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P029 Anaphylaxis: impact of a targeted educational intervention on the knowledge and practices of pediatric residents
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Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
lactose regularly with no adverse effect, experienced a reaction while using a training device for a lactose-containing DPI asthma medication.
P029 ANAPHYLAXIS: IMPACT OF A TARGETED EDUCATIONAL INTERVENTION ON THE KNOWLEDGE AND PRACTICES OF PEDIATRIC RESIDENTS M. Chitty Lopez1, A. Goyal*2, D. Vellaichamy Manian2, E. Pollak-Christian2, M. Vastardi2, 1. Stamford, CT; 2. Brooklyn, NY. Introduction: Prevention of anaphylaxis mortality depends on correct diagnosis and early epinephrine injection. Our study sought to evaluate pediatric resident knowledge regarding anaphylaxis recognition and management. Methods: An anonymous multiple choice survey was distributed to pediatric residents. A teaching intervention of a didactic lecture with demonstration of epinephrine auto-injectors use was performed. Anaphylaxis guidelines posters were distributed in resident continuity clinic, inpatient ward and pediatric emergency department (ED). Post-intervention survey was distributed one week and three months after intervention. Results: 42 residents responded to the pre-intervention survey. 35 responded to one week post-intervention survey. 36 responded to three month post-intervention survey. 50% were PGY1, 26% PGY 2 and 10% were PGY3 or above. Prior to intervention, 38% have seen a case of anaphylaxis, 24% had an Allergy and Immunology (A&I) rotation and 62% had two or more weeks of ED rotation. There was no significant difference in knowledge scores between residents with prior anaphylaxis case exposure, emergency room or A&I rotation. There was a positive correlation between PGY level and who answered correctly (r¼0.378). The mean composite knowledge score was 66% pre-intervention, 82% one week post-intervention (p< 0.001), and 79% three months post intervention (p< 0.001). Conclusions: Our study demonstrated a knowledge gap among pediatric residents regarding anaphylaxis recognition and management, indicating need for educational intervention. Lecture discussing anaphylaxis with hands on training in the use of epinephrine auto-injectors made a significant difference in residents knowledge of identifying and preventing life threatening anaphylaxis.
P030 LITHIUM-INDUCED DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS PRESENTING AS SEVERE HEADACHE C. Muglia*1, M. Crippen2, A. Wolff3, E. Capitle4, 1. Washington, NJ; 2. Morristown, NJ; 3. East Orange, NJ; 4. Marlboro, NJ. Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) presents a diagnostic challenge due to significant variability in presentation and long latent period following exposure to the offending agent. Classic features include a morbilliform rash, inflammatory response with eosinophilia, and systemic involvement; typically hepatic, renal, and/or pulmonary. We present a unique case of DRESS in which severe headache was the initial manifestation and lithium was the cause. Case Presentation: 16 year-old female with bipolar disorder presented with a one-week history of severe, unremitting headache with photophobia, nausea, and vomiting which began two weeks after starting lithium. While hospitalized, she developed a maculopapular, pruritic rash and myalgias. Lab abnormalities during her hospitalization included AST 86, ALT 141, creatine up to 1.7, creatine kinase up to 4116 and urinalysis with eosinophils, RBCs and WBCs. EKG revealed non-specific ST/T wave changes. CT head was unremarkable. On hospital day #6, absolute eosinophil count was 1,200/mL and she developed
worsening of her maculopapular rash with new onset angioedema of the face. She developed fever on hospital day #7, at which time Allergy/Immunology was consulted, DRESS was diagnosed, and treatment was initiated with methylprednisolone and intravenous immunoglobulin. She experienced rapid resolution of headache and marked improvement in clinical status within the first 24 hours. Discussion: The patient’s development of fever, rash, myositis, acute interstitial nephritis, myocarditis, and transaminitis are consistent with known complications of DRESS. Our patient represents a rare case of lithium-induced DRESS and, to the best of our knowledge, is the first case of DRESS presenting initially as headache.
