- Email: [email protected]
Non-Immediate Skin Reactions Due To Antibiotics
AB274 Abstracts
945
Non-Immediate Skin Reactions Due To Antibiotics Gabriela Zambrano, MD1, Dr. Tamara Fernandez2, Beatriz Ameiro, MD1, Celia Pinto3, Alberto Alvarez-Perea, MD4, Manuel De Barrio, MD5; 1Department of Allergy, Gregorio Mara~non University Hospital, Madrid, Spain, Spain, 2Hospital general universitario gregorio mara~ non, Madrid, Spain, 3Department of Allergy, Gregorio Mara~non University Hospital, Madrid, Spain, 4Hospital Materno Infantil Gregorio Mara~ n on, Pediatric Allergy Department, Madrid, Spain, 5Hospital General Universitario Gregorio Mara~non, Allergy Department, Madrid, Spain. RATIONALE: Antibiotics have been described as a frequent cause of non-immediate skin reactions (NIR). Our goal was to determine: incidence, type of reaction, culprit drug and diagnosis of NIR to antibiotics in our service. METHODS: A descriptive, retrospective study was performed at a third level Hospital in Madrid. Electronic records from patients that consulted about possible drug hypersensitivity reactions to antibiotics from January 2010 to December 2012 were reviewed. Data of skin tests and controlled challenge tests (CCT), if performed, were analyzed. RESULTS: During the study period, 784 patients were attended with suspected antibiotics hypersensitivity, of which 531 presented immediate reactions and 253 NIR. NIR was established in 72 patients (29%). Clinical presentations were maculopapular exanthema (54%), delayed urticaria (21%), fixed drug eruption (8%), erythema multiforme (4%), DRESS (2%), acute generalized exanthematous pustulosis (2%), others (4%). Culprit drugs were beta-lactams (41%), quinolones (27%), macrolides (14%), sulfonamides (13%), others (5%). Diagnosis was based on skin tests in 19 patients, among which 14 were intradermal (57% beta-lactams, 22% quinolones, 14% cotrimoxazole, 7% macrolides) and 5 patch test (80% quinolones, 20% betalactams). CCT turned out positive in 23 patients (48% beta-lactams, 22% macrolides, 17% quinolones, 4.3% cotrimoxazole, others 8.6%). Diagnosis was based on anamnesis in 41%, in patients with comorbidities or severe reactions with negative tests and highly suggestive anamnesis. CONCLUSIONS: Most of NIR to antibiotics were maculopapular exanthema and urticaria. Beta-lactams was the main group involved, followed by quinolones. Although skin tests are useful, anamnesis and -in some cases- CCT are necessary to achieve a diagnosis.
946
TUESDAY
Multiple Drug Hypersensitivity Syndrome In Our Allergy Service Dr. Inmaculada Do~ na, MD, PhD, Dr. Maria J. Torres, MD, PhD, Dr. Paloma Campo, MD, PhD, Dr. Francisca Gomez, MD, PhD, Dr. Maria Salas, MD, PhD, Ms. Maria Dolores Ruiz, Ms. Maria Auxiliadora Guerrero, Dr. Miguel Blanca, MD, PhD; Allergy Service, Carlos Haya Hospital, Malaga, Spain. RATIONALE: Multiple drug hypersensitivity (MDH) has been defined as a hypersensitivity to two or more chemically unrelated drugs. This has been specially studied in IgE-mediated hypersensitivity reactions to antibiotics and more recently in T-cell-mediated reactions. However, studies focusing in MDH in large populations are lacking. The aim of our study was to describe a well-characterized group of patients diagnosed of MDH. METHODS: We analyzed retrospectively all patients with a confirmed diagnosis of drug hypersensitivity evaluated in our allergy department between January 2005 and December 2010. RESULTS: A MDH was diagnosed in 48 (2.41%) of the 1989 patients evaluated, being 32 females, with a mean age of 50614,43 years. A total of 137 episodes were reported: 80 (58,39%) suggested an IgE-mediated reaction, 37 (27%) a non-immunologic mechanism (cross-reactive to NSAIDs) and 20 (14,55%) a T-cell mediated reaction. The percentage of MHD in patients with IgE-mediated reactions (9,78%) was higher compared to those with T-cell mediated reactions (5,23%) and nonimmunologic reactions (1,91%) (p<0,0001). The drugs most frequently involved were dypirone (13,6%), ciprofloxacin (12,1%), amoxicillinclavulanic acid (11,4%), amoxicillin (10%), ASA (8,6%), ibuprofen
J ALLERGY CLIN IMMUNOL FEBRUARY 2014
(7,1%) and moxifloxacin (5,7%). Sensitivity to 2 chemically unrelated drugs was diagnosed in 44 patients and to 3 drugs in 4. The most frequent clinical entities were anaphylaxis/shock (42,85%) and urticaria (34,92%). CONCLUSIONS: Patients with IgE-mediated reactions have a higher risk for developing MHD. More studies are needed to confirm this finding.
