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RAPID INTRAVENOUS DESENSITIZATION TO HORSE ANTITHYMOCYTE GLOBULIN IN A WOMAN WITH SEVERE APLASTIC ANEMIA
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
with already known toxicity of these drugs. When hypersensitivity reactions take place, there is a dilemma concerning whether chemotherapy should continue. Desensitization protocols have been explored as therapeutic options, but their results have not been consistent. A 12step desensitization protocol has promising results. Table 1. Desensitization protocol
M031 LIVER TRANSPLANTATION AND DEATH WITHIN 4 MONTHS OF SUSPECTED DRUG-INDUCED LIVER INJURY (DILI) FROM AMOXICILLIN S. Alagheband*, P. Stewart, G. Marshall, Jackson, MS Introduction: Antibiotic prescription is not without risk. We present a case of suspected Drug induced liver injury (DILI) secondary to amoxicillin. Case Description: An 18-year-old African American male presents from an outside hospital for acute liver failure. Initially, he reports developing “yellow eyes” on day 5 of taking amoxicillin, which was prescribed by his primary care provider for sore throat and a positive rapid strep test. He is an athlete with no significant medical history or antibiotic use prior to this encounter. He does not drink alcohol, smoke or do illicit drugs. Extensive workup following the AASLD (American Association for Study of Liver Diseases) guidelines was unremarkable for biliary, autoimmune, infectious, genetic, obstructive, veno-occlusive, alcohol or salicylic acid-induced causes. Laboratory tests show a hepatocellular pattern without significant peripheral eosinophilia (AEC 110). The patient receives a liver transplant but has a hospital course complicated by bacteremia and multiorgan failure resulting in death. Discussion: There is yet to be a reliable method to predict, diagnose, and risk assess DILI. The two most common causes of DILI are acetaminophen and amoxicillin-clavulanic acid. Amoxicillin alone is less likely to cause DILI, although it may, and it can be associated with a mixed hepatocellular/cholestatic picture. The chronologic association between initiation of antibiotic and the onset of liver injury is pertinent. Immediate hypersensitivity reactions are IgE mediated and can occur within 1 hour after last drug administration. Delayed reactions are often T lymphocyte specific and can occur more than 1 hour after the last drug administration.
M032 SEVERE ANAPHYLACTIC REACTION TO ALLERGEN IMMUNOTHERAPY WHILE ON A BETA-BLOCKER AND SUCCESSFUL RESUMPTION OF IMMUNOTHERAPY A. Finley*, L. Wild, E. Atkinson, New Orleans, LA Introduction: Severe systemic reactions can occur with allergen immunotherapy (AIT). Beta-blockers do not increase incidence of anaphylaxis with AIT, but they can affect severity of reaction. Case Description: A 57-year-old man with allergic rhinoconjunctivitis presented early August for maintenance AIT injection. He is allergic to
S73
grasses, weeds, dust mites, tree pollen, dog, cat and molds but was feeling well. Within three minutes of injection he developed emesis and symptomatic hypotension. Intramuscular epinephrine was promptly administered and he was positioned on the ground on his side to protect his airway and mitigate hypotension. He required three additional doses of epinephrine and normal saline bolus given persistent hypotension. He received nebulized albuterol for bronchospasm with hypoxia. Once stabilized, he was transferred to ICU and discharged after observation overnight. Serum tryptase one hour after symptom onset was 10.9 ng/dL. Upon chart review, his neurologist had recently started propranolol for migraine prophylaxis, though patient cannot recall if he took propranolol prior to his injection. Baseline serum tryptase was 4 ng/dL. After thorough discussion, the patient elected to resume AIT given symptom control, and propranolol was discontinued. He presented to clinic two days after the event and received 20% of his maintenance dose. He reached maintenance dose in the following weeks and will receive injections at two-week intervals for the time being. Discussion: This case underscores the importance of carefully screening for beta-blocker use at all AIT visits. It also provides an example of resuming AIT following severe anaphylactic reaction and the relevance of baseline tryptase levels.
