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P176 A case of acute urticaria and angioedema from an underlying bacterial infection
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Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
P175 NON-SURGICAL MANAGEMENT OF INTUSSUSCEPTION IN A PEDIATRIC PATIENT WITH HEREDITARY ANGIOEDEMA Z. Rivera*, C. Ramos, San Juan, Puerto Rico. Introduction: Intussusception is a known manifestation of Hereditary Angioedema however, only a handful of cases have been treated conservatively and most, if not all, have been adult patients. To our knowledge, this is the first case of a pediatric patient treated conservatively without undergoing a surgical procedure. Case: A 17-year-old female presented with acute onset abdominal pain, associated with nausea. She denied fever, vomiting and diarrhea. Her past medical history was significant for Hereditary Angioedema Type 1, with low C4 and C1 esterase inhibitor levels and function, treated for the past 2 years with subcutaneous (SC) Kalbitor for acute attacks. At the local emergency department an abdominal CT scan revealed a colo-colonic intussusception measuring 18cm long at the region of the descending colon. After the CT, she had 2 episodes of vomiting and bloody stools and was transferred to a Tertiary Pediatric Hospital for further evaluation after receiving a dose of SC Kalbitor. Surgery service was consulted and surgical intervention considered but her allergist recommended infusion of fresh frozen plasma (FFP) and conservative management. She received FFP and a subsequent abdominal CT scan with contrast revealed decreased intussusception measuring 8cm long. She was kept under observation and the next morning her abdominal pain had resolved and repeat abdominal CT scan showed complete resolution of the intussusception. The patient was started on regular diet and discharged 2-3 days later. Conclusion: We present a case of intussusception in a pediatric patient with Hereditary Angioedema that resolved conservatively without the need for surgery.
Conclusion: This case illustrates a clinical scenario where new onset urticaria/angioedema was from a bacterial trigger rather than an antibiotic allergy. This recognition can lead to improved management and future antibiotic utilization. In addition, further investigation into predisposing factors, other causative pathogens, and pathogenesis of mast cell deactivation from infection is warranted.
P177 AN ATYPICAL CASE OF ANGIOEDEMA A. Pandya*, Lenexa, KS. Background: Angioedema is a hypersensitivity reaction causing vasodilation and resulting in edema of dermal and subcutaneous tissue. The classic locations for angioedema include the periorbital, perioral, and genital regions. For allergic angioedema specifically, isolated extremity swelling is rarely reported and considered very atypical. Case Presentation: The patient is a 25 year old female with a history of polycystic ovarian syndrome who began treatment with minocycline for acne vulgaris. After five days of initiation of the medication, she developed whole body pruritus and severe, isolated, nontender edema of her left foot which prevented ambulation. Swelling was localized below the ankle, without signs of superior spread. She was evaluated in the emergency department, and deemed to have no signs of infection given lack of warmth or associated pain. Her inflammatory markers were negative. She was instructed to stop minocycline and was treated with five days of high-dose prednisone. Within two days, she had complete resolution of her symptoms. Given dramatic response to steroids and cessation of the offending agent, etiology of symptoms was attributed to allergic angioedema. Discussion: Angioedema remains a common condition that is treated in the emergency department. Prompt diagnosis is needed to help prevent progression of disease. While the most common location for allergic angioedema includes the perioral and periorbital areas, isolated extremity angioedema can manifest atypi-
P176 A CASE OF ACUTE URTICARIA AND ANGIOEDEMA FROM AN UNDERLYING BACTERIAL INFECTION G. Patel*, E. Kellner, C. Saltoun, Chicago, IL. Background: The relationship between infection and spontaneous urticaria/angioedema has been reported. Although classically attributed to viral infections, bacterial infections, notably Helicobacter pylori, staphylococcus and streptococcus pathogens have been documented. Case Presentation: An 83-year-old male physician with no significant allergy history presented to the emergency department with fever and rigors. He also developed acute urticaria after taking levofloxacin and azithromycin at home. His urticaria worsened after ceftriaxone and during ampicillin/sulbactam graded dose challenge. Infectious work up showed diverticulitis and gram negative rod bacteremia. He was started on metronidazole and aztreonam with recurrence of urticaria and new angioedema. Final blood culture showed extended-spectrum-beta-lactamase (ESBL) positive E. Coli with aztreonam resistance, thus ertapenem was initiated after tolerating a graded dose challenge. His remaining hospital course was uncomplicated. On follow-up, patient had negative penicillin skin testing and passed amoxicillin and levofloxacin oral challenges. Discussion: The initial presentation suggests a type I hypersensitivity reaction given the temporal relationship with antibiotics. This led to avoidance of multiple antibiotics due to reasonable concern for allergy. The exacerbation of his urticaria with multiple antibiotics suggests another etiology such as underlying bacterial sepsis. This case demonstrates a causal relationship between bacterial infection, notably ESBL-producing E. Coli, and urticaria/ angioedema.
cally as a hypersensitivity reaction. Allergic angioedema should particularly be suspected when pruritis or urticaria are present. Drugs remain a common cause of angioedema, and if suspected, should be stopped promptly.
Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96
P175 NON-SURGICAL MANAGEMENT OF INTUSSUSCEPTION IN A PEDIATRIC PATIENT WITH HEREDITARY ANGIOEDEMA Z. Rivera*, C. Ramos, San Juan, Puerto Rico. Introduction: Intussusception is a known manifestation of Hereditary Angioedema however, only a handful of cases have been treated conservatively and most, if not all, have been adult patients. To our knowledge, this is the first case of a pediatric patient treated conservatively without undergoing a surgical procedure. Case: A 17-year-old female presented with acute onset abdominal pain, associated with nausea. She denied fever, vomiting and diarrhea. Her past medical history was significant for Hereditary Angioedema Type 1, with low C4 and C1 esterase inhibitor levels and function, treated for the past 2 years with subcutaneous (SC) Kalbitor for acute attacks. At the local emergency department an abdominal CT scan revealed a colo-colonic intussusception measuring 18cm long at the region of the descending colon. After the CT, she had 2 episodes of vomiting and bloody stools and was transferred to a Tertiary Pediatric Hospital for further evaluation after receiving a dose of SC Kalbitor. Surgery service was consulted and surgical intervention considered but her allergist recommended infusion of fresh frozen plasma (FFP) and conservative management. She received FFP and a subsequent abdominal CT scan with contrast revealed decreased intussusception measuring 8cm long. She was kept under observation and the next morning her abdominal pain had resolved and repeat abdominal CT scan showed complete resolution of the intussusception. The patient was started on regular diet and discharged 2-3 days later. Conclusion: We present a case of intussusception in a pediatric patient with Hereditary Angioedema that resolved conservatively without the need for surgery.
Conclusion: This case illustrates a clinical scenario where new onset urticaria/angioedema was from a bacterial trigger rather than an antibiotic allergy. This recognition can lead to improved management and future antibiotic utilization. In addition, further investigation into predisposing factors, other causative pathogens, and pathogenesis of mast cell deactivation from infection is warranted.
P177 AN ATYPICAL CASE OF ANGIOEDEMA A. Pandya*, Lenexa, KS. Background: Angioedema is a hypersensitivity reaction causing vasodilation and resulting in edema of dermal and subcutaneous tissue. The classic locations for angioedema include the periorbital, perioral, and genital regions. For allergic angioedema specifically, isolated extremity swelling is rarely reported and considered very atypical. Case Presentation: The patient is a 25 year old female with a history of polycystic ovarian syndrome who began treatment with minocycline for acne vulgaris. After five days of initiation of the medication, she developed whole body pruritus and severe, isolated, nontender edema of her left foot which prevented ambulation. Swelling was localized below the ankle, without signs of superior spread. She was evaluated in the emergency department, and deemed to have no signs of infection given lack of warmth or associated pain. Her inflammatory markers were negative. She was instructed to stop minocycline and was treated with five days of high-dose prednisone. Within two days, she had complete resolution of her symptoms. Given dramatic response to steroids and cessation of the offending agent, etiology of symptoms was attributed to allergic angioedema. Discussion: Angioedema remains a common condition that is treated in the emergency department. Prompt diagnosis is needed to help prevent progression of disease. While the most common location for allergic angioedema includes the perioral and periorbital areas, isolated extremity angioedema can manifest atypi-
P176 A CASE OF ACUTE URTICARIA AND ANGIOEDEMA FROM AN UNDERLYING BACTERIAL INFECTION G. Patel*, E. Kellner, C. Saltoun, Chicago, IL. Background: The relationship between infection and spontaneous urticaria/angioedema has been reported. Although classically attributed to viral infections, bacterial infections, notably Helicobacter pylori, staphylococcus and streptococcus pathogens have been documented. Case Presentation: An 83-year-old male physician with no significant allergy history presented to the emergency department with fever and rigors. He also developed acute urticaria after taking levofloxacin and azithromycin at home. His urticaria worsened after ceftriaxone and during ampicillin/sulbactam graded dose challenge. Infectious work up showed diverticulitis and gram negative rod bacteremia. He was started on metronidazole and aztreonam with recurrence of urticaria and new angioedema. Final blood culture showed extended-spectrum-beta-lactamase (ESBL) positive E. Coli with aztreonam resistance, thus ertapenem was initiated after tolerating a graded dose challenge. His remaining hospital course was uncomplicated. On follow-up, patient had negative penicillin skin testing and passed amoxicillin and levofloxacin oral challenges. Discussion: The initial presentation suggests a type I hypersensitivity reaction given the temporal relationship with antibiotics. This led to avoidance of multiple antibiotics due to reasonable concern for allergy. The exacerbation of his urticaria with multiple antibiotics suggests another etiology such as underlying bacterial sepsis. This case demonstrates a causal relationship between bacterial infection, notably ESBL-producing E. Coli, and urticaria/ angioedema.
cally as a hypersensitivity reaction. Allergic angioedema should particularly be suspected when pruritis or urticaria are present. Drugs remain a common cause of angioedema, and if suspected, should be stopped promptly.