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DESENSITIZATION PROTOCOL FOR HYPERSENSITIVITY TO CARBOPLATIN IN-PATIENT WITH METASTATIC CANCER, A SAFE AND EFFECTIVE METHOD
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Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
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M029
EARLY AND DELAYED HYPERSENSITIVITY REACTIONS TO PACLITAXEL: DESENSITIZATION AS A CHALLENGE C. De Lira-Quezada*1, A. Macias-Weinmann1, S. Gonzalez-Diaz1, A. Arias-Cruz1, R. Villarreal Gonzalez1, I. Perez Gomez1, R. Ramirez-Rodriguez2, 1. Monterrey, Nuevo Leon, Mexico; 2. Monterrey, Mexico
SUCCESSFUL DESENSITIZATION TO PACLITAXEL: A CASE REPORT R. Guzman Cotaya*, S. Gonzalez-Diaz, A. Arias-Cruz, A. Macias-Weinmann, C. De Lira-Quezada, D. Roman Canamar, R. Villarreal Gonzalez, Monterrey, Nuevo Leon, Mexico
Introduction: Taxanes are among the most frequently implicated antineoplastics in anaphylaxis and occur in around 1% of patients. Immediate hypersensitivity reactions (HSR) to taxanes are generally attributed to the surfactants used in their formulation however IgE mediated reactions have been reported. Case Description: A 36 year old female patient with breast cancer stage IIB diagnosed on November 2017 was referred to our center by the Oncology Service. Patient started chemotherapy with paclitaxel 120 mg, however 3 minutes after the second dose she presented pruritus, chest pain and throat tightness; dexamethasone and clorpheniramine was administered by oncologist with complete resolution of symptoms. We performed skin tests with paclitaxel (1 mg/1ml): prick tests were negative, intradermal test (0.01 mg/ml) 0.05 ml was positive (wheal was 5 mm greater than negative control). Desensitization was performed with an 8 hour method and total dose of 120 mg; premedication was methylprednisolone 40 mg, clorpheniramine 10 mg and ondansetron 8 mg. No immediate reactions ocurred. Two days later patient presented cutaneous vasculitis lesions in lower limbs and abdomen so 50 mg of prednisone for 7 days was started. CBC, urinalysis, LDH and hepatic enzymes were normal. Skin lesions resolved 2 days later. Treatment with docetaxel was considered as treatment despite high costs and limited availability for most patients. Discussion: Administration of docetaxel with premedication is considered as a treatment option however patients with delayed taxaneinduced HSRs, with onset of 48 hours or less after the infusion might be at risk of an immediate reaction on re-exposure as reported with our patient.
Introduction: Antineoplastics are the third leading cause of death due to drug-induced anaphylaxis. Taxanes are an integral part of the chemotherapeutic regimen used in gynecological malignancies. Drug desensitization is a therapeutic technique that induces a temporary state of tolerance to a drug responsible for a hypersensitivity reaction. Case Description: A 48 year old female diagnosed with stage IV mixed epithelial ovarian cancer and arterial hypertension. Chemotherapy with carboplatin + paclitaxel is indicated, during the first cycle. She presents within the first 5 minutes of application of paclitaxel: lipotimia and wheals, without hypotension, hypoxemia, or wheezing. Skin tests are performed, resulting positive to paclitaxel at dilution 1:1000, a protocol of desensitization was performed based on 6 bags of sodium chloride, and paclitaxel in different concentrations. The desensitization doses were administered within six hours of preparation, and there was no reaction to the administration of the medication. Discussion: Hypersensitivity reactions are common with the administration of taxanes. A desensitization protocol was performed, considering it successful since the patient was able to continue her treatment without adverse reactions.
M030 M028 HORSEFLY-WASP SYNDROME C. Punch*, T. Banks, C. Mikita, Bethesda, MD Introduction: We present a 67 year old male who developed anaphylaxis after being bitten by a horsefly; likely a more common diagnosis than previously documented. Case Description: 67 year old male farmer presented to ED with symptoms of anaphylaxis. He had eaten crab and ten minutes later was bitten by a horsefly on his left hand. He became lightheaded, developed left arm swelling, and itchy hands. Symptoms progressed to peri-oral numbness, neck erythema, emesis and loss of consciousness. His evaluation revealed positive specific IgE by serology to HB, WA, YH, YJ, WFH, horsefly and crab. Six weeks later, patient successfully passed crab challenge. Probable horsefly-wasp syndrome suspected and patient decided to undergo VIT to mixed vespids, wasp, and honeybee. Discussion: At least 30 cases of severe allergic reactions to horsefly allergy (family Tabanidae) have been recorded; however, this is thought to be underreported secondary to poor diagnostics and lack of awareness. Clinically, a co-existence of anaphylaxis to horsefly and hymenoptera has been reported. Tab y 2 (a hyaluronidase) and Tab y 5 (antigen 5) have been identified as potential allergen proteins from the saliva of the horsefly as well as wasp venom which supports evidence of horsefly-wasp syndrome. Given the patient’s occupational risk, lack of specific immunotherapy for horsefly allergy, and suspected cross reactivity between the wasp and horsefly, VIT for wasp should be considered as a scientifically plausible but limited treatment option for horsefly allergy.
