Causes of anaphylaxis

Allergens (IgE-dependent immunologic mechanism)

Foods, especially peanut, tree nut, crustacean shellfish, finned fish, cow's milk, hen's egg

Insect stings (eg, Hymenoptera venom) and insect bites (eg, kissing bugs)

Medications (eg, antibiotics, NSAIDs)

Biologic materials, including allergen immunotherapy, monoclonal antibodies, chemotherapy agents, and vaccines*

Natural rubber latex

Food additives, including spices, insect-derived colorants (eg, carmine), and vegetable gums

Inhalants (rare; eg, horse dander, cat dander, grass pollen)

Human seminal fluid (rare trigger of anaphylaxis in women)

Occupational allergens (eg, stinging insects, natural rubber latex)

Immunologic triggers (IgE-independent mechanism)

IgG dependent (rare; eg, to high-molecular-weight dextran, infliximab)

Coagulation system activation (eg, heparin contaminated with oversulfated chondroitin sulfate)

Idiopathic anaphylaxis

Consider the possibility of a hidden or previously unrecognized trigger

Consider the possibility of a mast cell activation syndrome, including systemic mastocytosis

Nonimmunologic triggers (direct activation of mast cells and basophils)

Physical factors (eg, exercise^¶, cold, heat)

Medications (eg, opioids, NSAIDs)

Radiocontrast agents

Alcohol (ethanol; may augment, rarely induces)

Any food, insect sting or bite, or medication or biologic can potentially trigger anaphylaxis. Novel or unusual allergen triggers include storage mite-contaminated flour and saliva from kissing bugs. They also include mosquitoes, pigeon ticks, green ants, and pharaoh ants and venoms from jellyfish, scorpions, and snakes. Medications include taxanes, platins, and other chemotherapy drugs, biologic agents, including monoclonal antibodies, such as rituximab, cetuximab, infliximab, and, uncommonly, omalizumab. Some triggers, such as radiocontrast media, insect venoms, and medications (such as NSAIDs) can act through more than one mechanism.

IgE: immunoglobulin E; NSAID: nonsteroidal antiinflammatory drug; IgG: immunoglobulin G.
* Reactions to vaccines are rare and typically involve an excipient, such as gelatin, rather than microbial content.
¶ Often involves a cofactor, such as a food, medication (eg, an NSAID), or exposure to cold air or water.

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Causes of anaphylaxis