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P049 Acute interstitial pneumonitis following talc-pleurodesis
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Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 117 (2016) S22eS124
expected dose (120mg) was used with increasing doses every 30 minutes until 120mg was administered. The patient tolerated the 12-step protocol over 6 hours without any allergic symptoms. Conclusion: This is the first report of successful oral IDT to voriconazole in a pediatric patient with history of delayed hypersensitivity. Although reported with IgE-mediated hypersensitivity to foods, to our knowledge, there have been no reports of disappearance of delayed type-hypersensitivity to drugs following BMT. Maintenance dose 9 mg/kg/dose every 12 hours, approximately 117 mg.
P048 CASE REPORT: ANEMIC MULTIPLE MYELOMA PATIENT WITH A PANREATCVIE COMB’S TEST A. Sokolova*1, A. Haghshenas1, M. Frieri2, 1. East Meadow, NY; 2. Bayside, NY. Introduction: 20.9 million units of blood components were transfused in USA in 2011, with Ab-mediated hemolytic reactions as the most severe and fatal adverse reactions. Introduction of new immunochemotherapies can complicate type and screening(T&S) by masking antigens or causing panreactivity. We present an interesting case of anemia and panreactive Coombs-test on T&S, which was treated with incompatible blood products. Case Presentation: 74-year-old male with multiple myeloma(MM) presented with anemia. He complained of abdominal pain and melena. CBC revealed Hb/Hct of 3.8/13. His T&S showed +Coombs reaction to all samples available in the Blood Bank. A decision was made to premedicate him with acetaminophen/benadryl/prednisone and to transfuse what was thought incompatible blood. He tolerated the transfusion well and his gastrointestinal bleed was treated with EGD. Later, his oncologist notified, that he received Daratumumab. Discussion: Daratumumab(DARA) is IgG1k anti-CD38 monoclonal antibody approved for MM-treatment. It binds to CD38 on RBCs and leads to positive indirect Coombs-test, which may persist up to 6 months after treatment, while detection of the patient’s ABO/Rh type is not affected. To facilitate transfusions physicians should order T&S before starting patients on DARA and blood bank should be informed about DARA-therapy status. It was studied that panreactivity caused by DARA could be overcome by treating RBCs with dithiothreitol(DTT). But DTT also denaturates Kell antigens, therfore K-negative units should be provided to these patients. Conclusion: We bring to physicians attention that patients with MM might have a panreactive Coombs-test on T&S and it could be secondary to Daratumumab binding to CD38 on RBCs.
P049 ACUTE INTERSTITIAL PNEUMONITIS FOLLOWING TALC-PLEURODESIS C. Clark*1, G. Hudes2, K. Swedish3, 1. Bronxville, NY; 2. New York City, NY; 3. Bronx, NY. Introduction: Recurrence of secondary spontaneous pneumothorax in adults is common and often life-threatening. Preventative surgical interventions are preferred, however chemical pleurodesis is recommended for non-surgical candidates rather than no intervention at all. Among sclerosing agents for pleurodesis, talc is the most commonly used due to its established efficacy and low risk for complications. Methods: We report a case of talc-induced acute hypersensitivity pneumonitis following talc-pleurodesis. Results: A 61 year-old-woman presented for right tension pneumothorax with a left mediastinal shift. An urgent chest-tube was placed with subsequent lung re-expansion. Talc pleurodesis via chest tube was performed 4 days later. Several hours post-pleurodesis, the patient developed severe pleurisy, acute respiratory
distress and systemic inflammatory response syndrome. She was transferred to ICU and initially required vasopressor support. Respiratory status progressively deteriorated with increasing high-flow nasal oxygen demands. Exam was significant for dyspnea, bilateral rales, and a large, tender purpuric and indurated plaque on lateral chest wall around the chest tube site. Echocardiogram revealed new pulmonary hypertension (RSVP 58) and right ventricular failure. Pulmonary embolism was ruled out. CT angiogram was consistent with interstitial pneumonitis and was notable for linear tracking of dense material in lateral chest wall soft tissue at chest tube site. Systemic steroids were initiated with progressive improvement and the patient was discharged 2 weeks later. Conclusion: Talc-induced hypersensitivity pneumonitis resulting in acute respiratory failure is a rare, but often fatal complication of talc-pleurodesis. High clinical suspicion is needed for diagnosis of pneumonitis following talc-pleurodesis. Clinical diagnosis can offer timely and life-saving medical intervention.
