- Email: [email protected]
Severe anaphylactic reactions caused by chlorhexidine-coated central venous lines during renal transplantation
AB40 Abstracts
SATURDAY
130
Drug Provocation Tests in Patients with NonSteroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen Hypersensitivity Reactions
Wat Mitthamsiri, MD, Panithan Pradubpongsa, MD, Atik Sangasapaviliya, MD, and Tadech Boonpiyathad, MD; Division of Allergy and Clinical Immunology, Department of Medicine, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand. RATIONALE: Drug provocation test (DPT) is the gold standard to diagnose analgesic drugs hypersensitivity reactions (HRs). The purpose of this study was to confirm the diagnosis in patients with NSAIDs and acetaminophen HRs and to find the safe alternatives. METHODS: This is a retrospective study which enrolled adult participants with history of NSAIDs and acetaminophen-induced immediate drug HRs whose skin prick test results were negative. Their DPTs were singleblinded and placebo controlled. The analgesic drugs included acetaminophen, NSAIDs (aspirin, ibuprofen, diclofenac, mefenamic acid, and meloxicam), COX-2 inhibitor (etoricoxib) and tramadol. All participants were challenged with placebo and the analgesic drugs by ingestion of increasing dose every 60 minutes, started from 25%, 50%, 75% and then 100% of their targeted therapeutic dose. RESULTS: Eighteen participants consented to DPTs. We performed 404 DPTs. Sixty-seven (16.58%) tests were positive with 2 of those were anaphylaxis. DPTs confirmed the diagnosis in all of 5 participants with the history of NSAIDs and acetaminophen HRs and 8 participants with the history of only NSAIDs HRs. DPTs were able to diagnose 50% of 4 participants with the history of acetaminophen HRs. Eleven participants had multiple NSIADs positive results. DPTs with etoricoxib and tramadol were negative in 12 (66.66%) and 14 (77.78%) out of 18 participants, respectively. Six participants with etoricoxib positive DPTs had multiple NSIADs positive DPTs too. CONCLUSIONS: This study indicated the DPT was a good diagnostic test for analgesic drugs HRs. Etoricoxib and tramadol were tolerated in the majority but not all participants tested.
131
Severe anaphylactic reactions caused by chlorhexidine-coated central venous lines during renal transplantation
Lisa W. Fu, MD, Alexander Ho, MD, Jeffrey Zaltzman, MD, Lucy Chen, RPh, and Peter Vadas, MD, PhD; University of Toronto, Toronto, ON, Canada. RATIONALE: Chlorhexidine is commonly used as an antimicrobial agent in the perioperative setting. Severe and life-threatening allergic reactions may occur sporadically in some patients, but there are no patient cohorts known to be at high risk. We describe a cohort of 8 patients who had been on hemodialysis and experienced near-fatal anaphylaxis during surgery for kidney transplantation. Investigation identified chlorhexidine-coated central venous lines as the trigger. METHODS: Patients were referred for investigation of severe perioperative anaphylaxis in a tertiary care university teaching hospital. All drugs administered prior to the anaphylactic reaction were tested by prick and/or intradermal methods, and where appropriate, serologic testing was done for specific IgE by ImmunoCAP. RESULTS: All 8 (100%) patients were male. Cardiac arrest was seen in 3 (38%) patients, hypotension in 4 (50%) patients, and wheezing and desaturation in 1 patient. Anaphylaxis severity scores were grade 3 (severe) in 100%. Post-anaphylaxis tryptase levels were measured in 3 patients and were all elevated (range: 27.3 to >200 mg/L). All patients tested positive for chlorhexidine by one or more of testing methods. Other causes of intraoperative anaphylaxis were ruled out by testing. CONCLUSIONS: This study identifies a unique population at risk for fatal anaphylaxis triggered by chlorhexidine-coated central venous lines. The postulated route of sensitization is via repeated disinfection of fistula sites with chlorhexidine in preparation for hemodialysis sessions. High risk
J ALLERGY CLIN IMMUNOL FEBRUARY 2017
patients should be pre-screened and tested prior to elective surgery to identify those patients in whom strict peri-operative avoidance of chlorhexidine exposure is required.
