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CATAMENIAL ANAPHYLAXIS PRESENTING PRIOR TO ONSET OF MENSES
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134 Contact Dermatitis due to ECG Leads
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performed, he developed localized pruritic erythematous lesions coinciding with previously placed ECG leads. He had similar reactions to various ECG leads identified as contact dermatitis. He had no changes to medications or foods. The next day, the patient reattached a displaced ECG lead, touching the conductive gel. He then placed a straw into glass of water and drank through the straw. He developed immediate tongue and facial swelling, acute respiratory distress, and was subsequently intubated for airway protection. He received treatment for anaphylaxis with epinephrine, solumedrol, diphenhydramine, and famotidine and was extubated after 2 days. Discussion: Anaphylaxis is an IgE-mediated type 1 hypersensitivity reaction, while contact dermatitis is a T-cell-mediated type 4 hypersensitivity reaction. Though uncommon, documented cases of contact dermatitis related to ECG leads exist, typically caused by polyacrylates, such as propylene glycol, found in the conductive gel. There are no published reports of anaphylaxis to ECG lead materials. Here, ingestion of proposed antigen, the conductive gel, led to a severe type 1 hypersensitivity reaction. This case mimics reactions observed with latex gloves. Natural latex can cause allergic IgE-mediated type 1 reaction, while other chemicals in latex gloves, like accelerators, can cause type 4 reactions.
M052 CATAMENIAL ANAPHYLAXIS PRESENTING PRIOR TO ONSET OF MENSES M. Patrawala*, G. Lee, Atlanta, GA
This image illustrates the patient’s history of contact dermatitis after ECG lead placement. During a prior admission, patient had cardiac arrest. Multiple ECGs were performed which lead to localized affected areas. Larger areas of erythema represent placement of defibrillator pads during code blue event. He reports reaction to various electrodes, including pediatric and ‘hypoallergenic’ types. Interestingly, he does not demonstrate allergic response to MRI-compatible ECG electrodes.
a patient with history of contact dermatitis to ECG leads who had anaphylaxis after inadvertent ingestion of ECG lead conductive gel. Case Description: A 47-year-old male with history of coronary artery disease was admitted for chest pain. After ECG was
Introduction: Catamenial anaphylaxis is an uncommon, heterogeneous disorder related to type 1 hypersensitivity to endogenous progesterone. We report a twelve-year old premenstrual female who presented with recurrent episodes of anaphylaxis with improvement after starting an oral contraceptive. Case Description: A twelve-year old female presented with six episodes of anaphylaxis that occurred monthly. Her symptoms included nausea, vomiting, diarrhea, urticaria, dizziness, and facial angioedema all requiring hospitalization. She was treated with intramuscular epinephrine, antihistamines, and systemic steroids. Her third episode occurred thirty-six hours after she had received her first dose of omalizumab. Her symptoms were uncontrolled despite treatment with prednisone, cromolyn, ketotifen, anti-leukotrienes and
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Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
antihistamines. Her work-up for anaphylactic triggers, systemic mastocytosis, and carcinoid syndrome was negative. Her lab-work showed an elevated tryptase to 13.2 ug/L from a baseline of 2.0 ug/L. There was concern for catamenial anaphylaxis given the cyclical nature of her symptoms, however the patient had not started menstruation. She underwent an oral challenge with progesterone with no reaction. She was started on low-ogestrel and did not have any subsequent episodes of anaphylaxis. Discussion: Catamenial anaphylaxis is described as recurrent episodes of multi-system allergic reactions occurring around the time of menstruation. This case is the first description of a premenstrual female who presented with catamenial anaphylaxis. The patient had no further episodes of anaphylaxis following initiation of an oral contraceptive as opposed to previous therapies. It is important to consider catamenial anaphylaxis in the differential diagnosis of idiopathic anaphylaxis prior to the onset of menses.
