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P007 Drug rash eosinophilia and systemic symptoms syndrome secondary to vancomycin
S18
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
P004
P006
DRESS SECONDARY TO FEBUXOSTAT IN A PATIENT WITH PRIOR DRESS FROM ALLOPURINOL R. Altisheh*, T. Carr, Tucson, AZ.
SUCCESSFUL DESENSITIZATIONS WITH CEFTRIAXONE AND AZITHROMYCIN IN A PATIENT WITH MAST CELL ACTIVATION SYNDROME P. Staso*, A. Leonov, Kalamazoo, MI.
Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare potentially life threatening hypersensitivity reaction. Febuxostat is a novel non-purine analogue inhibitor of xanthine oxidase, which is used as an alternative to the purine analogue allopurinol for lowering serum urate. Case Presentaion: A 77 year old female with type 2 diabetes, chronic kidney disease and gout was started on allopurinol as gout prophylaxis. Ten weeks later, the patient presented with a four-week history of progressive diffuse pruritic erythematous peeling coalescing papules involving extremities, trunk, palms, soles and oral mucosa with tender cervical lymphadenopathy. Renal failure and pronounced peripheral eosinophil count (9200 /uL) were identified. Skin biopsy was consistent with DRESS. Allopurinol was discontinued and systemic corticosteroids was initiated with a slow taper and eventual resolution of symptoms. Several months later, febuxostat was introduced as an alternative gout prophylaxis. The next day, the patient developed a diffuse morbilliform eruption all over her body with facial swelling and decreased urine output. Renal failure and peripheral blood eosinophilia (500/uL) were again noted. Febuxostat was discontinued and a corticosteroid taper was re-initiated with resolution of symptoms. Discussion: Used as the first-line urate-lowering therapy for decades, allpurinol has been reported as one of the most common causative agents of DRESS. Febuxostat has also been rarely reported to spontaneously cause DRESS. However, the risk of DRESS from febuxostat in individuals with DRESS from allopurinol is not clear. This case suggests a possible relationship, which should be assessed through careful post-marketing surveillance and case-reporting.
P005
Introduction: Mast Cell Activation Syndrome (MCAS), is defined by episodic symptoms consistent with mast cell mediator release, closely resembling anaphylaxis and may be triggered by multiple agents including medications. The development of rapid desensitization protocols for the treatment of drug hypersensitivities is aimed at providing essential medications while protecting patients from severe reactions induced by anaphylactic and anaphylactoid mechanisms. Methods: In our patient with Chlamydia pneumoniae and hypersensitivity to cephalosporins and azithromycin, a protocol consisting of progressive amounts of ceftriaxone and azithromycin until therapeutic doses were clinically tolerated. Results: We present the first reported case of a patient with MCAS with a history of anaphylactic reaction to cephalosporins and azithromycin who underwent successful desensitizations with ceftriaxone as empiric pneumonia therapy and azithromycin to treat Chlamydia pneumoniae infection once cultures were finalized. Conclusion: Medication administration in the setting of MCAS is challenging as patients may react randomly. Drug-induced type I hypersensitivity reactions result from the release of mediators from IgE-sensitized mast cells. Anaphylactoid reactions in contrast, are not mediated by IgE, but still result in a release of inflammatory mediators. Desensitization is a method of preventing a negative immune response by increasing progressive doses until a full therapeutic dose is achieved, thus providing basal and mast cell stabilization. Rapid desensitization protocols have been published for non-IgE-mediated reactions, but mechanisms of action are still largely unclear. Desensitization provided a way to administer medications safely and may be extrapolated in future cases in patients with allergies or when starting new medications.
P007
ALLERGY TO COBALT-CONTAINING SUPPLEMENTS: A CASE REPORT Y. Tsyzuki*, Sapporo, Japan.
DRUG RASH EOSINOPHILIA AND SYSTEMIC SYMPTOMS SYNDROME SECONDARY TO VANCOMYCIN A. Bansal*, L. Kallur, C. Cooper, A. Patel, G. Youngber, A. Gonzalez-Estrada, Johnson City, TN.