132
A Case Series of Eight Patients with Clinical Anaphylaxis in the Setting of Vincristine Administration
David A. Hill, MD, PhD, Allison Barz, MD, Joseph Sciasci, PharmD, Sean P. O’Neill, PharmD, Anne Reilly, MD, MPH, Naomi Balamuth, MD, Steven Seeholzer, PhD, Terri F. Brown-Whitehorn, MD, FAAAAI, and Jonathan M. Spergel, MD, PhD, FAAAAI; The Children’s Hospital of Philadelphia, Philadelphia, PA. RATIONALE: Vincristine, a vinca alkaloid that is purified from the Madagascar periwinkle Catharanthus roseus, is a common chemotherapeutic used to treat multiple pediatric and adult malignancies. While cases of anaphylaxis to vincristine have been reported, reactions are rare and typically isolated to a single individual. METHODS: This report describes a case series of eight patients who experienced clinical symptoms of anaphylaxis after receiving vincristine. RESULTS: Between July of 2015 and May of 2016, eight patients had symptoms of anaphylaxis immediately after receiving vincristine. There were five male and three female patients, with an average age of 5 years. Patients were treated with three lots of vincristine, from two different manufacturers. Underlying oncologic diagnoses were acute lymphoblastic leukemia, vaginal sarcoma, oligodendroglioma, medulloblastoma, lymphoblastic lymphoma, and Wilm’s tumor. Symptoms experienced were immediate and included respiratory distress/cough (100%), hypotension (25%), flushing (13%), mouth itch (13%), and cardiac arrest (13%). Patients required therapy with antihistamines (88%), epinephrine (50%), fluids (38%), and steroids (38%). Reactions occurred on first exposure to vincristine in two of the eight patients. Seven of the patients were treated with vincristine subsequently without reaction, four were treated with premedications prior to subsequent infusion. CONCLUSIONS: Given the number of cases, and that most patients were tolerating vincristine prior to their reaction and were able to tolerate vincristine subsequently, we favor a contaminant as the etiology of the reactions. It is important to recognize the potential for complications related to anaphylaxis when treating patients with vincristine, and other therapeutics derived from natural sources.
SATURDAY
130
Drug Provocation Tests in Patients with NonSteroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen Hypersensitivity Reactions
Wat Mitthamsiri, MD, Panithan Pradubpongsa, MD, Atik Sangasapaviliya, MD, and Tadech Boonpiyathad, MD; Division of Allergy and Clinical Immunology, Department of Medicine, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand. RATIONALE: Drug provocation test (DPT) is the gold standard to diagnose analgesic drugs hypersensitivity reactions (HRs). The purpose of this study was to confirm the diagnosis in patients with NSAIDs and acetaminophen HRs and to find the safe alternatives. METHODS: This is a retrospective study which enrolled adult participants with history of NSAIDs and acetaminophen-induced immediate drug HRs whose skin prick test results were negative. Their DPTs were singleblinded and placebo controlled. The analgesic drugs included acetaminophen, NSAIDs (aspirin, ibuprofen, diclofenac, mefenamic acid, and meloxicam), COX-2 inhibitor (etoricoxib) and tramadol. All participants were challenged with placebo and the analgesic drugs by ingestion of increasing dose every 60 minutes, started from 25%, 50%, 75% and then 100% of their targeted therapeutic dose. RESULTS: Eighteen participants consented to DPTs. We performed 404 DPTs. Sixty-seven (16.58%) tests were positive with 2 of those were anaphylaxis. DPTs confirmed the diagnosis in all of 5 participants with the history of NSAIDs and acetaminophen HRs and 8 participants with the history of only NSAIDs HRs. DPTs were able to diagnose 50% of 4 participants with the history of acetaminophen HRs. Eleven participants had multiple NSIADs positive results. DPTs with etoricoxib and tramadol were negative in 12 (66.66%) and 14 (77.78%) out of 18 participants, respectively. Six participants with etoricoxib positive DPTs had multiple NSIADs positive DPTs too. CONCLUSIONS: This study indicated the DPT was a good diagnostic test for analgesic drugs HRs. Etoricoxib and tramadol were tolerated in the majority but not all participants tested.