947
Desensitization To Anakinra Case Report Dr. Miriam Zamora Verduga, Dr. Maria Alicia Urena Tavera, Mrs. Denisse Angel Pereira, Dr. Ricardo Madrigal-Burgaleta, MD, Dr. Pilar Berges-Gimeno, PhD, Dr. Emilio Alvarez-Cuesta, MD, PhD; Ramon y Cajal University Hospital, Madrid, Spain. RATIONALE: Injection-site reactions with Anakinra are adverse events that can present a challenge to patients and sometimes lead to discontinue therapy. The delayed type of these reactions is less frequent and can present with severe symptoms. The histopathological findings of these lesions described on the literature suggest features of delayed-type hypersensitivity. METHODS: 34 years old man who was diagnosed with Familiar Mediterranean Fever, presented 14 hours after the 7th administration of Anakinra (100mg daily subcutaneous) with erythema, pruritus and a wheal of 10cm in the site of the injection, without any other symptoms and the last one week. He stated that in the following five administrations he presented the same symptoms and had to discontinue therapy. The patient received dexchlorpheniramine orally and topic corticosteroids, with mild clinical response. After the medication was held the patient worsened his baseline condition. His rheumatologist considered the administration of Anakinra as a first-choise therapy. RESULTS: Anakinra: ID readings with 1:1, 1:10 concentrations were positive at 48 hours. 1:100 concentration and all ID with polysorbate were negative. Three controls showed negative results. Patch test with latex and True TestÒ were negative. Desensitization: Daily administration of Anakinra. It began with 10mg/0.6ml administration for 3 days with subsequent progressive rise reaching 100mg/0.6ml as final dose. It took 18 days. After desensitization skin tests became negative. CONCLUSIONS: - We present a case of an effective desensitization in a patient with delayed hypersensitivity to Anakinra. - Allergological study and desensitization programs are of key importance to ensure first-choise therapies.
945
Non-Immediate Skin Reactions Due To Antibiotics Gabriela Zambrano, MD1, Dr. Tamara Fernandez2, Beatriz Ameiro, MD1, Celia Pinto3, Alberto Alvarez-Perea, MD4, Manuel De Barrio, MD5; 1Department of Allergy, Gregorio Mara~non University Hospital, Madrid, Spain, Spain, 2Hospital general universitario gregorio mara~ non, Madrid, Spain, 3Department of Allergy, Gregorio Mara~non University Hospital, Madrid, Spain, 4Hospital Materno Infantil Gregorio Mara~ n on, Pediatric Allergy Department, Madrid, Spain, 5Hospital General Universitario Gregorio Mara~non, Allergy Department, Madrid, Spain. RATIONALE: Antibiotics have been described as a frequent cause of non-immediate skin reactions (NIR). Our goal was to determine: incidence, type of reaction, culprit drug and diagnosis of NIR to antibiotics in our service. METHODS: A descriptive, retrospective study was performed at a third level Hospital in Madrid. Electronic records from patients that consulted about possible drug hypersensitivity reactions to antibiotics from January 2010 to December 2012 were reviewed. Data of skin tests and controlled challenge tests (CCT), if performed, were analyzed. RESULTS: During the study period, 784 patients were attended with suspected antibiotics hypersensitivity, of which 531 presented immediate reactions and 253 NIR. NIR was established in 72 patients (29%). Clinical presentations were maculopapular exanthema (54%), delayed urticaria (21%), fixed drug eruption (8%), erythema multiforme (4%), DRESS (2%), acute generalized exanthematous pustulosis (2%), others (4%). Culprit drugs were beta-lactams (41%), quinolones (27%), macrolides (14%), sulfonamides (13%), others (5%). Diagnosis was based on skin tests in 19 patients, among which 14 were intradermal (57% beta-lactams, 22% quinolones, 14% cotrimoxazole, 7% macrolides) and 5 patch test (80% quinolones, 20% betalactams). CCT turned out positive in 23 patients (48% beta-lactams, 22% macrolides, 17% quinolones, 4.3% cotrimoxazole, others 8.6%). Diagnosis was based on anamnesis in 41%, in patients with comorbidities or severe reactions with negative tests and highly suggestive anamnesis. CONCLUSIONS: Most of NIR to antibiotics were maculopapular exanthema and urticaria. Beta-lactams was the main group involved, followed by quinolones. Although skin tests are useful, anamnesis and -in some cases- CCT are necessary to achieve a diagnosis.