Introduction: Allergy to cobalt-containing supplements is rare, but it may trigger systemic symptoms, such as systemic urticaria. We report a case of cobalt allergy that might be caused by cobalt-containing supplements, and its management is discussed. Case Report: A 29-year-old female, with a medical history of atopic dermatitis, allergic rhinitis, seasonal rhinitis, and metal allergy, was referred to us for sustained itchy rash of both her arms and legs. She was administered antihistamine, but her symptom persisted. She reported that her symptoms developed after regular use of commercial supplements approximately one month ago. The supplements contained cyanocobalamin (unknown amount of cobalt). We performed a patch test of metals, and it was positive for cobalt, nickel, and tin. We diagnosed her with allergies to the supplements containing these metals. After she avoided the supplements, her symptoms disappeared. However, she redeveloped an itchy rash on both legs when she ate salmon roe, which is cobalt abundant. Finally, we diagnosed a cobalt allergy. Conclusions: Cobalt is an essential element of vitamin B12 (cobalamin), and it is widely used in supplements. Allergy to cobalt-containing supplements is a relatively infrequent event, but intramuscular vitamin B12 injection may cause anaphylaxis. Cobalt allergy should be considered when diagnosing allergies to supplements.
Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a life threatening, delayed cutaneous adverse drug reaction (cADR) leading to rash, fever and inflammation. Case Description: A 38-year-old male with a past medical history of hepatitis C, opiate abuse and recent diagnosis of osteomyelitis treated with vancomycin presented with a two-day pruritic rash. Patient first noticed the rash on his back, which spread peripherally during the span of 2 days. The patient had been on vancomycin for the last 3 weeks. On physical exam, he had a diffuse blanching maculopapular exanthema (Figure 1A and 1B); facial angioedema; palpable axillary and inguinal lymph nodes. Laboratory evaluation was relevant for leukocytosis (13.3 K/uL with 83% neutrophilia and 8% eosinophilia), mild elevation of liver function tests and peripheral smear revealed atypical lymphocytes (Figure 1C). Skin biopsy demonstrated superficial perivascular dermatitis with papillary dermal edema (Figure 1D). Vancomycin was discontinued and daptomycin was started. He also received high dose antihistamines and systemic corticosteroids, prednisone 40 mg per day with a 6 week taper. On follow up, rash had resolved. Conclusion: Almost 50% of cADRs are due to antibiotics. Till date, 31 cases of vancomycin induced cADRs have been reported. Variable presentation, which may mimic other causes, proves to be a challenge in diagnosing this condition. Prompt recognition and withdrawal of causative agent provides complete resolution.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
S19
P009 PEDIATRIC INTRAOPERATIVE ANAPHYLAXIS OF UNKNOWN ETIOLOGY D. Paulk*, J. Kuhlen, C. Greene, Greenville, SC.
Diffuse blanching maculopapular exanthema (Figure 1A and 1B); Atypical lymphocytes (Figure 1C); Skin biopsy showing superficial perivascular dermatitis with papillary dermal edema (Figure 1D)
Introduction: Anaphylaxis is increasing in the general population and is more common in the pediatric population. Intraoperative anaphylactic events are rare but can be life threatening with a higher mortality rate compared to events in other settings. Appropriate recognition and management of these events is important, and an effort should be made to identify the culprit agent to avoid re-exposure and prevent future reactions. Case Presentation: This case illustrates a 14 year old male who underwent posterior spinal fusion with instrumentation for idiopathic adolescent scoliosis and experienced intraoperative anaphylaxis. Intraoperative tryptase was elevated to 7ng/ml with baseline level of 2ng/ml. The patient recovered and was referred to an outpatient allergy and immunology clinic. A comprehensive allergy evaluation to determine the culprit agent was completed. The patient underwent clindamycin, penicillin, and propofol skin testing in the office with negative results. Discussion: Similar to previously published literature, we were unable to identify the responsible agent that led to anaphylaxis. However, it is also known that despite an unidentified culprit after a comprehensive evaluation, patients often are able to tolerate subsequent anesthesia regardless of severity of initial reaction. Additional investigations regarding pediatric anaphylaxis and post-procedure evaluation and management need to be completed.