M053 A COMMON THERAPY FOR ALLERGIC REACTION YET A RARELY SUSPECTED CAUSE OF HYPERSENSITIVITY J. Cafone*1, K. Kennedy2, J. Corry2, J. Lee2, 1. Morristown, NJ; 2. Philadelphia, PA Introduction: While corticosteroid allergy is uncommon, reactions have been described. Increasing reports suggest the frequency of steroid reactions may be increasing, though the exact incidence is unknown. Case Description: A 10-year-old girl with bronchiolitis obliterans presented for evaluation of corticosteroid allergy. She had been started on weekly methylprednisolone infusions 2 years prior. During her most recent infusion, she developed acute hives, wheezing, and hypoxia within minutes of infusion onset and was treated for anaphylaxis. Further review revealed four additional reactions associated with prior methylprednisolone infusions. Two episodes had required epinephrine. Subsequent tolerance of a methylprednisolone challenge had been achieved and therefore she continued to receive infusions with cetirizine premedication. The patient underwent skin prick testing (SPT), which was negative. Intradermal (ID) testing to methylprednisolone was positive at a 1:1 concentration (W/F 7/25). Both SPT and ID were negative to dexamethasone, which she has been tolerating since. Discussion: While corticosteroid allergy is rare, evaluation should be pursued if history is suggestive. Given the wide use of corticosteroids for many different conditions, including allergic reactions, diagnosis can often go unmissed or be attributed to other etiologies. Further, while in vivo testing lacks validation at this time, skin testing can provide useful information supporting the diagnosis of corticosteroid hypersensitivity. Skin testing may also be helpful in identifying alternative corticosteroids for therapy. Several studies have demonstrated the absence of cross reactivity between different steroids despite their structural similarities. As corticosteroid hypersensitivity is increasingly recognized, further work is needed to standardize testing and guidance on selection of alternative therapy.
M054 ANGIOEDEMA AFTER SILDENAFINDUCED DEEP VEIN THROMBOSIS C. Cheah*, K. Dass, Royal Oak, MI Introduction: Anaphylaxis is a life-threatening condition occurring due to diffuse inflammatory process. Coagulation cascades share similar mediators as anaphylaxis. Although many processes are associated with increased thrombosis risk, an anaphylaxis association has
been reported in three cases. We present a case of deep vein thrombosis (DVT) induced by recurrent anaphylaxis. Case Description: A 54-year-old female presented with recurrent anaphylactic episodes. Two weeks prior to her office visit, the patient developed daily mild tongue swelling resolving with anti-histamines. Ultimately, she developed severe tongue swelling with drooling, dysphagia, pruritic urticaria, and wheeze. She was evaluated in an emergency room, requiring two doses of subcutaneous epinephrine and intravenous methylprednisolone, famotidine, and diphenhydramine. Prior to this time, the patient had never had any urticaria, angioedema, or anaphylaxis. Despite high dose corticosteroids, she still had angioedema and urticaria on exam. In the following two weeks, there were three additional anaphylactic episodes. The patient was treated with subcutaneous omalizumab 300 mg monthly, BID H2 antagonists, four times daily H1 anti-histamines, montelukast, and corticosteroids. The patient then developed right calf pain. She was diagnosed with an unprovoked soleal vein DVT with negative coagulation/genetic studies. The DVT cause was attributed to her recurrent anaphylaxis, and apixaban was started. Discussion: This is one of the first cases of anaphylaxis-induced DVT. Three previous cases implicated platelet activating factor as the key mediator, though there is no evidence of this in our case. This highlights the importance of monitoring for signs and symptoms of DVT in patients with episodes of anaphylaxis.
M055 ANAPHYLAXIS TREATMENT OR TRIGGER? A CASE REPORT OF REACTION TO DIPHENHYDRAMINE AND STEROIDS AS PREMEDICATIONS J. Freeman*, C. Reynolds, W. Soong, J. Anderson, Birmingham, AL Introduction: Anaphylaxis affects 1.6%-5.1% of adults. Treatment with epinephrine is generally effective, and supplementary medications can be used for prevention/treatment of anaphylactoid symptoms. Common adjuncts include corticosteroids and antihistamines. Radiocontrast is necessary for evaluation of certain conditions and cannot always be avoided even with history of reaction. While underlying mechanisms of contrast reactions are not well-understood, premedication with corticosteroids/antihistamines can often be used for prevention of reactions. Case Description: 64-year-old male with DM2, hemodialysis-dependent ESRD, and known contrast reactions presented for routine fistulogram and experienced severe anaphylaxis 10 minutes postadministration of IV premedications (methylprednisolone/diphenhydramine), prior to contrast administration. Anaphylaxis resolved after epinephrine, albuterol, and fluids, and he was referred to Allergy for identification of offending agents. Prick/intradermal testing to various steroids/antihistamines was performed. Testing was positive to IV methylprednisolone succinate, IV hydrocorticone succinate, and IV diphenhydramine. Patient has since tolerated PO prednisone, loratadine, and fexofenadine. Discussion: Our patient may have anaphylaxed to steroid, succinate, and/or diphenhydramine. Negative testing to prednisolone and prednisone-tolerance make succinate a more likely culprit than steroid, but further testing/challenge is needed to elucidate. Regarding antihistamines, this is one of few reports of reaction/ positive testing to diphenhydramine with concurrent negative testing/tolerance to loratadine and fexofenadine. Adjunct therapies for prevention/treatment of allergic reactions can occasionally trigger anaphylaxis. These medications should therefore be included in anaphylaxis workup. Allergy testing may help predict tolerability of alternative agents when similar medications are needed. Given limited reports in the literature, further studies are needed to better determine reliability of testing for these agents and cross-reactivity between them.
