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P031 Anaphylaxis to resorcinol
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 117 (2016) S22eS124
Conclusion: Our case adds to the literature supporting omalizumab treatment for IA/MCAS refractory to usual therapy.
P030 DESENSITIZATION PROTOCOL FOR PEGASPARGASE ANAPHYLAXIS J. Zacharias*, K. Mulieri, L. Mcgregor, T. Fausnight, Hershey, PA. Introduction: There is limited information on desensitization protocols in the setting of anaphylaxis to both Pegaspargase and Erwinia-derived products. Current literature provides information regarding conventional E. coli derived L-asparaginase. We present a successful Pegaspargase desensitization protocol. Case Presentation: Patient is a 4 year old male with a history of relapsing Pre B cell acute lymphoblastic leukemia (ALL) diagnosed at age 21 months who experienced an anaphylactic reaction with symptoms consisting of nausea, vomiting, angioedema of the tongue and lips, and wheezing minutes into his second Pegaspargase infusion. As per standard risk protocol, he then received IM injections of Asparaginase Erwinia chrysanthemi, but developed facial redness, mild lip angioedema, hives, and increased irritability 40 minutes after the second injection. Both reactions required hospitalizations and treatment with epinephrine and diphenhydramine. To treat his relapsed Pre B ALL, it was decided to attempt Pegaspargase desensitization. Methods: After Allergy and Immunology consultation, a desensitization protocol was designed for Pegaspargase that is similar to protocols for conventional E. coli derived L- asparaginase. Patient was premedicated with cetirizine, ranitidine, and montelukast. He also received dexamethasone which was part of his chemotherapy regimen. Epinephrine and diphenhydramine were available during the desensitization. Results: Patient underwent a successful Pegaspargase desensitization protocol despite his history of anaphylaxis. See below for the desensitization protocol performed in Table 1. Conclusions: Currently there are no known published successful desensitization protocols to Pegaspargase. We report a case in which successful desensitization to Pegaspargase, using a protocol modeled after E. coli derived L-asparaginase, was performed.
P031 ANAPHYLAXIS TO RESORCINOL L. Fu*1, C. Song2, 1. Aurora, ON, Canada; 2. Toronto, ON, Canada. Background: The most common form of allergic reaction to hair dye is contact dermatitis. There have been rare reports of anaphylaxis to hair dye, predominantly to para-phenylenediamine (PPD). Rationale: We present the first case of anaphylaxis to resorcinol. Case Presentation: A 68 year old woman presented with anaphylaxis within 15 minutes of hair dye touching her scalp. She developed diffuse itching, which was particularly severe at the scalp, urticaria, facial swelling and difficulty breathing. She went to the emergency department and there was visible swelling of her face and tongue. She received several doses of intramuscular epinephrine, IV steroids, antihistamines and IV fluids. She was intubated and admitted to the Intensive Care Unit. She does have a history of dry itchy skin around the nape of her neck and behind the ears which lasts for a few weeks after she dyes her hair for the last 2-3 years. There were no medications, NSAIDS, new foods, or insect stings around the time of this reaction. She was only taking cod liver oil and vitamin D. The hair dye that was used did not contain PPD. We did skin prick testing to the ingredients found in the hair dye; she tested positive to resorcinol 1% while testing negative to para-phenylenediamine and latex. Conclusion: This case illustrates that resorcinol should be considered as a potential allergen in anaphylaxis to hair dye.
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P032 WHAT A CONTRAST! A RARE CASE OF PERFLUTREN LIPID MICROSPHERE-INDUCED TRUE ANAPHYLAXIS A. Zahiruddin*1, S. Melethil2, J. McCracken3, S. Sur2, 1. Houston, TX; 2. Galveston, TX; 3. League City, TX. Introduction: Perflutren lipid microspheres, microbubbles with thin shells filled with high molecular weight gas, have been used as contrast for better visualization during ultrasound studies. Case Description: A 35-year-old female with transfusion-dependent anemia presented with symptoms of fatigue, dizziness, and palpitations. She received 2 units of packed red blood cells uneventfully. On day 2, EKG showed prolonged QT, and she underwent transthoracic echocardiogram with perflutren lipid microsphere injectable suspension contrast. Although typical dosage is 10cc, within two minutes of receiving 2cc of contrast, the patient developed localized pruritus at the IV site. Symptoms progressed to diffuse pruritus, urticaria, dyspnea, and blurred vision. Vitals revealed tachycardia, hypotension, and tachypnea requiring non-rebreather mask. Patient initially received IV methylprednisolone 125mg, famotidine 20mg, and diphenhydramine 50mg. She became unresponsive with stridor and received epinephrine 1mg subcutaneously, 1L normal saline bolus, and hydrocortisone 100mg with significant improvement. Patient’s C3, C4, C1 esterase inhibitor panel, and AH50 were normal. Tryptase was elevated to 124ug/L. Discussion: To our knowledge, this is the first case of true anaphylaxis from perflutren lipid microspheres. The symptoms developed acutely within minutes with involvement of skin and mucosa, were accompanied by respiratory compromise, hypotension, and occurred after an identifiable trigger. A 2008 retrospective analysis of 78,383 contrast-enhanced ultrasound studies revealed only 4 adverse events (0.006%) compatible with anaphylactoid or complement activation-related pseudoallergy. Our patient will be prick tested for another contrast that utilizes human serum albumin as the microbubble shell. Early recognition of this rare cause of anaphylaxis is crucial to patient prognosis.