P008 ANAPHYLAXIS: CLOSER TO HOME? S. Anvari*, A. Blackman, A. Anagnostou, Houston, TX. Introduction: Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction. We examined causes, clinical features and location of anaphylactic episodes, in our patient population, over a 1-year period. Methods: We performed a retrospective case-note review between January-December 2016 for children 0-18 years old, presenting with anaphylaxis. We report results on the first 46 patients. Results: Among the first forty-six children (4months-16 years; median:8.5yrs) presenting with anaphylaxis, food was the most common cause (43%); specifically, tree nuts (40%), followed by eggs (15%). Other causes included drug (17%), venom (13%), immunotherapy (4%), vaccinations (2%) and unknown (19%). Twelve children (26%) had a prior history of anaphylaxis and 10 (21%) had epinephrine available at the time of reaction. Interestingly, the majority of episodes occurred in the home setting (61%), followed by 15% in a medical facility, 11% at school/daycare, 4% at restaurants, 2% at cinemas, 2% at church, 2% unrecorded. Cutaneous symptoms were most commonly reported (91%), followed by respiratory (69%), gastrointestinal (17%), and cardiovascular (8%). Most symptoms (46%) developed within 5 min, 8% within 5-30 min, 4% within 30-120 min, 6% in more than 2hrs and 35% unrecorded. 63% of children received treatment within a few minutes, 26% after 30 minutes, and in 10% unrecorded. Almost all (91%) received epinephrine, with 17% requiring 2 doses. Conclusions: Despite parents’ concerns that anaphylaxis occurs frequently outside the home environment, the majority of episodes occurred at home, with food remaining the most common cause. This may be the result of allergen/nutfree schools or increasing awareness of food allergies in the community.
P010 SINGLE AND TWO-DOSE ORAL CHALLENGE WITH TRIMETHOPRIM-SULFAMETHOXAZOLE IN HIVUNINFECTED ADULTS LABELED AS “SULFA” ALLERGIC A. Abreo*1, C. Stone1, E. McKinnon2, E. Phillips1, 1. Nashville, TN; 2. Perth, WA, Australia. Introduction: A label of “sulfa” allergy (SA) associated with unknown, remote, vague or non-serious cutaneous reactions frequently leads to lifelong avoidance of both sulfa antimicrobials and the non-cross-reactive non-antibiotic sulfonamides. Multiple dose graded challenge or desensitization to trimethoprim-sulfamethoxazole (TMP-SMX) are guideline-favored approaches that have been studied in HIV-infected patients; however, literature in non-HIV SA labeled patients is lacking. Methods: We retrospectively identified 57 non-HIV immunocompromised or immunocompetent adults with histories of vague, remote or non-serious cutaneous reactions to sulfonamide medications who underwent a single (400/80 mg) or two-dose (40/ 8;400/80 mg) TMP-SMX oral challenge over a 3-year period. Patient demographics, reaction history, and the type of challenge were compared between individuals that were successfully and unsuccessfully de-labeled. Results: There were no immediate or delayed reactions in 54/57 (95%) patients. SA label removal was associated with younger age at reaction (32.616 vs 54.014 years, P¼0.03) and time since the original reaction (24.817 vs 87 years, P¼0.02). Those not tolerating the challenge were female and experienced mild, transient rash, fever, or myalgia 6-24 hours following the challenge that did not require any treatment. No other differences were noted between baseline demographics, indication for SA de-labeling, comorbidities or immunocompetency between these patients and those successfully de-labeled. Of nine patients requiring TMP-SMX for long-term infection prophylaxis, 100% have tolerated Bactrim >12 weeks.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
P004
P006
DRESS SECONDARY TO FEBUXOSTAT IN A PATIENT WITH PRIOR DRESS FROM ALLOPURINOL R. Altisheh*, T. Carr, Tucson, AZ.
