Severe allergies without epinephrine

There's this thing called Benadryl.

MDSchafer said:

There's this thing called Benadryl.

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Antihistamines aren't effective against anaphylaxis. So even if the secondary world had it, it wouldn't work.

How much do the secondary world people understand about allergies? Do they know what's happened to your character or has she just collapsed for no apparent reason?

Benadryl is an adjunctive treatment; on its own it won't be much help with anaphylactic shock. Same with corticosteroids.

If the patient is in shock, there is no substitute for epinephrine. A tracheostomy might keep the patient's airway open, but it wouldn't address the other symptoms, most importantly the drop in blood pressure.

I don't think keeping the airway open would be enough; probably the patient would need assisted breathing. But I'm wondering if the world has that capacity.

Agree with the others above-- anaphylactic shock isn't just about a closing airway, it involves cardiovascular collapse, as well. So in addition to an emergent surgical airway (which, incidentally, is more likely to be a cricothyrotomy with whatever they can shove in the airway as opposed to a tracheostomy with a trach tube), the medical staff is going to need to support blood pressure and heart contractility. That's where epinephrine comes into play most of the time.

That being said, this is your world you're creating. Maybe they don't have epinephrine, but maybe they have an herbal concoction that's similar. Figure out what your story needs, and build to suit.

ssbittner said:

The world does not have benadryl, but if there is no substitute for epinephrine, I may have to invent a herb or something that has a similar effect (although I am not sure what sort of herb would, since epinephrine is a hormone.)

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Some plants produce chemicals that are similar to hormones. The hormones in birth control pills, according to my research, are produced by certain yams. So it's not out of the question for there to be a root or something that contains a hormone-like substance that would work.

Digitalin is used in heart treatments, and that comes from the foxglove. As Orianna says, a lot of our drugs come from plants. They could easily have something that would cause the body to produce a surge of adrenaline naturally. Even if they didn't really understand how it worked.

On rashes - I'm not a medical person but have worked around dangerous chemicals - so some snippets for you:

1. Allergies can be tested for with a trace amount on the skin - I remember someone having a sneeze/itch reaction every time they came in the lab and their arm was dotted with a small sample of each of the solvents thought to be possibly responsible and they came up in a rash on a couple of dots.

2. Some allergies are cumulative - repeat exposure makes it worse. So you could start with rash, itching eyes, irritated throat and when you tip over the threshold for number of exposures then you go into full swollen throat etc. See respiratory sensitisers.

3. You can also develop a tolerance for some irritants and poisons by repeat exposure to small amounts. (Arsenic is one that you can learn to tolerate to some extent - see one of the Dorothy Sayers novels.)

How much is dependent on which substance and how much on the individual I don't know.

And, I suspect that the reason the rates of people with allergies appears to be rising is that we can save them. Now. Who knows if historically the rates were just the same, but people having an extreme allergic reaction died young. The first bee, the first tree-nut or piece of fish, they died as children of unknown causes, known now only as victims of 'high infant mortality'.
Perhaps your character could have some less extreme reaction?

Not all allergies are that severe. People who are allergic to one thing are often allergic to other things. Wouldn't your main character be aware she was allergic and carry the treatment.

Allergies are an auto immune disease.

The person may not react to the first bee sting or tree nut. The body doesn't always fight off what it's never seen before. It may be the second one that's deadly. (That's what the EMT/First Aide person said at Sea World when my daughter was stung for the first time.)

The numbers of people with these severe allergies has risen. Even 40 years ago, the cause of death would have been understood to be an allergy. I'm allergic, but I've never been hospitalized for it. Neither has my dad. Yep, allergies can be hereditary. They can also come and go - I was able to eat peanuts for a few years. I got pregnant with my son, and bang - sore throat and stuffy nose again. I'd like to grow out of it again.

Last I saw, they were rethinking much of what they do in the field of allergies and immunology. They now try to build immunity by giving very small doses of foods, the same as what they do with environmental shots.

I think it's very plausible for a plant to have evolved on a fantasy world with thorns that contain a "poison" known to cause panic and even heart attacks in healthy individuals (if they get scratched by a LOT of them perhaps), but which can save lives in severe allergic reactions.

Lots of catecholamines and amino acids can be found in plant sources.

