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Heparin desensitization in a patient requiring cardiopulmonary bypass for aortic valve replacement (AVR)
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Abstracts
J ALLERGY CLIN IMMUNOL FEBRUARY 2003
76 Antibiotic Desensitization for the Allergic Patient: 5 Years of Experience and Practice
78 Successful Desensitization to Intravenous Cyclosporine: A Case Report
S. E. Turvey I, B. Cronin 1, A. D. Arnold 2, A. F. Diounl; lDivision of Immunology, Children's Hospital, Boston, MA, 2Department of Pharmacy, Children's Hospital, Boston, MA. RATIONALE: Antibiotic de.,~ sitization is an option for patients with an IgE-mediated antibiotic allergy when no other alternative exists for treating life-threatening bacterial infections. However, there is limited data describing the outcomes of this procedure with newer commonly used antibiotics. METHODS: We performed a chart review of all patients undergoing antibiotic desensitization in our institution between November 1996 and November 2001. RESULTS: There were a total of 57 desensitizations performed in 21 patients. The mean age was 22.8 years (range 1.9 to 44.5 years) and there were 15 females (71.4%). Nineteen patients (90.5%) had cystic fibrosis. In 97% (32/33) of these patients the indication for desensitization was a history suggestive of an IgE-mediated reaction to the antibiotic and/or positive skin test to the antibiotic or a closely related antibiotic, while for 3% (1/33) empiric desensitization was performed due to the urgency of the clinical situation. Desensitizations were performed to 12 different antibiotics. Successful outcomes were achieved in 75.4% (43) of the desensitizations. Of the 10 cases (17.5%) that were terminated due to an allergic reaction there were no fatalities, intubations, or other aggressive interventions aside from epinephrine, corticosteroids, and/or antihistamines. In 6/10 unsuccessful desensitizations there appeared to be a nonIgE mechanism responsible for the allergic reaction. CONCLUSIONS: Antibiotic desensitization is a useful option when treating patients with life-threatening infections who must receive antibiotics to which they have an allergy. These data indicate that in the majority of cases, patients with an IgE-mediated antibiotic allergy may safely receive antibiotics after desensitization.
H. M. Patel; Department of Medicine/Division of" Allergy/Immunology, SUNY-Stony Brook, Stony Brook, NY. RATIONALE: Anaphylaxis to cyclosporine, a potent immunosuppressant agent, is rare. Intravenous desensitization was not reported in a recent MEDLINE search using keywords cyclosporine, immunologic desensitization on August 20, 2002. An 18 year old lady with ulcerative colitis that was refractory to high dose steroids, pentasa, azathioprine, balsalazide disodium, ciprofloxacin, and metronidazole received cyclosporine. She developed indigestion, dyspnea, wheezing, laryngospasm, and angioedema involving her face within minutes of initiation of an intravenous infusion. The infusion was disconnected and symptoms remitted over 30 minutes. 6 months after this episode, we successfully desensitized her to intravenous cyclosporine. METHODS: Cyclosporine desensitization was attempted because of her refractory ulcerative colitis and lack of alternative medical treatment options. We transferred her to the intensive care unit and started with a 0.025 mg per hour infusion for 2 hours on day 1. The dose was doubled on a daily basis till she received 12.5 mg per hour for 2 hours on day 10. She continued a 271 mg infusion over the next 24 hours. She tolerated the protocol well. On day 5 she developed a fiat, nonpruritic circumoral erythema 22 hours after the day 4 infusion that was self-limited. RESULTS: Successful desensitization to intravenous cyclosporine is possible. CONCLUSIONS: Anaphylaxis to cyclosporine and its intravenous carrier cremophor EL have been previously described. Our patient was able to tolerate intravenous cyclosporine after our desensitization protocol. We believe this is the first reported case of successful desensitization to intravenous cyclosporine.
Funding: Se!f-funded
77 monary Heparin Desensitization in a Patient Requiring CardiopulBypassfor Aortic Valve Replacement (AVR)
M. B. Strub, E. Brigino-Buenaventura, E R. Bocobo, D. E German, R. C. Richter, M. Ghotbi; Kaiser Permanente Medical Center, San Francisco and Vallejo, CA. Heparin anticoagulation is required for cardiopulmonary bypass. There are no rapidly reversible alternatives and none are FDA-approved for anticoagulation during cardiopulmonary bypass. We present a patient with a history of heparin allergy requiring desensitization for AVR surgery. A 60year-old male with a history of aortic valve disease presented for AVR surgery. In 1994, during renal dialysis, the patient developed a systemic reaction to heparin with flushing and wheezing. This reaction occurred on multiple occasions with porcine or bovine heparin. Dialysis without heparin produced no reaction but persistent clotting necessitated peritoneal dialysis prior to transplant. Prick skin testing to preservative-free heparin was performed with negative/positive controls and was positive at a 1:5000 dilution. Testing of normal controls was negative. The patient was admitted to SF Kaiser Hospital one day prior to surgery. Informed consent was obtained. Heparin desensitization was perfomed by administering progressively increasing doses from 0.1 to 5000u 1V in 25 cc normal saline at 15 min intervals. A cumulative dose of 10,000u was given over 5 hours, timed to finish 8 hrs prior to surgery. Based on the patient's creatinine clearance, <10% of the dose remained at the start of surgery. The patient was pretreated with methylprednisolone 40 mg IV at 7 hours, and IV methylprednisolone 40 mg, diphenhydramine 50 mg, and cimetidine 300 mg, 1 hour prior to surgery. The patient tolerated both the desensitization and the subsequent heparinization for cardiopulmonary bypass uneventfully. It is concluded that heparin desensitization is feasible in heparin-allergy patients unde~oing cardiopulmonary bypass.