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performed, he developed localized pruritic erythematous lesions coinciding with previously placed ECG leads. He had similar reactions to various ECG leads identified as contact dermatitis. He had no changes to medications or foods. The next day, the patient reattached a displaced ECG lead, touching the conductive gel. He then placed a straw into glass of water and drank through the straw. He developed immediate tongue and facial swelling, acute respiratory distress, and was subsequently intubated for airway protection. He received treatment for anaphylaxis with epinephrine, solumedrol, diphenhydramine, and famotidine and was extubated after 2 days. Discussion: Anaphylaxis is an IgE-mediated type 1 hypersensitivity reaction, while contact dermatitis is a T-cell-mediated type 4 hypersensitivity reaction. Though uncommon, documented cases of contact dermatitis related to ECG leads exist, typically caused by polyacrylates, such as propylene glycol, found in the conductive gel. There are no published reports of anaphylaxis to ECG lead materials. Here, ingestion of proposed antigen, the conductive gel, led to a severe type 1 hypersensitivity reaction. This case mimics reactions observed with latex gloves. Natural latex can cause allergic IgE-mediated type 1 reaction, while other chemicals in latex gloves, like accelerators, can cause type 4 reactions.
M052 CATAMENIAL ANAPHYLAXIS PRESENTING PRIOR TO ONSET OF MENSES M. Patrawala*, G. Lee, Atlanta, GA
This image illustrates the patient’s history of contact dermatitis after ECG lead placement. During a prior admission, patient had cardiac arrest. Multiple ECGs were performed which lead to localized affected areas. Larger areas of erythema represent placement of defibrillator pads during code blue event. He reports reaction to various electrodes, including pediatric and ‘hypoallergenic’ types. Interestingly, he does not demonstrate allergic response to MRI-compatible ECG electrodes.
a patient with history of contact dermatitis to ECG leads who had anaphylaxis after inadvertent ingestion of ECG lead conductive gel. Case Description: A 47-year-old male with history of coronary artery disease was admitted for chest pain. After ECG was
Introduction: Catamenial anaphylaxis is an uncommon, heterogeneous disorder related to type 1 hypersensitivity to endogenous progesterone. We report a twelve-year old premenstrual female who presented with recurrent episodes of anaphylaxis with improvement after starting an oral contraceptive. Case Description: A twelve-year old female presented with six episodes of anaphylaxis that occurred monthly. Her symptoms included nausea, vomiting, diarrhea, urticaria, dizziness, and facial angioedema all requiring hospitalization. She was treated with intramuscular epinephrine, antihistamines, and systemic steroids. Her third episode occurred thirty-six hours after she had received her first dose of omalizumab. Her symptoms were uncontrolled despite treatment with prednisone, cromolyn, ketotifen, anti-leukotrienes and
S80
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
antihistamines. Her work-up for anaphylactic triggers, systemic mastocytosis, and carcinoid syndrome was negative. Her lab-work showed an elevated tryptase to 13.2 ug/L from a baseline of 2.0 ug/L. There was concern for catamenial anaphylaxis given the cyclical nature of her symptoms, however the patient had not started menstruation. She underwent an oral challenge with progesterone with no reaction. She was started on low-ogestrel and did not have any subsequent episodes of anaphylaxis. Discussion: Catamenial anaphylaxis is described as recurrent episodes of multi-system allergic reactions occurring around the time of menstruation. This case is the first description of a premenstrual female who presented with catamenial anaphylaxis. The patient had no further episodes of anaphylaxis following initiation of an oral contraceptive as opposed to previous therapies. It is important to consider catamenial anaphylaxis in the differential diagnosis of idiopathic anaphylaxis prior to the onset of menses.
M053 A COMMON THERAPY FOR ALLERGIC REACTION YET A RARELY SUSPECTED CAUSE OF HYPERSENSITIVITY J. Cafone*1, K. Kennedy2, J. Corry2, J. Lee2, 1. Morristown, NJ; 2. Philadelphia, PA Introduction: While corticosteroid allergy is uncommon, reactions have been described. Increasing reports suggest the frequency of steroid reactions may be increasing, though the exact incidence is unknown. Case Description: A 10-year-old girl with bronchiolitis obliterans presented for evaluation of corticosteroid allergy. She had been started on weekly methylprednisolone infusions 2 years prior. During her most recent infusion, she developed acute hives, wheezing, and hypoxia within minutes of infusion onset and was treated for anaphylaxis. Further review revealed four additional reactions associated with prior methylprednisolone infusions. Two episodes had required epinephrine. Subsequent tolerance of a methylprednisolone challenge had been achieved and therefore she continued to receive infusions with cetirizine premedication. The patient underwent skin prick testing (SPT), which was negative. Intradermal (ID) testing to methylprednisolone was positive at a 1:1 concentration (W/F 7/25). Both SPT and ID were negative to dexamethasone, which she has been tolerating since. Discussion: While corticosteroid allergy is rare, evaluation should be pursued if history is suggestive. Given the wide use of corticosteroids for many different conditions, including allergic reactions, diagnosis can often go unmissed or be attributed to other etiologies. Further, while in vivo testing lacks validation at this time, skin testing can provide useful information supporting the diagnosis of corticosteroid hypersensitivity. Skin testing may also be helpful in identifying alternative corticosteroids for therapy. Several studies have demonstrated the absence of cross reactivity between different steroids despite their structural similarities. As corticosteroid hypersensitivity is increasingly recognized, further work is needed to standardize testing and guidance on selection of alternative therapy.
