- Email: [email protected]
Skin Testing, Graded Challenge and Desensitization to the Tetracycline Class of Antimicrobials in Patients with Hypersensitivity Reactions
Abstracts AB123
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2
Pretreatment with IVIG and Corticosteroids for Contrast Media Induced Severe Adverse Drug Reaction Thao Nguyen N. Tran1, Colleen Adkins2, Vuong A. Nayima, DO3, John T. Anderson, MD2, James Ryan Bonner, MD, FAAAAI4; 1UAB Internal Medicine Residency Birmingham, Birmingham, AL, 2University of Alabama at Birmingham, Birmingham, AL, 3University of Alabama - Birmingham, Birmingham, AL, 4Alabama Allergy & Asthma Center, Birmingham, AL. RATIONALE: Contrast media (CM) is known to cause severe adverse drug reactions (ADR) including delayed reactions such as SJS/TEN and leukocytoclastic vasculitis (LCV). Pretreatment for subsequent administration is not standardized. Here we present a patient with history of severe delayed ADR to CM in whom pretreatment with IVIG and corticosteroids successfully reduced her reactions to repeated exposure. METHODS: Our patient is a 67 yo female with reported history of SJS to CM who presented with acute coronary syndrome requiring cardiac intervention. For two days prior to catheterization, she was treated following a previously published protocol (Hebert and Bogle) with IVIG 200mg/kg and prednisone 60mg daily. RESULTS: Hours after CM exposure, the patient developed a nonblanching purpuric rash on bilateral feet clinically consistent with mild LCV. Protocol was adjusted, changing steroids to methylprednisolone 40mg q6hrs with continuation of IVIG. Due to the necessity of repeat coronary angiography, IVIG and IV steroids were continued until 2 days post repeat catheterization. Thereafter she was transitioned to oral prednisone with one week taper. No further ADRs were observed. CONCLUSIONS: While history suggested SJS, our patient’s subsequent reaction was more consistent with LCV. The improvement of the LCV and lack of recurrence after repeat CM challenge suggests administering IVIG and steroids may be an effective option for preventing severe delayed ADR to CM in patients with a history of severe LCV.
397
Skin Testing, Graded Challenge and Desensitization to the Tetracycline Class of Antimicrobials in Patients with Hypersensitivity Reactions Stephanie L. Logsdon, MD1, Amy E. O’Connell, MD, PhD2, Ana Dioun Broyles, MD, FAAAAI3; 1Children’s Hospital Boston, Boston, MA, 2 Immunology, Boston Children’s Hospital, Boston, MA, 3Boston Childrens’ Hospital, Boston, MA. RATIONALE: Tetracyclines are becoming more widely utilized. Hypersensitivity reactions to this class of antimicrobials, mostly to doxycycline and minocycline, may limit therapeutic options particularly for tick-borne, respiratory or drug-resistant infections. Skin testing with establishment of highest non-irritating concentrations to these agents has not been previously reported, and graded challenge and oral desensitization protocols are rare. METHODS: Four patients, aged 12 to 67, developed likely IgE-mediated pruritic rash/urticaria during treatment with one of the tetracycline antimicrobials. Three patients subsequently required further therapy with this group of antimicrobials for respiratory infections or Lyme disease. All patients were evaluated with skin testing to either doxycycline and/or minocycline. Non-allergic control subjects were also tested to determine the highest non-irritating concentration for each drug. RESULTS: Two patients tested negative for minocycline, and subsequently completed successful graded challenges to the medication. The third patient’s skin testing to doxycycline was negative, however she had a previous reaction to minocycline, thus a graded oral challenge was performed. The patient underwent the challenge without symptoms and subsequently completed an uneventful full treatment course of doxycycline for a respiratory infection. The fourth patient had positive skin testing to doxycycline, and required an oral desensitization procedure which was successfully completed. CONCLUSIONS: This is the first report of protocols for doxycycline and minocycline skin testing, including utilization of non-allergic control subjects to establish the highest non-irritating concentrations for each drug. In addition it describes successful graded challenge and desensitization
protocols for these agents. These protocols will likely be of benefit for patients with hypersensitivity to tetracyclines.
398
Non-Invasive Management of Myocarditis Despite a Negative Gadolinium-Enhanced Cardiac MRI in a 15-Year-Old Boy with Minocycline Triggered Dress Syndrome Bradley A. Becker, MD, FAAAAI, Carrie N. Caruthers, MD, Saadeh Jureidini, MD, Jeremy S. Garrett, MD; Saint Louis University School of Medicine, Saint Louis, MO. RATIONALE: DRESS Syndrome (DS) is a life-threatening multisystem drug reaction that may cause rash, eosinophilia, hepatitis, interstitial nephritis and myocarditis. We report a 15-year-old boy with minocycline triggered DS and myocarditis managed despite a normal gadoliniumenhanced cardiac MRI (GE-MRI). METHODS: Case-report. RESULTS: The diagnosis of myocarditis rests on endomyocardial biopsy (EMCB). However, EMCB may not show patchy inflammation or alter management, and may cause harm. CBC, acute phase reactants, B-type natriuretic peptide (BNP), cardiac enzymes, ECG, echocardiographic fractional shortening (E-FS), and GE-MRI may yield a presumptive diagnosis. We report a 15-yo boy treated for acne with minocycline for 6-weeks, who then developed rash, fever, UGI symptoms, lymphadenopathy, facial swelling, eosinophilia (AEC 4,600), hepatitis (ALT 591, AST 447), and interstitial nephritis (creatinine 1.68). High cardiac output shock without myocarditis (E-FS 44.2 and BNP <10) and rhabdomyolysis (CK 657) ensued, requiring intensive support. High dose corticosteroids (HDCS) yielded improvement. A slow corticosteroid taper followed. Seven weeks after discontinuing minocycline, still on corticosteroids, the patient developed myocarditis and clinical heart failure (E-FS 21%, BNP 1196, troponin-I 7.202) with a normal GE-MRI. HDCS yielded improvement (E-FS 39.8%, BNP 166, troponin-I 4.014). These values rebounded with 2 more corticosteroid taper attempts. IVIG and then cyclosporine were added to the HDCS treatment, with incremental improvement. CONCLUSIONS: DS is a life-threatening multisystem drug reaction, which may cause myocarditis. EMCB is diagnostic, but seldom done because of limited utility and possible harm. E-FS, BNP and troponin-I were useful for diagnosis and therapeutic monitoring in our pediatric patient with minocycline triggered DS myocarditis.