M033 IMMEDIATE HYPERSENSITIVITY TO A DENTAL APPLIANCE CONTAINING NICKEL AND METHYL METHACRYLATE M. Itsara*1, A. Sood2, S. Teuber1, 1. Davis, CA; 2. Mather, CA Introduction: Type IV delayed hypersensitivity reactions causing allergic contact dermatitis secondary to nickel and acrylates are commonly reported. Immediate hypersensitivity from both of these materials is a rare presentation that should be taken into consideration from allergic reactions to dental appliances. Case Description: A 50-year old man with obstructive sleep apnea was referred by his dentist after an acute allergic reaction resulted in an emergency room (ER) visit after wearing a dental appliance for the first time. The patient describes symptoms began within 2 hours of wearing a mandibular advancement oral device. He developed redness and burning sensation in his legs, angioedema involving his face and tongue, metallic taste, and palpitations. In the ER, he was treated with epinephrine, as well as diphenhydramine, famotidine and methylprednisolone. His symptoms resolved within minutes of epinephrine administration. Upon further investigation, it was determined that the mandibular advancement device contained both alloy containing nickel and a mixture of acrylates. Both skin prick testing and patch testing are scheduled to be performed to determine either immediate or delayed hypersensitivity to nickel and acrylates. Discussion: While nickel and acrylates have previously been reported to cause delayed hypersensitivity reactions manifesting as allergic contact dermatitis, there are only a few published cases of type I hypersensitivity to nickel allergy manifesting as urticaria or angioedema. This case is a rare example of either nickel or acrylate potentially causing an immediate hypersensitivity reaction and should be further investigated as a cause of angioedema after initial use of a dental appliance.
M034 RAPID INTRAVENOUS DESENSITIZATION TO HORSE ANTITHYMOCYTE GLOBULIN IN A WOMAN WITH SEVERE APLASTIC ANEMIA M. Tsai*, A. Pham, Los Angeles, CA Introduction: Antithymocyte globulin (ATG) and cyclosporine is a first line regimen for the treatment of severe aplastic anemia in patients without a matched sibling donor for transplant. Administration of ATG is associated with life threatening anaphylaxis in up to 5% of post-marketing cases. Accordingly, the manufacturer’s insert recommends skin testing prior to first-time administration of ATG. We
S74
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
present a case of a 59 year-old woman with positive skin testing to horse ATG, who underwent successful desensitization to ATG for treatment of her severe aplastic anemia. Case Description: A 59 year-old woman with severe aplastic anemia was admitted to our institution for induction therapy with ATG and cyclosporine. Pre-treatment skin testing to ATG was positive, with a 13 mm wheal after intradermal injection of 5 mcg of ATG. Epicutaneous skin testing was negative. She underwent successful rapid intravenous desensitization to ATG with no adverse reactions during the procedure. She completed a four-day cycle of ATG and was started on daily cyclosporine. She had good response to ATG treatment, and at six-month follow-up, she had continued clinical remission sustained with cyclosporine and eltrombopag. Discussion: Our patient’s positive intradermal skin testing was suggestive of a Type I hypersensitivity to ATG. Patients with positive skin testing should avoid ATG or undergo desensitization when medically necessary. Previous reports have described several cases of life threatening hypoxia and hypotension during ATG desensitization, but our patient successfully underwent a rapid intravenous desensitization and subsequently tolerated a four-day continuous infusion of ATG.
M035 CHLORHEXIDINE: AN INCREASINGLY RECOGNIZED CAUSE OF PERI-OPERATIVE ANAPHYLAXIS A. Cruz*, L. Montelibano, J. Carlson, T. Aung, New Orleans, LA Introduction: Chlorhexidine is an antiseptic and disinfectant that has been increasingly used in medical care such as central venous lines, urinary catheters, and surgical skin preparations. It is also used in over-the-counter products such as mouthwash and cosmetics. A Pubmed search from 1994-2013 showed 65 case reports of chlorhexidine anaphylaxis. True incidence is likely to be underestimated as it is often overlooked as a causative factor. Case Description: A 63 yo male with PMH of recent prostate cancer diagnosis presented for radical prostatectomy. An hour into his procedure he developed sustained hypotension which responded well to multiple rounds of epinephrine. His peri-operative tryptase was 48 ng/ml. His initial skin testing to lidocaine, rocuronium, cis-atrocurium, and propofol were negative. During his second tier of testing, he was negative to ketamine and fentanyl. The decision had been made to add on chlorhexidine. He was positive with the skin prick test. A week later he successfully tolerated a repeat prostrate surgery using a chlorhexidine alternative. Discussion: The reaction is thought to be slower than with other perioperative agents. The reaction tends to occur more frequently in men with a mean age presentation of 58. Its presentation is often very difficult to treat requiring large doses of epinephrine. Chlorhexidine has historically been underestimated as cause of peri-operative anaphylaxis. In part it is due to limited recognition of its increasing trigger of anaphylaxis but also due to the slower onset of reaction. Chlorhexidine should be considered more regularly in peri-operative anaphylaxis testing.