A lot of people with severe allergies (myself included) have a story of the time when they should have used their Epi Pen, but didn't. We have these stories because we were fortunate enough to survive the experience (and it didn't quite go far enough for us to get past our pride/fear/denial/whatever to realize that we were going to die without it.) I'm not advocating this course of action, but my point is that allergic reactions can be survivable, and it's just some wacky nuance of the body's immune system (probably coupled with the level of exposure and who-knows-what other factors) that kept it just below the level of fatality. So maybe she can't breathe but a little bit of oxygen is still getting through, maybe her bp drops, but not quite far enough.

As to recovery time, I would say several hours, maybe longer. When people visit the emergency room for an anaphylactic reaction, they tend to stay for several hours, getting steroids and oxygen in addition to however many doses of epinephrine and antihistamines as were deemed necessary. Some of that time is monitoring to make sure everything is over. But without all the medical intervention, I would imagine the recovery would take longer. I was downing benadryl every four hours on the minute for probably a full 24 hours after my most recent close call. I felt like shit until at least midnight (incident happened early evening) and the rest was more precautionary. But I never did have trouble breathing.

As to whether or not benadryl (or a natural substance that behaves like it on your planet) can have any effect on anyphylaxis, I would argue that it can, albeit a small one. I'm sure most people (especially my own allergist) would argue with me on that one, but I think in cases where again, all the circumstances are just right, it might be enough to balance things barely back towards survival (again, witness the number of allergic adults who have a story to tell about the time they should have used their Epi Pen. We're usually guzzling benadryl instead.) It doesn't work that way every time, and shouldn't be counted on, because plenty of other people have died and not had such a story to tell, but personally I think it makes a difference.

As to other, minor reactions, two points. First, as someone previously mentioned, it often happens that successive exposures produce more and more severe reactions, so the minor symptoms would be more likely to be before her anyphylactic episode rather than after. HOWEVER, everybody has a threshold, (and that threshold can change over time.) That's the basis of desensitization studies. They find a dose (often as small as 1/500th of a peanut, for example) that does not cause a reaction, whereas 1/250th would. Then they progressively feed the person that dose every day for a few weeks. Then they up the dose to 1/250th for a few weeks, then 1/125th, etc. It has worked, but is still only in clinical trials. Some people go straight to anyphylaxis when exposed to an amount above their threshold, some have more minor reactions (beginning symptoms of anyphylaxis without it going deadly.) So she could have a minor reaction to much smaller amounts. For me, it's in my throat. It's not exactly an itch, it's some sort of cross between an itch and pain, which I've come to the conclusion is the feeling of various tissues in my mouth/throat swelling. There isn't a good word for it. My son knows it too, he reports that his mouth "feels like egg." Neither of us gets a visible signs until we're already in pretty deep trouble.

This has gone on for longer than I had intended it to. Hope you can take something away from it. Best of luck!

ssbittner said:

I am writing a book set on an alternative world with no epipens or epinephrine injections, and I have a character who has a severe allergy to an airborne substance. I need her to be exposed to a large amount of allergen and go into anaphylactic shock (with fainting and skin and throat swelling), but I also need her to survive.

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Hi! Don't know if this will help, but here goes . . .

My father has a severe reaction to cashews, and even the smallest bit in his mouth triggers an anaphylactic reaction. Long before there were epi-pens, he learned to treat himself by (a) recognizing the reaction as soon as it started (b) spitting out whatever was in his mouth (c) immediately gargling with the strongest form of alcohol (ethanol) that was on hand or (d) gargling with salt.

He has managed to survive to ripe old age of 90 by following these steps. He now carries an epi-pen, but I don't think he's ever used it.

Once, many decades ago, he was at a Christmas party at the high school where he taught chemistry. Something he ate triggered an anaphylactic reaction. He rushed to the storeroom for the chemistry department, grabbed the stock bottle of pure ethanol (well, 95% pure), took a big swig, and gargled with it. The ethanol denatured the cashew protein, and he managed to avoid going into shock.

I was only with him once when he had an anaphylactic reaction. He bit into a chocolate that must have had trace amounts of cashew in it. It was scary to see his face blow up with a red balloon. He gargled with some scotch we had on hand, but it took hours for the swelling to go down in his face and throat.

Needless to say, he's very careful about eating at potluck dinners!

Best,
Jen

An alternate solution --

An airborne allergen can trigger an asthma attack in your character, which should give you the symptoms you want without sending your character into anaphylactic shock. Mild asthma attacks can be treated without medication, while more severe cases require hospitalization.

I've had mold spores, paint fumes, and cigarette smoke cause an asthma attack. My asthma is triggered by both allergens and exercise, but it can be one or the other.