131
Severe anaphylactic reactions caused by chlorhexidine-coated central venous lines during renal transplantation
Lisa W. Fu, MD, Alexander Ho, MD, Jeffrey Zaltzman, MD, Lucy Chen, RPh, and Peter Vadas, MD, PhD; University of Toronto, Toronto, ON, Canada. RATIONALE: Chlorhexidine is commonly used as an antimicrobial agent in the perioperative setting. Severe and life-threatening allergic reactions may occur sporadically in some patients, but there are no patient cohorts known to be at high risk. We describe a cohort of 8 patients who had been on hemodialysis and experienced near-fatal anaphylaxis during surgery for kidney transplantation. Investigation identified chlorhexidine-coated central venous lines as the trigger. METHODS: Patients were referred for investigation of severe perioperative anaphylaxis in a tertiary care university teaching hospital. All drugs administered prior to the anaphylactic reaction were tested by prick and/or intradermal methods, and where appropriate, serologic testing was done for specific IgE by ImmunoCAP. RESULTS: All 8 (100%) patients were male. Cardiac arrest was seen in 3 (38%) patients, hypotension in 4 (50%) patients, and wheezing and desaturation in 1 patient. Anaphylaxis severity scores were grade 3 (severe) in 100%. Post-anaphylaxis tryptase levels were measured in 3 patients and were all elevated (range: 27.3 to >200 mg/L). All patients tested positive for chlorhexidine by one or more of testing methods. Other causes of intraoperative anaphylaxis were ruled out by testing. CONCLUSIONS: This study identifies a unique population at risk for fatal anaphylaxis triggered by chlorhexidine-coated central venous lines. The postulated route of sensitization is via repeated disinfection of fistula sites with chlorhexidine in preparation for hemodialysis sessions. High risk
J ALLERGY CLIN IMMUNOL FEBRUARY 2017
patients should be pre-screened and tested prior to elective surgery to identify those patients in whom strict peri-operative avoidance of chlorhexidine exposure is required.
132
A Case Series of Eight Patients with Clinical Anaphylaxis in the Setting of Vincristine Administration
David A. Hill, MD, PhD, Allison Barz, MD, Joseph Sciasci, PharmD, Sean P. O’Neill, PharmD, Anne Reilly, MD, MPH, Naomi Balamuth, MD, Steven Seeholzer, PhD, Terri F. Brown-Whitehorn, MD, FAAAAI, and Jonathan M. Spergel, MD, PhD, FAAAAI; The Children’s Hospital of Philadelphia, Philadelphia, PA. RATIONALE: Vincristine, a vinca alkaloid that is purified from the Madagascar periwinkle Catharanthus roseus, is a common chemotherapeutic used to treat multiple pediatric and adult malignancies. While cases of anaphylaxis to vincristine have been reported, reactions are rare and typically isolated to a single individual. METHODS: This report describes a case series of eight patients who experienced clinical symptoms of anaphylaxis after receiving vincristine. RESULTS: Between July of 2015 and May of 2016, eight patients had symptoms of anaphylaxis immediately after receiving vincristine. There were five male and three female patients, with an average age of 5 years. Patients were treated with three lots of vincristine, from two different manufacturers. Underlying oncologic diagnoses were acute lymphoblastic leukemia, vaginal sarcoma, oligodendroglioma, medulloblastoma, lymphoblastic lymphoma, and Wilm’s tumor. Symptoms experienced were immediate and included respiratory distress/cough (100%), hypotension (25%), flushing (13%), mouth itch (13%), and cardiac arrest (13%). Patients required therapy with antihistamines (88%), epinephrine (50%), fluids (38%), and steroids (38%). Reactions occurred on first exposure to vincristine in two of the eight patients. Seven of the patients were treated with vincristine subsequently without reaction, four were treated with premedications prior to subsequent infusion. CONCLUSIONS: Given the number of cases, and that most patients were tolerating vincristine prior to their reaction and were able to tolerate vincristine subsequently, we favor a contaminant as the etiology of the reactions. It is important to recognize the potential for complications related to anaphylaxis when treating patients with vincristine, and other therapeutics derived from natural sources.