M036 IODODERMA AND SIALADENOPATHY AFTER IODINATED CONTRAST MEDIA EXPOSURE S. Patel*, S. Cho, Tampa, FL Introduction: Iodinated contrast media (ICM) exposure may elicit a variety of rare adverse reactions, including iododerma and iodinerelated sialadenopathy (iodide mumps). This patient develops both after ICM exposure. Case Description: A 52-year-old AA female with granulomatosis with polyangiitis (GPA) on hemodialysis (HD) presents to the hospital with one-day onset of bilateral submandibular swelling. She had a CT TAP with contrast a day ago for renal transplant evaluation. In the ED, CT neck with contrast is significant for bilateral enlargement and enhancement of the submandibular glands. The next day, she develops bullous lesions on her extremities and face. Physical exam is pertinent for tense bullae on extremities and face and tender submandibular swelling. Skin biopsy is unrevealing. Serum iodine level is 177,360 (normal 52-109) mcg/L. Clinical diagnoses of iododerma and iodide mumps are made, and the patient is started on IV dexamethasone and sent for HD. Sialadenopathy resolves in a week, and skin lesions resolve over the next three weeks. Discussion: Iodide mumps and iododerma are rare complications of ICM. The mechanisms are not believed to be immune-mediated. Both reactions are likely secondary to excess accumulation of iodide in the body. Iodine concentration rapidly increases with impaired renal function; 98% of iodine is renally eliminated and the rest via salivary and sweat glands. Both reactions are generally benign and self-limiting; prior cases have utilized corticosteroids and HD, but it is unclear if these improve outcomes. This is a rare case of a patient with GPA on HD who develops two uncommon reactions together after ICM.
CT neck with contrast ordered in ED, showing bilateral submandibular swelling
M037 DELAYED LOCAL REACTION DUE TO PRESERVATIVE-CONTAINING RECOMBINANT GROWTH HORMONE FORMULATION Introduction: Recombinant human growth hormone (rhGH) therapy is widely used to treat an array of medical conditions in children. There is limited research published on growth hormone (GH) associated allergic reactions. Due to the increasing use of GH therapy in children, it is important to be aware of potential reactions to rhGH when both
with already known toxicity of these drugs. When hypersensitivity reactions take place, there is a dilemma concerning whether chemotherapy should continue. Desensitization protocols have been explored as therapeutic options, but their results have not been consistent. A 12step desensitization protocol has promising results. Table 1. Desensitization protocol
M031 LIVER TRANSPLANTATION AND DEATH WITHIN 4 MONTHS OF SUSPECTED DRUG-INDUCED LIVER INJURY (DILI) FROM AMOXICILLIN S. Alagheband*, P. Stewart, G. Marshall, Jackson, MS Introduction: Antibiotic prescription is not without risk. We present a case of suspected Drug induced liver injury (DILI) secondary to amoxicillin. Case Description: An 18-year-old African American male presents from an outside hospital for acute liver failure. Initially, he reports developing “yellow eyes” on day 5 of taking amoxicillin, which was prescribed by his primary care provider for sore throat and a positive rapid strep test. He is an athlete with no significant medical history or antibiotic use prior to this encounter. He does not drink alcohol, smoke or do illicit drugs. Extensive workup following the AASLD (American Association for Study of Liver Diseases) guidelines was unremarkable for biliary, autoimmune, infectious, genetic, obstructive, veno-occlusive, alcohol or salicylic acid-induced causes. Laboratory tests show a hepatocellular pattern without significant peripheral eosinophilia (AEC 110). The patient receives a liver transplant but has a hospital course complicated by bacteremia and multiorgan failure resulting in death. Discussion: There is yet to be a reliable method to predict, diagnose, and risk assess DILI. The two most common causes of DILI are acetaminophen and amoxicillin-clavulanic acid. Amoxicillin alone is less likely to cause DILI, although it may, and it can be associated with a mixed hepatocellular/cholestatic picture. The chronologic association between initiation of antibiotic and the onset of liver injury is pertinent. Immediate hypersensitivity reactions are IgE mediated and can occur within 1 hour after last drug administration. Delayed reactions are often T lymphocyte specific and can occur more than 1 hour after the last drug administration.