SUCCESSFUL DESENSITIZATIONS WITH CEFTRIAXONE AND AZITHROMYCIN IN A PATIENT WITH MAST CELL ACTIVATION SYNDROME P. Staso*, A. Leonov, Kalamazoo, MI.
Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare potentially life threatening hypersensitivity reaction. Febuxostat is a novel non-purine analogue inhibitor of xanthine oxidase, which is used as an alternative to the purine analogue allopurinol for lowering serum urate. Case Presentaion: A 77 year old female with type 2 diabetes, chronic kidney disease and gout was started on allopurinol as gout prophylaxis. Ten weeks later, the patient presented with a four-week history of progressive diffuse pruritic erythematous peeling coalescing papules involving extremities, trunk, palms, soles and oral mucosa with tender cervical lymphadenopathy. Renal failure and pronounced peripheral eosinophil count (9200 /uL) were identified. Skin biopsy was consistent with DRESS. Allopurinol was discontinued and systemic corticosteroids was initiated with a slow taper and eventual resolution of symptoms. Several months later, febuxostat was introduced as an alternative gout prophylaxis. The next day, the patient developed a diffuse morbilliform eruption all over her body with facial swelling and decreased urine output. Renal failure and peripheral blood eosinophilia (500/uL) were again noted. Febuxostat was discontinued and a corticosteroid taper was re-initiated with resolution of symptoms. Discussion: Used as the first-line urate-lowering therapy for decades, allpurinol has been reported as one of the most common causative agents of DRESS. Febuxostat has also been rarely reported to spontaneously cause DRESS. However, the risk of DRESS from febuxostat in individuals with DRESS from allopurinol is not clear. This case suggests a possible relationship, which should be assessed through careful post-marketing surveillance and case-reporting.
P005
Introduction: Mast Cell Activation Syndrome (MCAS), is defined by episodic symptoms consistent with mast cell mediator release, closely resembling anaphylaxis and may be triggered by multiple agents including medications. The development of rapid desensitization protocols for the treatment of drug hypersensitivities is aimed at providing essential medications while protecting patients from severe reactions induced by anaphylactic and anaphylactoid mechanisms. Methods: In our patient with Chlamydia pneumoniae and hypersensitivity to cephalosporins and azithromycin, a protocol consisting of progressive amounts of ceftriaxone and azithromycin until therapeutic doses were clinically tolerated. Results: We present the first reported case of a patient with MCAS with a history of anaphylactic reaction to cephalosporins and azithromycin who underwent successful desensitizations with ceftriaxone as empiric pneumonia therapy and azithromycin to treat Chlamydia pneumoniae infection once cultures were finalized. Conclusion: Medication administration in the setting of MCAS is challenging as patients may react randomly. Drug-induced type I hypersensitivity reactions result from the release of mediators from IgE-sensitized mast cells. Anaphylactoid reactions in contrast, are not mediated by IgE, but still result in a release of inflammatory mediators. Desensitization is a method of preventing a negative immune response by increasing progressive doses until a full therapeutic dose is achieved, thus providing basal and mast cell stabilization. Rapid desensitization protocols have been published for non-IgE-mediated reactions, but mechanisms of action are still largely unclear. Desensitization provided a way to administer medications safely and may be extrapolated in future cases in patients with allergies or when starting new medications.
P007
ALLERGY TO COBALT-CONTAINING SUPPLEMENTS: A CASE REPORT Y. Tsyzuki*, Sapporo, Japan.
DRUG RASH EOSINOPHILIA AND SYSTEMIC SYMPTOMS SYNDROME SECONDARY TO VANCOMYCIN A. Bansal*, L. Kallur, C. Cooper, A. Patel, G. Youngber, A. Gonzalez-Estrada, Johnson City, TN.