P033 ANAPHYLAXIS AFTER A LABORATORY RAT BITE F. Pazheri*1, C. Radojicic2, 1. Solon, OH; 2. Independence, OH. Introduction: Allergy to laboratory rodents poses a serious occupational hazard and is commonly underreported. Common symptoms include skin irritation, rhinitis, and wheezing. We report a case of anaphylaxis after a laboratory rat bite. Methods: 27-year-old laboratory researcher presented to the emergency room following an anaphylactic reaction to a laboratory rat bite. Within minutes after a bite to her finger through a nonlatex glove, the patient developed flushing, generalized hives and shortness of breath. She was treated with epinephrine, diphenhydramine, methylprednisolone and famotidine. Symptoms resolved over 1-2 hours. She was referred to allergy clinic for further evaluation. Patient had worked with laboratory rats for 8 years and had been bitten previously without allergic symptoms. She had symptoms of chronic rhinitis for 3 years prior to the anaphylaxis episode but had no prior history of asthma or anaphylaxis. Results: Skin prick testing was positive for multiple rodents e rats (10mm x35 mm), mouse, guinea pig, rabbit, gerbils, and hamster. Specific IgE to rat epithelium (25.6 kU/L), rat serum (23.5 kU/L) and rat urine (54.7 kU/L) were strongly positive. She tested positive to multiple aeroallergens. Skin prick testing to latex was negative but serum specific IgE to latex was positive (2.63 kU/L). Immunotherapy to rat allergen was offered but our patient declined, opting for workplace accommodations. Conclusion: Rat bite anaphylaxis is extremely rare. Identification of triggers with exposure reduction or avoidance is the mainstay of treatment. Allergen immunotherapy to rodents has been described
Conclusion: Our case adds to the literature supporting omalizumab treatment for IA/MCAS refractory to usual therapy.
P030 DESENSITIZATION PROTOCOL FOR PEGASPARGASE ANAPHYLAXIS J. Zacharias*, K. Mulieri, L. Mcgregor, T. Fausnight, Hershey, PA. Introduction: There is limited information on desensitization protocols in the setting of anaphylaxis to both Pegaspargase and Erwinia-derived products. Current literature provides information regarding conventional E. coli derived L-asparaginase. We present a successful Pegaspargase desensitization protocol. Case Presentation: Patient is a 4 year old male with a history of relapsing Pre B cell acute lymphoblastic leukemia (ALL) diagnosed at age 21 months who experienced an anaphylactic reaction with symptoms consisting of nausea, vomiting, angioedema of the tongue and lips, and wheezing minutes into his second Pegaspargase infusion. As per standard risk protocol, he then received IM injections of Asparaginase Erwinia chrysanthemi, but developed facial redness, mild lip angioedema, hives, and increased irritability 40 minutes after the second injection. Both reactions required hospitalizations and treatment with epinephrine and diphenhydramine. To treat his relapsed Pre B ALL, it was decided to attempt Pegaspargase desensitization. Methods: After Allergy and Immunology consultation, a desensitization protocol was designed for Pegaspargase that is similar to protocols for conventional E. coli derived L- asparaginase. Patient was premedicated with cetirizine, ranitidine, and montelukast. He also received dexamethasone which was part of his chemotherapy regimen. Epinephrine and diphenhydramine were available during the desensitization. Results: Patient underwent a successful Pegaspargase desensitization protocol despite his history of anaphylaxis. See below for the desensitization protocol performed in Table 1. Conclusions: Currently there are no known published successful desensitization protocols to Pegaspargase. We report a case in which successful desensitization to Pegaspargase, using a protocol modeled after E. coli derived L-asparaginase, was performed.