Funding: Self-.funded
Funding: Self-funded
879 "o""'~ DesensitizationReacti~to High Dose Methotrexate with SucS. McKnight, R. W. Fox, R. E. Crockett, R. F. Lockey; University of South Florida College of Medicine and James A. Haley Veterans Medical Center, Tampa, FL. RATIONALE: A 19-year-old male with CNS lymphoma had an anaphylactic reaction secondary to methotrexate (MTX). This report documents successful desensitization to high dose MTX, >4 mg/m2. METHODS: Two weeks prior to his anaphylactic reaction, the patient tolerated IV MTX, 8 gm/m 2, without incident. He had received MTX, approximately 800 mg, during his second infusion and developed scalp pruritus, chest tightness, difficulty breathing, nausea, and generalized urticaria 25 minutes after starting the infusion. He had no other symptoms. The MTX was discontinued and he was treated with methylprednisolone, diphenhydramine, and promethazine and his symptoms resolved. Prick-puncture and intraderma[ testing 5 weeks later with MTX, 0.25 mg/ml and 25 mg/ml, caused a 7 x l I mm wheal and 28 x 28 mm flare within 45 minutes to the 25 mg/ml intradermal test dose. Two control subjects had negative prick puncture and intradermal skin tests to saline and MTX and had a positive histamine control. On the same day he tolerated oral MTX, 2.5 mg. He underwent MTX desensitization because he failed other forms of chemotherapy and radiation therapy. After premedication with montelukast, dexamethasone, diphenhydramine, ranitidine, and ephedrine, he received MTX, 2.5 mg orally. The oral dose was incrementally increased to 60 mg over 2.5 hours. Next, he received boluses of IV MTX, 1.2 mg progressing to 17.8 mg over 1.5 hours and then was started on continuous MTX, 17.8 mg/min. CONCLUSIONS: The patient tolerated the MTX desensitization and received 8.6 grams of IV MTX.
Funding: Se!f-funded
Abstracts
J ALLERGY CLIN IMMUNOL FEBRUARY 2003
76 Antibiotic Desensitization for the Allergic Patient: 5 Years of Experience and Practice
78 Successful Desensitization to Intravenous Cyclosporine: A Case Report
S. E. Turvey I, B. Cronin 1, A. D. Arnold 2, A. F. Diounl; lDivision of Immunology, Children's Hospital, Boston, MA, 2Department of Pharmacy, Children's Hospital, Boston, MA. RATIONALE: Antibiotic de.,~ sitization is an option for patients with an IgE-mediated antibiotic allergy when no other alternative exists for treating life-threatening bacterial infections. However, there is limited data describing the outcomes of this procedure with newer commonly used antibiotics. METHODS: We performed a chart review of all patients undergoing antibiotic desensitization in our institution between November 1996 and November 2001. RESULTS: There were a total of 57 desensitizations performed in 21 patients. The mean age was 22.8 years (range 1.9 to 44.5 years) and there were 15 females (71.4%). Nineteen patients (90.5%) had cystic fibrosis. In 97% (32/33) of these patients the indication for desensitization was a history suggestive of an IgE-mediated reaction to the antibiotic and/or positive skin test to the antibiotic or a closely related antibiotic, while for 3% (1/33) empiric desensitization was performed due to the urgency of the clinical situation. Desensitizations were performed to 12 different antibiotics. Successful outcomes were achieved in 75.4% (43) of the desensitizations. Of the 10 cases (17.5%) that were terminated due to an allergic reaction there were no fatalities, intubations, or other aggressive interventions aside from epinephrine, corticosteroids, and/or antihistamines. In 6/10 unsuccessful desensitizations there appeared to be a nonIgE mechanism responsible for the allergic reaction. CONCLUSIONS: Antibiotic desensitization is a useful option when treating patients with life-threatening infections who must receive antibiotics to which they have an allergy. These data indicate that in the majority of cases, patients with an IgE-mediated antibiotic allergy may safely receive antibiotics after desensitization.
