A rare anaphylactic reaction to sparkling water
Anaphylaxis is a potentially life-threatening, type I hypersensitivity reaction which can occur within seconds to minutes after exposure to an allergen. Sulfites have been implicated in causing such reactions with symptoms ranging from mild to potentially life-threatening. Published in The American Journal of Emergency Medicine, the authors present a case of a patient who had an anaphylactic reaction secondary to exposure to sulfites found in sparkling water.

A 25-year-old female with a past medical history of asthma and anaphylactic reactions to multiple medications, including sulfa antibiotics, presented with a facial rash, generalized pruritus, swelling of the tongue, difficulty swallowing and shortness of breath shortly after drinking sparkling water. She was initially given diphenhydramine, ranitidine and methylprednisolone at an urgent care center and was transferred to the emergency department (ED) for incomplete resolution of her symptoms.

She was given epinephrine and intravenous fluids in ED. She was admitted to the ICU and given intravenous methylprednisolone, famotidine, diphenhydramine and albuterol nebulizers with subsequent symptomatic improvement. At one point during hospitalization, she was re-challenged with the same sparkling water, which precipitated an additional anaphylactic reaction.

These reactions could not be explained by any new medications. Given her significant allergy history as well as familial allergy history, a C1 esterase inhibitor and complement levels were tested and were ultimately found to be normal.

Learning points
• Sulfiting agents (sulfur dioxide and the sodium and potassium salts of bisulfites, sulfite, and metabisulfites) are widely used, mainly for its inherent cleaning and disinfecting properties. It also has a use as a preservative in food, alcoholic beverages such as beer and wine, and medications. In the food industry, sulfites are used to prevent the growth of bacteria, maintain the color of the food, and allow for a longer shelf life.

• Allergies to sulfur are common, but mainly appear when the patient takes certain medications that contain sulfur. However, “sulfa allergies” are a response to sulfonamides, which is a different molecule than the sulfites. While the allergies to sulfa containing drugs are usually easy to diagnose, determining other sensitivities are often not. Patients can develop sensitivities to seemingly anything.

• This makes it easy to see how it can be challenging to determine the specific culprit for a reaction from the patient. Actually making a diagnosis of sensitivity to a specific entity requires a provocative challenge.

• Something as small and minor as sulfite can be easily overlooked in the search for the cause of an adverse reaction

Know more here: https://www.ajemjournal.com/article/S0735-6757(17)30824-0/fulltext
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