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Local Anesthetic Injection Reactions- Which One Is Frequently the Allergic Component?
AB120 Abstracts
387
SUNDAY
Utility and Safety of Skin and Drug Provocation Tests in Children with a History of Penicillin-Induced Rash Wipa Jessadapakorn, MD1, Prapasri Kulalert, MD2, Araya Yuenyongviwat, MD3, Pasuree Sangsupawanich, MD4; 1Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand, 2Thammasat University, Pathumtani, Thailand, 3Prince of Songkla University, Songkhla, Thailand, 4Prince Songkhlanagarind hospital, Hadyai, Thailand. RATIONALE: Penicillin allergy is the most commonly reported drug allergy. A history of skin rash is unreliable to determine a drug allergy. A skin test is a more specific test while the drug provocation test is a standard tool for the diagnosis of drug allergy. We aimed to report the utility and safety of skin and drug provocation tests to confirm the diagnosis of penicillin allergy among Thai children with a history of rash after taking this antibiotic. METHODS: A prospective study was carried out in children with a history of skin rash during penicillin therapy from the database of Songklanagarind Hospital from 2009 to 2013. Allergologic testing included skin prick test (SPT), intradermal test (IDT) and drug provocation test (DPT) according to the international standard guidelines. The reagents for SPT were benzylpenicilloyl polylysine, minor determinant mixture, penicilloyl-polylysine, penicillin G, ampicillin, Augmentin and any other suspected penicillin. IDT was performed in subjects who had a negative SPT. In subjects who were negative for both SPT and IDT, a DPT with the suspected penicillin was performed. RESULTS: Sixty-three patients participated in this study. The mean age was 8 years. Amoxicillin was the most common culprit drug (87.3%). A penicillin allergy was confirmed in 5 (7.9%) of these 63 patients. One patient was identified by positive SPT and 4 by DPTs. No severe adverse reaction was found. CONCLUSIONS: Allergologic tests are important for the definite diagnosis of drug allergy. Our protocol is safe and efficient for the evaluation of children with a history of penicillin-induced rash.
388
Cefazolin Is a Common Cause of Perioperative Hypersensitivity Reactions James L. Kuhlen, MD1, Aidan Long, MD, FAAAAI1, Carlos Camargo, Jr, MD, DrPH1,2, Aleena Banerji, MD1; 1Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 2Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. RATIONALE: Hypersensitivity reactions (HSR) during the perioperative period are unpredictable and can be life threatening. Evidence based guidelines for evaluation of perioperative HSR are lacking and data on causative agents varies among different studies. We propose a standardized protocol to evaluate and manage all patients presenting with perioperative HSR. METHODS: All patients referred for perioperative HSR between November 2013 and September 2014 were evaluated using a standardized protocol. Comprehensive allergy evaluation included collection of patient demographics, atopic history and characteristics of HSR during anesthesia. We reviewed results of skin testing using non-irritating concentrations and/ or oral challenges (if necessary) for all potential culprit agents including antibiotics, neuromuscular blocking agents, propofol, midazolam, chlorhexidine, ondansetron, fentanyl, acetaminophen, oxycodone, celecoxib and latex. Event related tryptase levels were reviewed when available. RESULTS: To date, 16 patients with perioperative HSR were referred and 11 patients completed the comprehensive allergy evaluation. 50% (8/16) of the patients were female with a mean age of 54 (range 19 to 81) years. Only 13% (2/16) of patients were atopic. The most frequently observed HSR symptoms were urticaria (81%), hypotension (56%), and oropharyngeal edema (25%). A culprit drug, based on positive skin testing, was identified
J ALLERGY CLIN IMMUNOL FEBRUARY 2015
in 36% (4 /11) of patients. In all 4 cases, the causative agent was cefazolin. Tryptase levels were elevated in the 4 (67%) of 6 patients. CONCLUSIONS: Cefazolin is the most likely cause of perioperative HSR in our study population. Tryptase levels obtained during a perioperative HSR can aide in the diagnosis of HSR.
389
Steroid/ Local Anesthetic Injection Reactions- Which One Is Frequently the Allergic Component? Bhavisha Patel, MD, Joseph H. Butterfield, MD, FAAAAI; Mayo Clinic, Rochester, MN. RATIONALE: Some patients report adverse reactions to steroid/ local anesthetic injections used frequently for pain control. We describe skin testing results of patients presenting with local or systemic reactions to a combined steroid/ local anesthetic injection. METHODS: Retrospective analysis of 105 patients who had local anesthetic and/or steroid skin testing at Mayo Clinic from 01/2004 to 07/ 2012. RESULTS: We identified 23 patients who reported either a systemic or local reaction to a steroid/ local anesthetic injection. Of these, 5 patients were tested only to local anesthetics and all 5 tests were negative. 18 patients were tested to both steroids and local anesthetics and overall 44% (8/18) of these skin tests were positive. 62.5% (5/8) of positive tests were positive reactions to a steroid, 12.5% (1/8) was positive to a local anesthetic- lidocaine, and 25% (2/5) were positive to both a steroid and a local anesthetic. In only 2 cases (with triamcinolone and lidocaine), the drug causing the historical reaction correlated with the drug resulting in a positive skin test. In 5 cases the medication causing the historical reaction was not the same medication resulting in a positive skin test and in the remaining 1 case the historical steroid and local anesthetic were unknown. CONCLUSIONS: In cases of adverse reactions to combined steroid/ local anesthetic injections the steroid component resulted in a positive skin test significantly more often than the local anesthetic. However in only 25% of patients was there a confirmatory positive skin test to one of the agents causing the historical reaction.