DESENSITIZATION PROTOCOL FOR HYPERSENSITIVITY TO CARBOPLATIN INPATIENT WITH METASTATIC CANCER, A SAFE AND EFFECTIVE METHOD R. Ramirez Rodriquez*, S. Gonzalez-Diaz, A. Macias-Weinmann, A. Arias-Cruz, R. Villarreal Gonzalez, Monterrey, Neuvo Leon, Mexico Introduction: Use of chemotherapy compounds in clinical practice is increasing leading to a rise in the incidence of hypersensitivity reactions. Reactions to carboplatin usually occur between the fourth and eighth course of chemotherapy. The reaction manifests with rash, dyspnea, tightness in the chest, hypotension/hypertension, edema, back pain. Case Description: 53-year-old male without history of atopy, with metastatic adenocarcinoma in treatment with carboplatin and paclitaxel. During course number 6, at the end of the carboplatin infusion, the patient showed a cutaneous eruption in the face and neck, extended to the abdomen and chest, five minutes after presenting foreign body sensation and dyspnea, the management was with hydrocortisone and intravenous chlorpheniramine, the duration of eruption was less than 1 hour. During the seventh course of chemotherapy, at the end of carboplatin the eruption returned with the same characteristics, which remitted with hydrocortisone and chlorpheniramine. The patient was referred to our unit; skin test with carboplatin was performed. Prick test was negative and the intradermal test (undiluted drug 10 mg / 1 ml) was positive. The patient underwent carboplatin desensitization according to a 12-step protocol (Table 1), with good drug tolerance and adequate clinical response. Discussion: Hypersensitivity reactions to chemotherapy agents are defined as unexpected reactions with signs and symptoms inconsistent
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
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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
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
M027
M029
EARLY AND DELAYED HYPERSENSITIVITY REACTIONS TO PACLITAXEL: DESENSITIZATION AS A CHALLENGE C. De Lira-Quezada*1, A. Macias-Weinmann1, S. Gonzalez-Diaz1, A. Arias-Cruz1, R. Villarreal Gonzalez1, I. Perez Gomez1, R. Ramirez-Rodriguez2, 1. Monterrey, Nuevo Leon, Mexico; 2. Monterrey, Mexico
SUCCESSFUL DESENSITIZATION TO PACLITAXEL: A CASE REPORT R. Guzman Cotaya*, S. Gonzalez-Diaz, A. Arias-Cruz, A. Macias-Weinmann, C. De Lira-Quezada, D. Roman Canamar, R. Villarreal Gonzalez, Monterrey, Nuevo Leon, Mexico
Introduction: Taxanes are among the most frequently implicated antineoplastics in anaphylaxis and occur in around 1% of patients. Immediate hypersensitivity reactions (HSR) to taxanes are generally attributed to the surfactants used in their formulation however IgE mediated reactions have been reported. Case Description: A 36 year old female patient with breast cancer stage IIB diagnosed on November 2017 was referred to our center by the Oncology Service. Patient started chemotherapy with paclitaxel 120 mg, however 3 minutes after the second dose she presented pruritus, chest pain and throat tightness; dexamethasone and clorpheniramine was administered by oncologist with complete resolution of symptoms. We performed skin tests with paclitaxel (1 mg/1ml): prick tests were negative, intradermal test (0.01 mg/ml) 0.05 ml was positive (wheal was 5 mm greater than negative control). Desensitization was performed with an 8 hour method and total dose of 120 mg; premedication was methylprednisolone 40 mg, clorpheniramine 10 mg and ondansetron 8 mg. No immediate reactions ocurred. Two days later patient presented cutaneous vasculitis lesions in lower limbs and abdomen so 50 mg of prednisone for 7 days was started. CBC, urinalysis, LDH and hepatic enzymes were normal. Skin lesions resolved 2 days later. Treatment with docetaxel was considered as treatment despite high costs and limited availability for most patients. Discussion: Administration of docetaxel with premedication is considered as a treatment option however patients with delayed taxaneinduced HSRs, with onset of 48 hours or less after the infusion might be at risk of an immediate reaction on re-exposure as reported with our patient.