P031 ANAPHYLAXIS TO RESORCINOL L. Fu*1, C. Song2, 1. Aurora, ON, Canada; 2. Toronto, ON, Canada. Background: The most common form of allergic reaction to hair dye is contact dermatitis. There have been rare reports of anaphylaxis to hair dye, predominantly to para-phenylenediamine (PPD). Rationale: We present the first case of anaphylaxis to resorcinol. Case Presentation: A 68 year old woman presented with anaphylaxis within 15 minutes of hair dye touching her scalp. She developed diffuse itching, which was particularly severe at the scalp, urticaria, facial swelling and difficulty breathing. She went to the emergency department and there was visible swelling of her face and tongue. She received several doses of intramuscular epinephrine, IV steroids, antihistamines and IV fluids. She was intubated and admitted to the Intensive Care Unit. She does have a history of dry itchy skin around the nape of her neck and behind the ears which lasts for a few weeks after she dyes her hair for the last 2-3 years. There were no medications, NSAIDS, new foods, or insect stings around the time of this reaction. She was only taking cod liver oil and vitamin D. The hair dye that was used did not contain PPD. We did skin prick testing to the ingredients found in the hair dye; she tested positive to resorcinol 1% while testing negative to para-phenylenediamine and latex. Conclusion: This case illustrates that resorcinol should be considered as a potential allergen in anaphylaxis to hair dye.
S31
P032 WHAT A CONTRAST! A RARE CASE OF PERFLUTREN LIPID MICROSPHERE-INDUCED TRUE ANAPHYLAXIS A. Zahiruddin*1, S. Melethil2, J. McCracken3, S. Sur2, 1. Houston, TX; 2. Galveston, TX; 3. League City, TX. Introduction: Perflutren lipid microspheres, microbubbles with thin shells filled with high molecular weight gas, have been used as contrast for better visualization during ultrasound studies. Case Description: A 35-year-old female with transfusion-dependent anemia presented with symptoms of fatigue, dizziness, and palpitations. She received 2 units of packed red blood cells uneventfully. On day 2, EKG showed prolonged QT, and she underwent transthoracic echocardiogram with perflutren lipid microsphere injectable suspension contrast. Although typical dosage is 10cc, within two minutes of receiving 2cc of contrast, the patient developed localized pruritus at the IV site. Symptoms progressed to diffuse pruritus, urticaria, dyspnea, and blurred vision. Vitals revealed tachycardia, hypotension, and tachypnea requiring non-rebreather mask. Patient initially received IV methylprednisolone 125mg, famotidine 20mg, and diphenhydramine 50mg. She became unresponsive with stridor and received epinephrine 1mg subcutaneously, 1L normal saline bolus, and hydrocortisone 100mg with significant improvement. Patient’s C3, C4, C1 esterase inhibitor panel, and AH50 were normal. Tryptase was elevated to 124ug/L. Discussion: To our knowledge, this is the first case of true anaphylaxis from perflutren lipid microspheres. The symptoms developed acutely within minutes with involvement of skin and mucosa, were accompanied by respiratory compromise, hypotension, and occurred after an identifiable trigger. A 2008 retrospective analysis of 78,383 contrast-enhanced ultrasound studies revealed only 4 adverse events (0.006%) compatible with anaphylactoid or complement activation-related pseudoallergy. Our patient will be prick tested for another contrast that utilizes human serum albumin as the microbubble shell. Early recognition of this rare cause of anaphylaxis is crucial to patient prognosis.
P033 ANAPHYLAXIS AFTER A LABORATORY RAT BITE F. Pazheri*1, C. Radojicic2, 1. Solon, OH; 2. Independence, OH. Introduction: Allergy to laboratory rodents poses a serious occupational hazard and is commonly underreported. Common symptoms include skin irritation, rhinitis, and wheezing. We report a case of anaphylaxis after a laboratory rat bite. Methods: 27-year-old laboratory researcher presented to the emergency room following an anaphylactic reaction to a laboratory rat bite. Within minutes after a bite to her finger through a nonlatex glove, the patient developed flushing, generalized hives and shortness of breath. She was treated with epinephrine, diphenhydramine, methylprednisolone and famotidine. Symptoms resolved over 1-2 hours. She was referred to allergy clinic for further evaluation. Patient had worked with laboratory rats for 8 years and had been bitten previously without allergic symptoms. She had symptoms of chronic rhinitis for 3 years prior to the anaphylaxis episode but had no prior history of asthma or anaphylaxis. Results: Skin prick testing was positive for multiple rodents e rats (10mm x35 mm), mouse, guinea pig, rabbit, gerbils, and hamster. Specific IgE to rat epithelium (25.6 kU/L), rat serum (23.5 kU/L) and rat urine (54.7 kU/L) were strongly positive. She tested positive to multiple aeroallergens. Skin prick testing to latex was negative but serum specific IgE to latex was positive (2.63 kU/L). Immunotherapy to rat allergen was offered but our patient declined, opting for workplace accommodations. Conclusion: Rat bite anaphylaxis is extremely rare. Identification of triggers with exposure reduction or avoidance is the mainstay of treatment. Allergen immunotherapy to rodents has been described