387
SUNDAY
Utility and Safety of Skin and Drug Provocation Tests in Children with a History of Penicillin-Induced Rash Wipa Jessadapakorn, MD1, Prapasri Kulalert, MD2, Araya Yuenyongviwat, MD3, Pasuree Sangsupawanich, MD4; 1Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, Thailand, 2Thammasat University, Pathumtani, Thailand, 3Prince of Songkla University, Songkhla, Thailand, 4Prince Songkhlanagarind hospital, Hadyai, Thailand. RATIONALE: Penicillin allergy is the most commonly reported drug allergy. A history of skin rash is unreliable to determine a drug allergy. A skin test is a more specific test while the drug provocation test is a standard tool for the diagnosis of drug allergy. We aimed to report the utility and safety of skin and drug provocation tests to confirm the diagnosis of penicillin allergy among Thai children with a history of rash after taking this antibiotic. METHODS: A prospective study was carried out in children with a history of skin rash during penicillin therapy from the database of Songklanagarind Hospital from 2009 to 2013. Allergologic testing included skin prick test (SPT), intradermal test (IDT) and drug provocation test (DPT) according to the international standard guidelines. The reagents for SPT were benzylpenicilloyl polylysine, minor determinant mixture, penicilloyl-polylysine, penicillin G, ampicillin, Augmentin and any other suspected penicillin. IDT was performed in subjects who had a negative SPT. In subjects who were negative for both SPT and IDT, a DPT with the suspected penicillin was performed. RESULTS: Sixty-three patients participated in this study. The mean age was 8 years. Amoxicillin was the most common culprit drug (87.3%). A penicillin allergy was confirmed in 5 (7.9%) of these 63 patients. One patient was identified by positive SPT and 4 by DPTs. No severe adverse reaction was found. CONCLUSIONS: Allergologic tests are important for the definite diagnosis of drug allergy. Our protocol is safe and efficient for the evaluation of children with a history of penicillin-induced rash.
388
Cefazolin Is a Common Cause of Perioperative Hypersensitivity Reactions James L. Kuhlen, MD1, Aidan Long, MD, FAAAAI1, Carlos Camargo, Jr, MD, DrPH1,2, Aleena Banerji, MD1; 1Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 2Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA. RATIONALE: Hypersensitivity reactions (HSR) during the perioperative period are unpredictable and can be life threatening. Evidence based guidelines for evaluation of perioperative HSR are lacking and data on causative agents varies among different studies. We propose a standardized protocol to evaluate and manage all patients presenting with perioperative HSR. METHODS: All patients referred for perioperative HSR between November 2013 and September 2014 were evaluated using a standardized protocol. Comprehensive allergy evaluation included collection of patient demographics, atopic history and characteristics of HSR during anesthesia. We reviewed results of skin testing using non-irritating concentrations and/ or oral challenges (if necessary) for all potential culprit agents including antibiotics, neuromuscular blocking agents, propofol, midazolam, chlorhexidine, ondansetron, fentanyl, acetaminophen, oxycodone, celecoxib and latex. Event related tryptase levels were reviewed when available. RESULTS: To date, 16 patients with perioperative HSR were referred and 11 patients completed the comprehensive allergy evaluation. 50% (8/16) of the patients were female with a mean age of 54 (range 19 to 81) years. Only 13% (2/16) of patients were atopic. The most frequently observed HSR symptoms were urticaria (81%), hypotension (56%), and oropharyngeal edema (25%). A culprit drug, based on positive skin testing, was identified
J ALLERGY CLIN IMMUNOL FEBRUARY 2015
in 36% (4 /11) of patients. In all 4 cases, the causative agent was cefazolin. Tryptase levels were elevated in the 4 (67%) of 6 patients. CONCLUSIONS: Cefazolin is the most likely cause of perioperative HSR in our study population. Tryptase levels obtained during a perioperative HSR can aide in the diagnosis of HSR.
389
Steroid/ Local Anesthetic Injection Reactions- Which One Is Frequently the Allergic Component? Bhavisha Patel, MD, Joseph H. Butterfield, MD, FAAAAI; Mayo Clinic, Rochester, MN. RATIONALE: Some patients report adverse reactions to steroid/ local anesthetic injections used frequently for pain control. We describe skin testing results of patients presenting with local or systemic reactions to a combined steroid/ local anesthetic injection. METHODS: Retrospective analysis of 105 patients who had local anesthetic and/or steroid skin testing at Mayo Clinic from 01/2004 to 07/ 2012. RESULTS: We identified 23 patients who reported either a systemic or local reaction to a steroid/ local anesthetic injection. Of these, 5 patients were tested only to local anesthetics and all 5 tests were negative. 18 patients were tested to both steroids and local anesthetics and overall 44% (8/18) of these skin tests were positive. 62.5% (5/8) of positive tests were positive reactions to a steroid, 12.5% (1/8) was positive to a local anesthetic- lidocaine, and 25% (2/5) were positive to both a steroid and a local anesthetic. In only 2 cases (with triamcinolone and lidocaine), the drug causing the historical reaction correlated with the drug resulting in a positive skin test. In 5 cases the medication causing the historical reaction was not the same medication resulting in a positive skin test and in the remaining 1 case the historical steroid and local anesthetic were unknown. CONCLUSIONS: In cases of adverse reactions to combined steroid/ local anesthetic injections the steroid component resulted in a positive skin test significantly more often than the local anesthetic. However in only 25% of patients was there a confirmatory positive skin test to one of the agents causing the historical reaction.