H. M. Patel; Department of Medicine/Division of" Allergy/Immunology, SUNY-Stony Brook, Stony Brook, NY. RATIONALE: Anaphylaxis to cyclosporine, a potent immunosuppressant agent, is rare. Intravenous desensitization was not reported in a recent MEDLINE search using keywords cyclosporine, immunologic desensitization on August 20, 2002. An 18 year old lady with ulcerative colitis that was refractory to high dose steroids, pentasa, azathioprine, balsalazide disodium, ciprofloxacin, and metronidazole received cyclosporine. She developed indigestion, dyspnea, wheezing, laryngospasm, and angioedema involving her face within minutes of initiation of an intravenous infusion. The infusion was disconnected and symptoms remitted over 30 minutes. 6 months after this episode, we successfully desensitized her to intravenous cyclosporine. METHODS: Cyclosporine desensitization was attempted because of her refractory ulcerative colitis and lack of alternative medical treatment options. We transferred her to the intensive care unit and started with a 0.025 mg per hour infusion for 2 hours on day 1. The dose was doubled on a daily basis till she received 12.5 mg per hour for 2 hours on day 10. She continued a 271 mg infusion over the next 24 hours. She tolerated the protocol well. On day 5 she developed a fiat, nonpruritic circumoral erythema 22 hours after the day 4 infusion that was self-limited. RESULTS: Successful desensitization to intravenous cyclosporine is possible. CONCLUSIONS: Anaphylaxis to cyclosporine and its intravenous carrier cremophor EL have been previously described. Our patient was able to tolerate intravenous cyclosporine after our desensitization protocol. We believe this is the first reported case of successful desensitization to intravenous cyclosporine.
Funding: Se!f-funded
77 monary Heparin Desensitization in a Patient Requiring CardiopulBypassfor Aortic Valve Replacement (AVR)
M. B. Strub, E. Brigino-Buenaventura, E R. Bocobo, D. E German, R. C. Richter, M. Ghotbi; Kaiser Permanente Medical Center, San Francisco and Vallejo, CA. Heparin anticoagulation is required for cardiopulmonary bypass. There are no rapidly reversible alternatives and none are FDA-approved for anticoagulation during cardiopulmonary bypass. We present a patient with a history of heparin allergy requiring desensitization for AVR surgery. A 60year-old male with a history of aortic valve disease presented for AVR surgery. In 1994, during renal dialysis, the patient developed a systemic reaction to heparin with flushing and wheezing. This reaction occurred on multiple occasions with porcine or bovine heparin. Dialysis without heparin produced no reaction but persistent clotting necessitated peritoneal dialysis prior to transplant. Prick skin testing to preservative-free heparin was performed with negative/positive controls and was positive at a 1:5000 dilution. Testing of normal controls was negative. The patient was admitted to SF Kaiser Hospital one day prior to surgery. Informed consent was obtained. Heparin desensitization was perfomed by administering progressively increasing doses from 0.1 to 5000u 1V in 25 cc normal saline at 15 min intervals. A cumulative dose of 10,000u was given over 5 hours, timed to finish 8 hrs prior to surgery. Based on the patient's creatinine clearance, <10% of the dose remained at the start of surgery. The patient was pretreated with methylprednisolone 40 mg IV at 7 hours, and IV methylprednisolone 40 mg, diphenhydramine 50 mg, and cimetidine 300 mg, 1 hour prior to surgery. The patient tolerated both the desensitization and the subsequent heparinization for cardiopulmonary bypass uneventfully. It is concluded that heparin desensitization is feasible in heparin-allergy patients unde~oing cardiopulmonary bypass.
Funding: Self-.funded
Funding: Self-funded
879 "o""'~ DesensitizationReacti~to High Dose Methotrexate with SucS. McKnight, R. W. Fox, R. E. Crockett, R. F. Lockey; University of South Florida College of Medicine and James A. Haley Veterans Medical Center, Tampa, FL. RATIONALE: A 19-year-old male with CNS lymphoma had an anaphylactic reaction secondary to methotrexate (MTX). This report documents successful desensitization to high dose MTX, >4 mg/m2. METHODS: Two weeks prior to his anaphylactic reaction, the patient tolerated IV MTX, 8 gm/m 2, without incident. He had received MTX, approximately 800 mg, during his second infusion and developed scalp pruritus, chest tightness, difficulty breathing, nausea, and generalized urticaria 25 minutes after starting the infusion. He had no other symptoms. The MTX was discontinued and he was treated with methylprednisolone, diphenhydramine, and promethazine and his symptoms resolved. Prick-puncture and intraderma[ testing 5 weeks later with MTX, 0.25 mg/ml and 25 mg/ml, caused a 7 x l I mm wheal and 28 x 28 mm flare within 45 minutes to the 25 mg/ml intradermal test dose. Two control subjects had negative prick puncture and intradermal skin tests to saline and MTX and had a positive histamine control. On the same day he tolerated oral MTX, 2.5 mg. He underwent MTX desensitization because he failed other forms of chemotherapy and radiation therapy. After premedication with montelukast, dexamethasone, diphenhydramine, ranitidine, and ephedrine, he received MTX, 2.5 mg orally. The oral dose was incrementally increased to 60 mg over 2.5 hours. Next, he received boluses of IV MTX, 1.2 mg progressing to 17.8 mg over 1.5 hours and then was started on continuous MTX, 17.8 mg/min. CONCLUSIONS: The patient tolerated the MTX desensitization and received 8.6 grams of IV MTX.
Funding: Se!f-funded