Introduction: Allergy to cobalt-containing supplements is rare, but it may trigger systemic symptoms, such as systemic urticaria. We report a case of cobalt allergy that might be caused by cobalt-containing supplements, and its management is discussed. Case Report: A 29-year-old female, with a medical history of atopic dermatitis, allergic rhinitis, seasonal rhinitis, and metal allergy, was referred to us for sustained itchy rash of both her arms and legs. She was administered antihistamine, but her symptom persisted. She reported that her symptoms developed after regular use of commercial supplements approximately one month ago. The supplements contained cyanocobalamin (unknown amount of cobalt). We performed a patch test of metals, and it was positive for cobalt, nickel, and tin. We diagnosed her with allergies to the supplements containing these metals. After she avoided the supplements, her symptoms disappeared. However, she redeveloped an itchy rash on both legs when she ate salmon roe, which is cobalt abundant. Finally, we diagnosed a cobalt allergy. Conclusions: Cobalt is an essential element of vitamin B12 (cobalamin), and it is widely used in supplements. Allergy to cobalt-containing supplements is a relatively infrequent event, but intramuscular vitamin B12 injection may cause anaphylaxis. Cobalt allergy should be considered when diagnosing allergies to supplements.
Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a life threatening, delayed cutaneous adverse drug reaction (cADR) leading to rash, fever and inflammation. Case Description: A 38-year-old male with a past medical history of hepatitis C, opiate abuse and recent diagnosis of osteomyelitis treated with vancomycin presented with a two-day pruritic rash. Patient first noticed the rash on his back, which spread peripherally during the span of 2 days. The patient had been on vancomycin for the last 3 weeks. On physical exam, he had a diffuse blanching maculopapular exanthema (Figure 1A and 1B); facial angioedema; palpable axillary and inguinal lymph nodes. Laboratory evaluation was relevant for leukocytosis (13.3 K/uL with 83% neutrophilia and 8% eosinophilia), mild elevation of liver function tests and peripheral smear revealed atypical lymphocytes (Figure 1C). Skin biopsy demonstrated superficial perivascular dermatitis with papillary dermal edema (Figure 1D). Vancomycin was discontinued and daptomycin was started. He also received high dose antihistamines and systemic corticosteroids, prednisone 40 mg per day with a 6 week taper. On follow up, rash had resolved. Conclusion: Almost 50% of cADRs are due to antibiotics. Till date, 31 cases of vancomycin induced cADRs have been reported. Variable presentation, which may mimic other causes, proves to be a challenge in diagnosing this condition. Prompt recognition and withdrawal of causative agent provides complete resolution.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
S19
P009 PEDIATRIC INTRAOPERATIVE ANAPHYLAXIS OF UNKNOWN ETIOLOGY D. Paulk*, J. Kuhlen, C. Greene, Greenville, SC.
Diffuse blanching maculopapular exanthema (Figure 1A and 1B); Atypical lymphocytes (Figure 1C); Skin biopsy showing superficial perivascular dermatitis with papillary dermal edema (Figure 1D)
Introduction: Anaphylaxis is increasing in the general population and is more common in the pediatric population. Intraoperative anaphylactic events are rare but can be life threatening with a higher mortality rate compared to events in other settings. Appropriate recognition and management of these events is important, and an effort should be made to identify the culprit agent to avoid re-exposure and prevent future reactions. Case Presentation: This case illustrates a 14 year old male who underwent posterior spinal fusion with instrumentation for idiopathic adolescent scoliosis and experienced intraoperative anaphylaxis. Intraoperative tryptase was elevated to 7ng/ml with baseline level of 2ng/ml. The patient recovered and was referred to an outpatient allergy and immunology clinic. A comprehensive allergy evaluation to determine the culprit agent was completed. The patient underwent clindamycin, penicillin, and propofol skin testing in the office with negative results. Discussion: Similar to previously published literature, we were unable to identify the responsible agent that led to anaphylaxis. However, it is also known that despite an unidentified culprit after a comprehensive evaluation, patients often are able to tolerate subsequent anesthesia regardless of severity of initial reaction. Additional investigations regarding pediatric anaphylaxis and post-procedure evaluation and management need to be completed.