Chest X-ray before (left) and after (right) talc pleurodesis demonstrating acute bilateral hazy opacities, interstitial infiltrates, and pleural effusions.
P050 AN UNUSUAL CULPRIT OF URTICARIAL VASCULITIS L. Zhu*, L. Padhye, C. Ciaccio, Chicago, IL. Introduction: Urticarial vasculitis is characterized by recurrent tender or pruritic skin lesions with leukocytoclastic vasculitis (LCV) by histology. Although rare, urticarial vasculitis may be a symptom of drug hypersensitivity. Methods: Chart review. Results/Case Report: This case is a 50 year old woman with sarcoidosis, diabetes type II, hypertension, and gastroesophageal reflux disease who presented to clinic with a recurrent rash. The rash was erythematous, pruritic, and nonblanching lesions on her feet and lower extremities. Biopsy confirmed LCV. Prednisone was started with improvement. One month later, the patient developed eye redness and was diagnosed with episcleritis. The rash reappeared multiple times despite treatment with steroids, hydroxyzine, and diphenhydramine. Many medications including losartan, lisinopril, infliximab, methotrexate, azathioprine, sulfasalazine, and leucovorin were discontinued. Six months after initial presentation, the rash spread to her arms and trunk. Complete blood count demonstrated 2820 eosinophils. ESR, C3, C4, and C1q levels were normal. Medications at the time were prednisone, diltiazem, pantoprazole, furosemide, and metformin. A careful history revealed that metformin was started three months prior to the initial eruption, supporting a diagnosis of urticarial vasculitis secondary to metformin. The drug was discontinued with complete resolution of the rash and eosinophilia. Glipizide was initiated, but the skin lesions immediately returned. The rash again resolved after stopping glipizide. Insulin was started, and all sulfonylureas and biguanides were avoided with no further redemonstration of the rash. Conclusion: Metformin and glipizide are common but structurally distinct hypoglycemic agents. This case highlights a rare cutaneous adverse effect to both that should prompt discontinuation of the drugs.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 117 (2016) S22eS124
expected dose (120mg) was used with increasing doses every 30 minutes until 120mg was administered. The patient tolerated the 12-step protocol over 6 hours without any allergic symptoms. Conclusion: This is the first report of successful oral IDT to voriconazole in a pediatric patient with history of delayed hypersensitivity. Although reported with IgE-mediated hypersensitivity to foods, to our knowledge, there have been no reports of disappearance of delayed type-hypersensitivity to drugs following BMT. Maintenance dose 9 mg/kg/dose every 12 hours, approximately 117 mg.
P048 CASE REPORT: ANEMIC MULTIPLE MYELOMA PATIENT WITH A PANREATCVIE COMB’S TEST A. Sokolova*1, A. Haghshenas1, M. Frieri2, 1. East Meadow, NY; 2. Bayside, NY. Introduction: 20.9 million units of blood components were transfused in USA in 2011, with Ab-mediated hemolytic reactions as the most severe and fatal adverse reactions. Introduction of new immunochemotherapies can complicate type and screening(T&S) by masking antigens or causing panreactivity. We present an interesting case of anemia and panreactive Coombs-test on T&S, which was treated with incompatible blood products. Case Presentation: 74-year-old male with multiple myeloma(MM) presented with anemia. He complained of abdominal pain and melena. CBC revealed Hb/Hct of 3.8/13. His T&S showed +Coombs reaction to all samples available in the Blood Bank. A decision was made to premedicate him with acetaminophen/benadryl/prednisone and to transfuse what was thought incompatible blood. He tolerated the transfusion well and his gastrointestinal bleed was treated with EGD. Later, his oncologist notified, that he received Daratumumab. Discussion: Daratumumab(DARA) is IgG1k anti-CD38 monoclonal antibody approved for MM-treatment. It binds to CD38 on RBCs and leads to positive indirect Coombs-test, which may persist up to 6 months after treatment, while detection of the patient’s ABO/Rh type is not affected. To facilitate transfusions physicians should order T&S before starting patients on DARA and blood bank should be informed about DARA-therapy status. It was studied that panreactivity caused by DARA could be overcome by treating RBCs with dithiothreitol(DTT). But DTT also denaturates Kell antigens, therfore K-negative units should be provided to these patients. Conclusion: We bring to physicians attention that patients with MM might have a panreactive Coombs-test on T&S and it could be secondary to Daratumumab binding to CD38 on RBCs.