946
TUESDAY
Multiple Drug Hypersensitivity Syndrome In Our Allergy Service Dr. Inmaculada Do~ na, MD, PhD, Dr. Maria J. Torres, MD, PhD, Dr. Paloma Campo, MD, PhD, Dr. Francisca Gomez, MD, PhD, Dr. Maria Salas, MD, PhD, Ms. Maria Dolores Ruiz, Ms. Maria Auxiliadora Guerrero, Dr. Miguel Blanca, MD, PhD; Allergy Service, Carlos Haya Hospital, Malaga, Spain. RATIONALE: Multiple drug hypersensitivity (MDH) has been defined as a hypersensitivity to two or more chemically unrelated drugs. This has been specially studied in IgE-mediated hypersensitivity reactions to antibiotics and more recently in T-cell-mediated reactions. However, studies focusing in MDH in large populations are lacking. The aim of our study was to describe a well-characterized group of patients diagnosed of MDH. METHODS: We analyzed retrospectively all patients with a confirmed diagnosis of drug hypersensitivity evaluated in our allergy department between January 2005 and December 2010. RESULTS: A MDH was diagnosed in 48 (2.41%) of the 1989 patients evaluated, being 32 females, with a mean age of 50614,43 years. A total of 137 episodes were reported: 80 (58,39%) suggested an IgE-mediated reaction, 37 (27%) a non-immunologic mechanism (cross-reactive to NSAIDs) and 20 (14,55%) a T-cell mediated reaction. The percentage of MHD in patients with IgE-mediated reactions (9,78%) was higher compared to those with T-cell mediated reactions (5,23%) and nonimmunologic reactions (1,91%) (p<0,0001). The drugs most frequently involved were dypirone (13,6%), ciprofloxacin (12,1%), amoxicillinclavulanic acid (11,4%), amoxicillin (10%), ASA (8,6%), ibuprofen
J ALLERGY CLIN IMMUNOL FEBRUARY 2014
(7,1%) and moxifloxacin (5,7%). Sensitivity to 2 chemically unrelated drugs was diagnosed in 44 patients and to 3 drugs in 4. The most frequent clinical entities were anaphylaxis/shock (42,85%) and urticaria (34,92%). CONCLUSIONS: Patients with IgE-mediated reactions have a higher risk for developing MHD. More studies are needed to confirm this finding.
947
Desensitization To Anakinra Case Report Dr. Miriam Zamora Verduga, Dr. Maria Alicia Urena Tavera, Mrs. Denisse Angel Pereira, Dr. Ricardo Madrigal-Burgaleta, MD, Dr. Pilar Berges-Gimeno, PhD, Dr. Emilio Alvarez-Cuesta, MD, PhD; Ramon y Cajal University Hospital, Madrid, Spain. RATIONALE: Injection-site reactions with Anakinra are adverse events that can present a challenge to patients and sometimes lead to discontinue therapy. The delayed type of these reactions is less frequent and can present with severe symptoms. The histopathological findings of these lesions described on the literature suggest features of delayed-type hypersensitivity. METHODS: 34 years old man who was diagnosed with Familiar Mediterranean Fever, presented 14 hours after the 7th administration of Anakinra (100mg daily subcutaneous) with erythema, pruritus and a wheal of 10cm in the site of the injection, without any other symptoms and the last one week. He stated that in the following five administrations he presented the same symptoms and had to discontinue therapy. The patient received dexchlorpheniramine orally and topic corticosteroids, with mild clinical response. After the medication was held the patient worsened his baseline condition. His rheumatologist considered the administration of Anakinra as a first-choise therapy. RESULTS: Anakinra: ID readings with 1:1, 1:10 concentrations were positive at 48 hours. 1:100 concentration and all ID with polysorbate were negative. Three controls showed negative results. Patch test with latex and True TestÒ were negative. Desensitization: Daily administration of Anakinra. It began with 10mg/0.6ml administration for 3 days with subsequent progressive rise reaching 100mg/0.6ml as final dose. It took 18 days. After desensitization skin tests became negative. CONCLUSIONS: - We present a case of an effective desensitization in a patient with delayed hypersensitivity to Anakinra. - Allergological study and desensitization programs are of key importance to ensure first-choise therapies.