M054 ANGIOEDEMA AFTER SILDENAFINDUCED DEEP VEIN THROMBOSIS C. Cheah*, K. Dass, Royal Oak, MI Introduction: Anaphylaxis is a life-threatening condition occurring due to diffuse inflammatory process. Coagulation cascades share similar mediators as anaphylaxis. Although many processes are associated with increased thrombosis risk, an anaphylaxis association has
been reported in three cases. We present a case of deep vein thrombosis (DVT) induced by recurrent anaphylaxis. Case Description: A 54-year-old female presented with recurrent anaphylactic episodes. Two weeks prior to her office visit, the patient developed daily mild tongue swelling resolving with anti-histamines. Ultimately, she developed severe tongue swelling with drooling, dysphagia, pruritic urticaria, and wheeze. She was evaluated in an emergency room, requiring two doses of subcutaneous epinephrine and intravenous methylprednisolone, famotidine, and diphenhydramine. Prior to this time, the patient had never had any urticaria, angioedema, or anaphylaxis. Despite high dose corticosteroids, she still had angioedema and urticaria on exam. In the following two weeks, there were three additional anaphylactic episodes. The patient was treated with subcutaneous omalizumab 300 mg monthly, BID H2 antagonists, four times daily H1 anti-histamines, montelukast, and corticosteroids. The patient then developed right calf pain. She was diagnosed with an unprovoked soleal vein DVT with negative coagulation/genetic studies. The DVT cause was attributed to her recurrent anaphylaxis, and apixaban was started. Discussion: This is one of the first cases of anaphylaxis-induced DVT. Three previous cases implicated platelet activating factor as the key mediator, though there is no evidence of this in our case. This highlights the importance of monitoring for signs and symptoms of DVT in patients with episodes of anaphylaxis.
M055 ANAPHYLAXIS TREATMENT OR TRIGGER? A CASE REPORT OF REACTION TO DIPHENHYDRAMINE AND STEROIDS AS PREMEDICATIONS J. Freeman*, C. Reynolds, W. Soong, J. Anderson, Birmingham, AL Introduction: Anaphylaxis affects 1.6%-5.1% of adults. Treatment with epinephrine is generally effective, and supplementary medications can be used for prevention/treatment of anaphylactoid symptoms. Common adjuncts include corticosteroids and antihistamines. Radiocontrast is necessary for evaluation of certain conditions and cannot always be avoided even with history of reaction. While underlying mechanisms of contrast reactions are not well-understood, premedication with corticosteroids/antihistamines can often be used for prevention of reactions. Case Description: 64-year-old male with DM2, hemodialysis-dependent ESRD, and known contrast reactions presented for routine fistulogram and experienced severe anaphylaxis 10 minutes postadministration of IV premedications (methylprednisolone/diphenhydramine), prior to contrast administration. Anaphylaxis resolved after epinephrine, albuterol, and fluids, and he was referred to Allergy for identification of offending agents. Prick/intradermal testing to various steroids/antihistamines was performed. Testing was positive to IV methylprednisolone succinate, IV hydrocorticone succinate, and IV diphenhydramine. Patient has since tolerated PO prednisone, loratadine, and fexofenadine. Discussion: Our patient may have anaphylaxed to steroid, succinate, and/or diphenhydramine. Negative testing to prednisolone and prednisone-tolerance make succinate a more likely culprit than steroid, but further testing/challenge is needed to elucidate. Regarding antihistamines, this is one of few reports of reaction/ positive testing to diphenhydramine with concurrent negative testing/tolerance to loratadine and fexofenadine. Adjunct therapies for prevention/treatment of allergic reactions can occasionally trigger anaphylaxis. These medications should therefore be included in anaphylaxis workup. Allergy testing may help predict tolerability of alternative agents when similar medications are needed. Given limited reports in the literature, further studies are needed to better determine reliability of testing for these agents and cross-reactivity between them.