P049 ACUTE INTERSTITIAL PNEUMONITIS FOLLOWING TALC-PLEURODESIS C. Clark*1, G. Hudes2, K. Swedish3, 1. Bronxville, NY; 2. New York City, NY; 3. Bronx, NY. Introduction: Recurrence of secondary spontaneous pneumothorax in adults is common and often life-threatening. Preventative surgical interventions are preferred, however chemical pleurodesis is recommended for non-surgical candidates rather than no intervention at all. Among sclerosing agents for pleurodesis, talc is the most commonly used due to its established efficacy and low risk for complications. Methods: We report a case of talc-induced acute hypersensitivity pneumonitis following talc-pleurodesis. Results: A 61 year-old-woman presented for right tension pneumothorax with a left mediastinal shift. An urgent chest-tube was placed with subsequent lung re-expansion. Talc pleurodesis via chest tube was performed 4 days later. Several hours post-pleurodesis, the patient developed severe pleurisy, acute respiratory
distress and systemic inflammatory response syndrome. She was transferred to ICU and initially required vasopressor support. Respiratory status progressively deteriorated with increasing high-flow nasal oxygen demands. Exam was significant for dyspnea, bilateral rales, and a large, tender purpuric and indurated plaque on lateral chest wall around the chest tube site. Echocardiogram revealed new pulmonary hypertension (RSVP 58) and right ventricular failure. Pulmonary embolism was ruled out. CT angiogram was consistent with interstitial pneumonitis and was notable for linear tracking of dense material in lateral chest wall soft tissue at chest tube site. Systemic steroids were initiated with progressive improvement and the patient was discharged 2 weeks later. Conclusion: Talc-induced hypersensitivity pneumonitis resulting in acute respiratory failure is a rare, but often fatal complication of talc-pleurodesis. High clinical suspicion is needed for diagnosis of pneumonitis following talc-pleurodesis. Clinical diagnosis can offer timely and life-saving medical intervention.
Chest X-ray before (left) and after (right) talc pleurodesis demonstrating acute bilateral hazy opacities, interstitial infiltrates, and pleural effusions.
P050 AN UNUSUAL CULPRIT OF URTICARIAL VASCULITIS L. Zhu*, L. Padhye, C. Ciaccio, Chicago, IL. Introduction: Urticarial vasculitis is characterized by recurrent tender or pruritic skin lesions with leukocytoclastic vasculitis (LCV) by histology. Although rare, urticarial vasculitis may be a symptom of drug hypersensitivity. Methods: Chart review. Results/Case Report: This case is a 50 year old woman with sarcoidosis, diabetes type II, hypertension, and gastroesophageal reflux disease who presented to clinic with a recurrent rash. The rash was erythematous, pruritic, and nonblanching lesions on her feet and lower extremities. Biopsy confirmed LCV. Prednisone was started with improvement. One month later, the patient developed eye redness and was diagnosed with episcleritis. The rash reappeared multiple times despite treatment with steroids, hydroxyzine, and diphenhydramine. Many medications including losartan, lisinopril, infliximab, methotrexate, azathioprine, sulfasalazine, and leucovorin were discontinued. Six months after initial presentation, the rash spread to her arms and trunk. Complete blood count demonstrated 2820 eosinophils. ESR, C3, C4, and C1q levels were normal. Medications at the time were prednisone, diltiazem, pantoprazole, furosemide, and metformin. A careful history revealed that metformin was started three months prior to the initial eruption, supporting a diagnosis of urticarial vasculitis secondary to metformin. The drug was discontinued with complete resolution of the rash and eosinophilia. Glipizide was initiated, but the skin lesions immediately returned. The rash again resolved after stopping glipizide. Insulin was started, and all sulfonylureas and biguanides were avoided with no further redemonstration of the rash. Conclusion: Metformin and glipizide are common but structurally distinct hypoglycemic agents. This case highlights a rare cutaneous adverse effect to both that should prompt discontinuation of the drugs.