P008 ANAPHYLAXIS: CLOSER TO HOME? S. Anvari*, A. Blackman, A. Anagnostou, Houston, TX. Introduction: Anaphylaxis is a severe, life-threatening, systemic hypersensitivity reaction. We examined causes, clinical features and location of anaphylactic episodes, in our patient population, over a 1-year period. Methods: We performed a retrospective case-note review between January-December 2016 for children 0-18 years old, presenting with anaphylaxis. We report results on the first 46 patients. Results: Among the first forty-six children (4months-16 years; median:8.5yrs) presenting with anaphylaxis, food was the most common cause (43%); specifically, tree nuts (40%), followed by eggs (15%). Other causes included drug (17%), venom (13%), immunotherapy (4%), vaccinations (2%) and unknown (19%). Twelve children (26%) had a prior history of anaphylaxis and 10 (21%) had epinephrine available at the time of reaction. Interestingly, the majority of episodes occurred in the home setting (61%), followed by 15% in a medical facility, 11% at school/daycare, 4% at restaurants, 2% at cinemas, 2% at church, 2% unrecorded. Cutaneous symptoms were most commonly reported (91%), followed by respiratory (69%), gastrointestinal (17%), and cardiovascular (8%). Most symptoms (46%) developed within 5 min, 8% within 5-30 min, 4% within 30-120 min, 6% in more than 2hrs and 35% unrecorded. 63% of children received treatment within a few minutes, 26% after 30 minutes, and in 10% unrecorded. Almost all (91%) received epinephrine, with 17% requiring 2 doses. Conclusions: Despite parents’ concerns that anaphylaxis occurs frequently outside the home environment, the majority of episodes occurred at home, with food remaining the most common cause. This may be the result of allergen/nutfree schools or increasing awareness of food allergies in the community.
P010 SINGLE AND TWO-DOSE ORAL CHALLENGE WITH TRIMETHOPRIM-SULFAMETHOXAZOLE IN HIVUNINFECTED ADULTS LABELED AS “SULFA” ALLERGIC A. Abreo*1, C. Stone1, E. McKinnon2, E. Phillips1, 1. Nashville, TN; 2. Perth, WA, Australia. Introduction: A label of “sulfa” allergy (SA) associated with unknown, remote, vague or non-serious cutaneous reactions frequently leads to lifelong avoidance of both sulfa antimicrobials and the non-cross-reactive non-antibiotic sulfonamides. Multiple dose graded challenge or desensitization to trimethoprim-sulfamethoxazole (TMP-SMX) are guideline-favored approaches that have been studied in HIV-infected patients; however, literature in non-HIV SA labeled patients is lacking. Methods: We retrospectively identified 57 non-HIV immunocompromised or immunocompetent adults with histories of vague, remote or non-serious cutaneous reactions to sulfonamide medications who underwent a single (400/80 mg) or two-dose (40/ 8;400/80 mg) TMP-SMX oral challenge over a 3-year period. Patient demographics, reaction history, and the type of challenge were compared between individuals that were successfully and unsuccessfully de-labeled. Results: There were no immediate or delayed reactions in 54/57 (95%) patients. SA label removal was associated with younger age at reaction (32.616 vs 54.014 years, P¼0.03) and time since the original reaction (24.817 vs 87 years, P¼0.02). Those not tolerating the challenge were female and experienced mild, transient rash, fever, or myalgia 6-24 hours following the challenge that did not require any treatment. No other differences were noted between baseline demographics, indication for SA de-labeling, comorbidities or immunocompetency between these patients and those successfully de-labeled. Of nine patients requiring TMP-SMX for long-term infection prophylaxis, 100% have tolerated Bactrim >12 weeks.