P031 A CASE OF CEFEPIME IGE-MEDIATED REACTION WITH NEGATIVE SKIN TESTING. SHOULD CURRENT CONCENTRATIONS BE RECONSIDERED? I. Carrillo-Martin*1, K. Molony2, K. Reddy3, D. Youssef2, A. Gonzalez-Estrada2, 1. Madrid, Spain; 2. Johnson City, TN; 3. Griffin, GA. Introduction: Patients with cystic fibrosis (CF) are at an elevated risk for beta-lactam allergy. Skin testing concentrations for evaluation of cephalosporin allergy vary between US (10-33 mg/dL) and European (2 mg/dL) guidelines. Case Description: A 45-year-old female with history of CF was admitted with acute-on-chronic P. aeruginosa meropenem-resistant sinus disease. She was started on cefepime and within 3 hrs of the second dose she developed non-pruritic urticaria on her lower extremities and abdomen. She denied other symptoms such as angioedema, wheezing, or anaphylaxis. Her rash improved within 24 hrs of diphenhydramine, corticosteroids, and discontinuation of cefepime. She was started on inhaled colistin and piperacillin-tazobactam but developed a similar rash on her lower extremities, abdomen, back and ears. She denied other symptoms. Her symptom resolved within two days of diphenhydramine, corticosteroids and discontinuation of piperacillin-tazobactam and was started on linezolid and inhaled tobramycin. We perform skin testing (prick and intradermal) to penicillin G, penicilloylpolylysine, and, cefepime (0.2, 2, and 20 mg/mL). Skin testing was negative after which she underwent cefepime desensitization based on current US guidelines. After developing a generalized pruritic rash (Fig 1) during desensitization, the protocol had to be suspended due to patient’s preference. The patient was discharged on meropenemen and colistin without further adverse reactions. Discussion: We present a case of IgE-mediated reaction to cefepime clearly proven by the presence of pruritic urticaria during cefepime desensitization despite negative skin tests to commonly used concentrations for cephalosporins. Should we be rethinking our current concentrations for cephalosporin skin testing?
Pruritic urticaria on lower extremities during cefepime desensitization
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
lactose regularly with no adverse effect, experienced a reaction while using a training device for a lactose-containing DPI asthma medication.
P029 ANAPHYLAXIS: IMPACT OF A TARGETED EDUCATIONAL INTERVENTION ON THE KNOWLEDGE AND PRACTICES OF PEDIATRIC RESIDENTS M. Chitty Lopez1, A. Goyal*2, D. Vellaichamy Manian2, E. Pollak-Christian2, M. Vastardi2, 1. Stamford, CT; 2. Brooklyn, NY. Introduction: Prevention of anaphylaxis mortality depends on correct diagnosis and early epinephrine injection. Our study sought to evaluate pediatric resident knowledge regarding anaphylaxis recognition and management. Methods: An anonymous multiple choice survey was distributed to pediatric residents. A teaching intervention of a didactic lecture with demonstration of epinephrine auto-injectors use was performed. Anaphylaxis guidelines posters were distributed in resident continuity clinic, inpatient ward and pediatric emergency department (ED). Post-intervention survey was distributed one week and three months after intervention. Results: 42 residents responded to the pre-intervention survey. 35 responded to one week post-intervention survey. 36 responded to three month post-intervention survey. 50% were PGY1, 26% PGY 2 and 10% were PGY3 or above. Prior to intervention, 38% have seen a case of anaphylaxis, 24% had an Allergy and Immunology (A&I) rotation and 62% had two or more weeks of ED rotation. There was no significant difference in knowledge scores between residents with prior anaphylaxis case exposure, emergency room or A&I rotation. There was a positive correlation between PGY level and who answered correctly (r¼0.378). The mean composite knowledge score was 66% pre-intervention, 82% one week post-intervention (p< 0.001), and 79% three months post intervention (p< 0.001). Conclusions: Our study demonstrated a knowledge gap among pediatric residents regarding anaphylaxis recognition and management, indicating need for educational intervention. Lecture discussing anaphylaxis with hands on training in the use of epinephrine auto-injectors made a significant difference in residents knowledge of identifying and preventing life threatening anaphylaxis.