M032 SEVERE ANAPHYLACTIC REACTION TO ALLERGEN IMMUNOTHERAPY WHILE ON A BETA-BLOCKER AND SUCCESSFUL RESUMPTION OF IMMUNOTHERAPY A. Finley*, L. Wild, E. Atkinson, New Orleans, LA Introduction: Severe systemic reactions can occur with allergen immunotherapy (AIT). Beta-blockers do not increase incidence of anaphylaxis with AIT, but they can affect severity of reaction. Case Description: A 57-year-old man with allergic rhinoconjunctivitis presented early August for maintenance AIT injection. He is allergic to
S73
grasses, weeds, dust mites, tree pollen, dog, cat and molds but was feeling well. Within three minutes of injection he developed emesis and symptomatic hypotension. Intramuscular epinephrine was promptly administered and he was positioned on the ground on his side to protect his airway and mitigate hypotension. He required three additional doses of epinephrine and normal saline bolus given persistent hypotension. He received nebulized albuterol for bronchospasm with hypoxia. Once stabilized, he was transferred to ICU and discharged after observation overnight. Serum tryptase one hour after symptom onset was 10.9 ng/dL. Upon chart review, his neurologist had recently started propranolol for migraine prophylaxis, though patient cannot recall if he took propranolol prior to his injection. Baseline serum tryptase was 4 ng/dL. After thorough discussion, the patient elected to resume AIT given symptom control, and propranolol was discontinued. He presented to clinic two days after the event and received 20% of his maintenance dose. He reached maintenance dose in the following weeks and will receive injections at two-week intervals for the time being. Discussion: This case underscores the importance of carefully screening for beta-blocker use at all AIT visits. It also provides an example of resuming AIT following severe anaphylactic reaction and the relevance of baseline tryptase levels.
M033 IMMEDIATE HYPERSENSITIVITY TO A DENTAL APPLIANCE CONTAINING NICKEL AND METHYL METHACRYLATE M. Itsara*1, A. Sood2, S. Teuber1, 1. Davis, CA; 2. Mather, CA Introduction: Type IV delayed hypersensitivity reactions causing allergic contact dermatitis secondary to nickel and acrylates are commonly reported. Immediate hypersensitivity from both of these materials is a rare presentation that should be taken into consideration from allergic reactions to dental appliances. Case Description: A 50-year old man with obstructive sleep apnea was referred by his dentist after an acute allergic reaction resulted in an emergency room (ER) visit after wearing a dental appliance for the first time. The patient describes symptoms began within 2 hours of wearing a mandibular advancement oral device. He developed redness and burning sensation in his legs, angioedema involving his face and tongue, metallic taste, and palpitations. In the ER, he was treated with epinephrine, as well as diphenhydramine, famotidine and methylprednisolone. His symptoms resolved within minutes of epinephrine administration. Upon further investigation, it was determined that the mandibular advancement device contained both alloy containing nickel and a mixture of acrylates. Both skin prick testing and patch testing are scheduled to be performed to determine either immediate or delayed hypersensitivity to nickel and acrylates. Discussion: While nickel and acrylates have previously been reported to cause delayed hypersensitivity reactions manifesting as allergic contact dermatitis, there are only a few published cases of type I hypersensitivity to nickel allergy manifesting as urticaria or angioedema. This case is a rare example of either nickel or acrylate potentially causing an immediate hypersensitivity reaction and should be further investigated as a cause of angioedema after initial use of a dental appliance.
M034 RAPID INTRAVENOUS DESENSITIZATION TO HORSE ANTITHYMOCYTE GLOBULIN IN A WOMAN WITH SEVERE APLASTIC ANEMIA M. Tsai*, A. Pham, Los Angeles, CA Introduction: Antithymocyte globulin (ATG) and cyclosporine is a first line regimen for the treatment of severe aplastic anemia in patients without a matched sibling donor for transplant. Administration of ATG is associated with life threatening anaphylaxis in up to 5% of post-marketing cases. Accordingly, the manufacturer’s insert recommends skin testing prior to first-time administration of ATG. We
S74
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
present a case of a 59 year-old woman with positive skin testing to horse ATG, who underwent successful desensitization to ATG for treatment of her severe aplastic anemia. Case Description: A 59 year-old woman with severe aplastic anemia was admitted to our institution for induction therapy with ATG and cyclosporine. Pre-treatment skin testing to ATG was positive, with a 13 mm wheal after intradermal injection of 5 mcg of ATG. Epicutaneous skin testing was negative. She underwent successful rapid intravenous desensitization to ATG with no adverse reactions during the procedure. She completed a four-day cycle of ATG and was started on daily cyclosporine. She had good response to ATG treatment, and at six-month follow-up, she had continued clinical remission sustained with cyclosporine and eltrombopag. Discussion: Our patient’s positive intradermal skin testing was suggestive of a Type I hypersensitivity to ATG. Patients with positive skin testing should avoid ATG or undergo desensitization when medically necessary. Previous reports have described several cases of life threatening hypoxia and hypotension during ATG desensitization, but our patient successfully underwent a rapid intravenous desensitization and subsequently tolerated a four-day continuous infusion of ATG.
