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IODODERMA AND SIALADENOPATHY AFTER IODINATED CONTRAST MEDIA EXPOSURE
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
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