P030 LITHIUM-INDUCED DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS PRESENTING AS SEVERE HEADACHE C. Muglia*1, M. Crippen2, A. Wolff3, E. Capitle4, 1. Washington, NJ; 2. Morristown, NJ; 3. East Orange, NJ; 4. Marlboro, NJ. Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) presents a diagnostic challenge due to significant variability in presentation and long latent period following exposure to the offending agent. Classic features include a morbilliform rash, inflammatory response with eosinophilia, and systemic involvement; typically hepatic, renal, and/or pulmonary. We present a unique case of DRESS in which severe headache was the initial manifestation and lithium was the cause. Case Presentation: 16 year-old female with bipolar disorder presented with a one-week history of severe, unremitting headache with photophobia, nausea, and vomiting which began two weeks after starting lithium. While hospitalized, she developed a maculopapular, pruritic rash and myalgias. Lab abnormalities during her hospitalization included AST 86, ALT 141, creatine up to 1.7, creatine kinase up to 4116 and urinalysis with eosinophils, RBCs and WBCs. EKG revealed non-specific ST/T wave changes. CT head was unremarkable. On hospital day #6, absolute eosinophil count was 1,200/mL and she developed
worsening of her maculopapular rash with new onset angioedema of the face. She developed fever on hospital day #7, at which time Allergy/Immunology was consulted, DRESS was diagnosed, and treatment was initiated with methylprednisolone and intravenous immunoglobulin. She experienced rapid resolution of headache and marked improvement in clinical status within the first 24 hours. Discussion: The patient’s development of fever, rash, myositis, acute interstitial nephritis, myocarditis, and transaminitis are consistent with known complications of DRESS. Our patient represents a rare case of lithium-induced DRESS and, to the best of our knowledge, is the first case of DRESS presenting initially as headache.
P031 A CASE OF CEFEPIME IGE-MEDIATED REACTION WITH NEGATIVE SKIN TESTING. SHOULD CURRENT CONCENTRATIONS BE RECONSIDERED? I. Carrillo-Martin*1, K. Molony2, K. Reddy3, D. Youssef2, A. Gonzalez-Estrada2, 1. Madrid, Spain; 2. Johnson City, TN; 3. Griffin, GA. Introduction: Patients with cystic fibrosis (CF) are at an elevated risk for beta-lactam allergy. Skin testing concentrations for evaluation of cephalosporin allergy vary between US (10-33 mg/dL) and European (2 mg/dL) guidelines. Case Description: A 45-year-old female with history of CF was admitted with acute-on-chronic P. aeruginosa meropenem-resistant sinus disease. She was started on cefepime and within 3 hrs of the second dose she developed non-pruritic urticaria on her lower extremities and abdomen. She denied other symptoms such as angioedema, wheezing, or anaphylaxis. Her rash improved within 24 hrs of diphenhydramine, corticosteroids, and discontinuation of cefepime. She was started on inhaled colistin and piperacillin-tazobactam but developed a similar rash on her lower extremities, abdomen, back and ears. She denied other symptoms. Her symptom resolved within two days of diphenhydramine, corticosteroids and discontinuation of piperacillin-tazobactam and was started on linezolid and inhaled tobramycin. We perform skin testing (prick and intradermal) to penicillin G, penicilloylpolylysine, and, cefepime (0.2, 2, and 20 mg/mL). Skin testing was negative after which she underwent cefepime desensitization based on current US guidelines. After developing a generalized pruritic rash (Fig 1) during desensitization, the protocol had to be suspended due to patient’s preference. The patient was discharged on meropenemen and colistin without further adverse reactions. Discussion: We present a case of IgE-mediated reaction to cefepime clearly proven by the presence of pruritic urticaria during cefepime desensitization despite negative skin tests to commonly used concentrations for cephalosporins. Should we be rethinking our current concentrations for cephalosporin skin testing?
Pruritic urticaria on lower extremities during cefepime desensitization