins that may trigger reactions even in patients who tolerate fresh milk 5
• Cross-reactivity between cow's milk, sheep's milk, and goat's milk is variable and unpredictable—each requires individual testing 5
• Peanuts and tree nuts cause the majority of food anaphylaxis fatalities, but milk proteins are among the most common triggers in children 1, 6

Absolute Contraindications

There are no absolute contraindications to epinephrine use in anaphylaxis—the risk of death from anaphylaxis outweighs any theoretical adverse effects from epinephrine 1