Airway, Clinical

Love Hurts: Rare Hypersensitivity Reaction in the Emergency Department

Human seminal fluid hypersensitivity affects roughly 40,000 women in the U.S. 

Case
An 18-year-old female walked into the emergency department in acute distress complaining of shortness of breath secondary to oropharyngeal swelling, along with an urticarial rash spreading throughout her upper body. Her symptoms began suddenly 20 minutes prior. Her boyfriend was at her side, reporting a history of similar episodes of anaphylaxis in the past, with no identifiable source; meanwhile she had never been prescribed an epi-pen.

The patient was seen immediately upon arrival and taken into a critical care resuscitation room. She had visible urticarial rashes throughout her face, trunk, and arms, prominent swelling surrounding her orbits, and angioedema to her lips and tongue. Her breath sounds were clear to auscultation without the presence of stridor or wheezing.

Within minutes of her arrival we administered a 0.5 mL intramuscular injection of 1:1000 epinephrine. She was placed on 15 L non-rebreather of supplemental oxygen while 2.5 mg nebulized albuterol was prepared. Emergency airway kit was ready at her bedside. She was placed on a cardiac monitor showing sinus tachycardia. Initial vital signs displayed a temperature of 98.2 F orally, pulse of 136 BPM, respiratory rate of 28/min, BP of 108/60 and oxygen saturation of 96% on room air.

A few minutes later she responded to treatment, promptly reporting considerable relief. Delving deeper into her history, she stated her symptoms began following sexual intercourse. She denied the use of condoms, lubricants, foreign bodies, or food during coitus. She stated she had 2 prior episodes - the most recent of which occurred shortly after anal sex and prior to that was following oral sex. 

Learning Points
Sometimes the human body reacts in ways that defy the core principles of human self-preservation. A prime example of this is the female hypersensitivity reaction to seminal fluid. This allergy has been well documented since the late 1950s through case reports and small-scale research, with large studies yet to be conducted. The prevalence of seminal fluid hypersensitivity is approximated to affect nearly 40,000 females across the United States.

The allergic reaction to seminal fluid is an IgE-mediated type I hypersensitivity where patients, including all genders, can display a wide array of symptomatology. The symptoms of semen allergy can range from a localized manifestation, such as vulvovaginal irritation, to systemic anaphylaxis with widespread urticarial rash and airway angioedema - as was displayed in this case. The majority of those who suffer from a semen hypersensitivity have symptoms limited to mild local irritation at the area of exposure. Long term sequelae can include emotional strain on relationships, as well as difficulty conceiving due to inability to use protection during intercourse, among others.

Semen consists of various components derived throughout the male reproductive tract. Sperm, from the testes, is the genetic material required for reproduction and composes only 2-5% of semen. The seminal vesicles create various nutrients that provide fuel and immunoprotection for the sperm. The prostate produces several proteins and acids that pave the way for sperm implantation. All of these elements working together create ideal conditions for sperm to travel its course and penetrate a released ovum. The most common component of semen causing hypersensitivity is thought to be any of the various proteins, such as prostate-specific antigen (PSA)1.

Diagnosis
Definitive diagnosis of semen allergy does not occur within the acute care setting. Thorough history taking can provide clues, but rarely can a clear diagnosis be elicited. The gold standard of diagnosis is through continuous management, where multiple reactions occur following exposure to semen, then resolution of symptoms is noted upon the utilization of barrier method or abstinence for contraception.1 Because the symptoms – usually involving burning sensations, rashes, and welts – overlap with a number of infections (sexually transmitted or otherwise) - physicians frequently overlook the possibility in favor of more common explanations. The only real signifier of a semen allergy is that the reactions develop within a short time period following contact. On the outpatient basis, skin prick testing has shown to be a successful mode of diagnosis following centrifuging the partner's semen with subsequent exposure to seminal proteins.1,2

Emergency Department Treatment
Emergency management of human seminal fluid hypersensitivity is simple. It is treated via the same modality as any other type I hypersensitivity reaction within the ED. 

If the patient is displaying signs of systemic anaphylaxis, such as airway compromise, hypotension, angioedema, or widespread urticarial rash; than 0.3 - 0.5 mg of 1:1000 intramuscular epinephrine should be given immediately without delay. 

If a timely resolution is not observed, then an epinephrine infusion should be started at 2-10 mcg/min. If a pump or the ability to set one up is not feasible, start a 'dirty epi' drip. This is done by injecting your code cart's epinephrine injector (1:10,1000 or 1:1,000) into a 1 liter of normal saline bolus and titrating a drip at 1 cc/min. 

Supplemental oxygen should always be provided via nasal cannula and non-rebreather mask. If angioedema of the tongue or oropharynx is noted, do not hesitate to provide definitive airway protection via orotracheal intubation. Always have tools readily available for at least two backup plans, including your surgical airway kit. Antihistamines, bronchodilators, and steroids can also be given post stabilization for symptomatic treatment.  

Regarding long-term management, researchers at Albert Einstein College of Medicine discovered that desensitization therapy has displayed promising results when patients experience incremental exposure over extended time periods.

In order to maintain desensitization, patients are recommended to have frequent intercourse with their partner 2-3 times weekly. If a patient is away from their partner for a prolonged period, it is recommended to keep a frozen sample of semen with continued repeat exposure. Pretreatment with antihistamines has also shown to be effective when taken approximately 1 hour prior to intercourse.


References

  1. Sublett JW; Bernstein JA. Seminal Plasma Hypersensitivity Reactions: An updated Review. Mt Sinai J Med. 2011;78(5):803-809.
  2. Bernstein JA, Sugumaran R, Bernstein DI, Bernstein IL. Prevalence of Human Seminal Plasma Hypersensitivity Among Symptomatic Women. Ann Allergy Asthma Immunol. 1997;78(1):54-58.
  3. Prandini M, Marchesi S. Allergy to Human Seminal fluid: A Case of Self Diagnosis. Allergy. 1999;54(5):530.

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