M035 CHLORHEXIDINE: AN INCREASINGLY RECOGNIZED CAUSE OF PERI-OPERATIVE ANAPHYLAXIS A. Cruz*, L. Montelibano, J. Carlson, T. Aung, New Orleans, LA Introduction: Chlorhexidine is an antiseptic and disinfectant that has been increasingly used in medical care such as central venous lines, urinary catheters, and surgical skin preparations. It is also used in over-the-counter products such as mouthwash and cosmetics. A Pubmed search from 1994-2013 showed 65 case reports of chlorhexidine anaphylaxis. True incidence is likely to be underestimated as it is often overlooked as a causative factor. Case Description: A 63 yo male with PMH of recent prostate cancer diagnosis presented for radical prostatectomy. An hour into his procedure he developed sustained hypotension which responded well to multiple rounds of epinephrine. His peri-operative tryptase was 48 ng/ml. His initial skin testing to lidocaine, rocuronium, cis-atrocurium, and propofol were negative. During his second tier of testing, he was negative to ketamine and fentanyl. The decision had been made to add on chlorhexidine. He was positive with the skin prick test. A week later he successfully tolerated a repeat prostrate surgery using a chlorhexidine alternative. Discussion: The reaction is thought to be slower than with other perioperative agents. The reaction tends to occur more frequently in men with a mean age presentation of 58. Its presentation is often very difficult to treat requiring large doses of epinephrine. Chlorhexidine has historically been underestimated as cause of peri-operative anaphylaxis. In part it is due to limited recognition of its increasing trigger of anaphylaxis but also due to the slower onset of reaction. Chlorhexidine should be considered more regularly in peri-operative anaphylaxis testing.
M036 IODODERMA AND SIALADENOPATHY AFTER IODINATED CONTRAST MEDIA EXPOSURE S. Patel*, S. Cho, Tampa, FL Introduction: Iodinated contrast media (ICM) exposure may elicit a variety of rare adverse reactions, including iododerma and iodinerelated sialadenopathy (iodide mumps). This patient develops both after ICM exposure. Case Description: A 52-year-old AA female with granulomatosis with polyangiitis (GPA) on hemodialysis (HD) presents to the hospital with one-day onset of bilateral submandibular swelling. She had a CT TAP with contrast a day ago for renal transplant evaluation. In the ED, CT neck with contrast is significant for bilateral enlargement and enhancement of the submandibular glands. The next day, she develops bullous lesions on her extremities and face. Physical exam is pertinent for tense bullae on extremities and face and tender submandibular swelling. Skin biopsy is unrevealing. Serum iodine level is 177,360 (normal 52-109) mcg/L. Clinical diagnoses of iododerma and iodide mumps are made, and the patient is started on IV dexamethasone and sent for HD. Sialadenopathy resolves in a week, and skin lesions resolve over the next three weeks. Discussion: Iodide mumps and iododerma are rare complications of ICM. The mechanisms are not believed to be immune-mediated. Both reactions are likely secondary to excess accumulation of iodide in the body. Iodine concentration rapidly increases with impaired renal function; 98% of iodine is renally eliminated and the rest via salivary and sweat glands. Both reactions are generally benign and self-limiting; prior cases have utilized corticosteroids and HD, but it is unclear if these improve outcomes. This is a rare case of a patient with GPA on HD who develops two uncommon reactions together after ICM.
CT neck with contrast ordered in ED, showing bilateral submandibular swelling
M037 DELAYED LOCAL REACTION DUE TO PRESERVATIVE-CONTAINING RECOMBINANT GROWTH HORMONE FORMULATION Introduction: Recombinant human growth hormone (rhGH) therapy is widely used to treat an array of medical conditions in children. There is limited research published on growth hormone (GH) associated allergic reactions. Due to the increasing use of GH therapy in children, it is important to be aware of potential reactions to rhGH when both