Introduction: Antineoplastics are the third leading cause of death due to drug-induced anaphylaxis. Taxanes are an integral part of the chemotherapeutic regimen used in gynecological malignancies. Drug desensitization is a therapeutic technique that induces a temporary state of tolerance to a drug responsible for a hypersensitivity reaction. Case Description: A 48 year old female diagnosed with stage IV mixed epithelial ovarian cancer and arterial hypertension. Chemotherapy with carboplatin + paclitaxel is indicated, during the first cycle. She presents within the first 5 minutes of application of paclitaxel: lipotimia and wheals, without hypotension, hypoxemia, or wheezing. Skin tests are performed, resulting positive to paclitaxel at dilution 1:1000, a protocol of desensitization was performed based on 6 bags of sodium chloride, and paclitaxel in different concentrations. The desensitization doses were administered within six hours of preparation, and there was no reaction to the administration of the medication. Discussion: Hypersensitivity reactions are common with the administration of taxanes. A desensitization protocol was performed, considering it successful since the patient was able to continue her treatment without adverse reactions.
M030 M028 HORSEFLY-WASP SYNDROME C. Punch*, T. Banks, C. Mikita, Bethesda, MD Introduction: We present a 67 year old male who developed anaphylaxis after being bitten by a horsefly; likely a more common diagnosis than previously documented. Case Description: 67 year old male farmer presented to ED with symptoms of anaphylaxis. He had eaten crab and ten minutes later was bitten by a horsefly on his left hand. He became lightheaded, developed left arm swelling, and itchy hands. Symptoms progressed to peri-oral numbness, neck erythema, emesis and loss of consciousness. His evaluation revealed positive specific IgE by serology to HB, WA, YH, YJ, WFH, horsefly and crab. Six weeks later, patient successfully passed crab challenge. Probable horsefly-wasp syndrome suspected and patient decided to undergo VIT to mixed vespids, wasp, and honeybee. Discussion: At least 30 cases of severe allergic reactions to horsefly allergy (family Tabanidae) have been recorded; however, this is thought to be underreported secondary to poor diagnostics and lack of awareness. Clinically, a co-existence of anaphylaxis to horsefly and hymenoptera has been reported. Tab y 2 (a hyaluronidase) and Tab y 5 (antigen 5) have been identified as potential allergen proteins from the saliva of the horsefly as well as wasp venom which supports evidence of horsefly-wasp syndrome. Given the patient’s occupational risk, lack of specific immunotherapy for horsefly allergy, and suspected cross reactivity between the wasp and horsefly, VIT for wasp should be considered as a scientifically plausible but limited treatment option for horsefly allergy.
DESENSITIZATION PROTOCOL FOR HYPERSENSITIVITY TO CARBOPLATIN INPATIENT WITH METASTATIC CANCER, A SAFE AND EFFECTIVE METHOD R. Ramirez Rodriquez*, S. Gonzalez-Diaz, A. Macias-Weinmann, A. Arias-Cruz, R. Villarreal Gonzalez, Monterrey, Neuvo Leon, Mexico Introduction: Use of chemotherapy compounds in clinical practice is increasing leading to a rise in the incidence of hypersensitivity reactions. Reactions to carboplatin usually occur between the fourth and eighth course of chemotherapy. The reaction manifests with rash, dyspnea, tightness in the chest, hypotension/hypertension, edema, back pain. Case Description: 53-year-old male without history of atopy, with metastatic adenocarcinoma in treatment with carboplatin and paclitaxel. During course number 6, at the end of the carboplatin infusion, the patient showed a cutaneous eruption in the face and neck, extended to the abdomen and chest, five minutes after presenting foreign body sensation and dyspnea, the management was with hydrocortisone and intravenous chlorpheniramine, the duration of eruption was less than 1 hour. During the seventh course of chemotherapy, at the end of carboplatin the eruption returned with the same characteristics, which remitted with hydrocortisone and chlorpheniramine. The patient was referred to our unit; skin test with carboplatin was performed. Prick test was negative and the intradermal test (undiluted drug 10 mg / 1 ml) was positive. The patient underwent carboplatin desensitization according to a 12-step protocol (Table 1), with good drug tolerance and adequate clinical response. Discussion: Hypersensitivity reactions to chemotherapy agents are defined as unexpected reactions with signs and symptoms inconsistent
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