SUNDAY
396
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2
Pretreatment with IVIG and Corticosteroids for Contrast Media Induced Severe Adverse Drug Reaction Thao Nguyen N. Tran1, Colleen Adkins2, Vuong A. Nayima, DO3, John T. Anderson, MD2, James Ryan Bonner, MD, FAAAAI4; 1UAB Internal Medicine Residency Birmingham, Birmingham, AL, 2University of Alabama at Birmingham, Birmingham, AL, 3University of Alabama - Birmingham, Birmingham, AL, 4Alabama Allergy & Asthma Center, Birmingham, AL. RATIONALE: Contrast media (CM) is known to cause severe adverse drug reactions (ADR) including delayed reactions such as SJS/TEN and leukocytoclastic vasculitis (LCV). Pretreatment for subsequent administration is not standardized. Here we present a patient with history of severe delayed ADR to CM in whom pretreatment with IVIG and corticosteroids successfully reduced her reactions to repeated exposure. METHODS: Our patient is a 67 yo female with reported history of SJS to CM who presented with acute coronary syndrome requiring cardiac intervention. For two days prior to catheterization, she was treated following a previously published protocol (Hebert and Bogle) with IVIG 200mg/kg and prednisone 60mg daily. RESULTS: Hours after CM exposure, the patient developed a nonblanching purpuric rash on bilateral feet clinically consistent with mild LCV. Protocol was adjusted, changing steroids to methylprednisolone 40mg q6hrs with continuation of IVIG. Due to the necessity of repeat coronary angiography, IVIG and IV steroids were continued until 2 days post repeat catheterization. Thereafter she was transitioned to oral prednisone with one week taper. No further ADRs were observed. CONCLUSIONS: While history suggested SJS, our patient’s subsequent reaction was more consistent with LCV. The improvement of the LCV and lack of recurrence after repeat CM challenge suggests administering IVIG and steroids may be an effective option for preventing severe delayed ADR to CM in patients with a history of severe LCV.
397
Skin Testing, Graded Challenge and Desensitization to the Tetracycline Class of Antimicrobials in Patients with Hypersensitivity Reactions Stephanie L. Logsdon, MD1, Amy E. O’Connell, MD, PhD2, Ana Dioun Broyles, MD, FAAAAI3; 1Children’s Hospital Boston, Boston, MA, 2 Immunology, Boston Children’s Hospital, Boston, MA, 3Boston Childrens’ Hospital, Boston, MA. RATIONALE: Tetracyclines are becoming more widely utilized. Hypersensitivity reactions to this class of antimicrobials, mostly to doxycycline and minocycline, may limit therapeutic options particularly for tick-borne, respiratory or drug-resistant infections. Skin testing with establishment of highest non-irritating concentrations to these agents has not been previously reported, and graded challenge and oral desensitization protocols are rare. METHODS: Four patients, aged 12 to 67, developed likely IgE-mediated pruritic rash/urticaria during treatment with one of the tetracycline antimicrobials. Three patients subsequently required further therapy with this group of antimicrobials for respiratory infections or Lyme disease. All patients were evaluated with skin testing to either doxycycline and/or minocycline. Non-allergic control subjects were also tested to determine the highest non-irritating concentration for each drug. RESULTS: Two patients tested negative for minocycline, and subsequently completed successful graded challenges to the medication. The third patient’s skin testing to doxycycline was negative, however she had a previous reaction to minocycline, thus a graded oral challenge was performed. The patient underwent the challenge without symptoms and subsequently completed an uneventful full treatment course of doxycycline for a respiratory infection. The fourth patient had positive skin testing to doxycycline, and required an oral desensitization procedure which was successfully completed. CONCLUSIONS: This is the first report of protocols for doxycycline and minocycline skin testing, including utilization of non-allergic control subjects to establish the highest non-irritating concentrations for each drug. In addition it describes successful graded challenge and desensitization
protocols for these agents. These protocols will likely be of benefit for patients with hypersensitivity to tetracyclines.
398
Non-Invasive Management of Myocarditis Despite a Negative Gadolinium-Enhanced Cardiac MRI in a 15-Year-Old Boy with Minocycline Triggered Dress Syndrome Bradley A. Becker, MD, FAAAAI, Carrie N. Caruthers, MD, Saadeh Jureidini, MD, Jeremy S. Garrett, MD; Saint Louis University School of Medicine, Saint Louis, MO. RATIONALE: DRESS Syndrome (DS) is a life-threatening multisystem drug reaction that may cause rash, eosinophilia, hepatitis, interstitial nephritis and myocarditis. We report a 15-year-old boy with minocycline triggered DS and myocarditis managed despite a normal gadoliniumenhanced cardiac MRI (GE-MRI). METHODS: Case-report. RESULTS: The diagnosis of myocarditis rests on endomyocardial biopsy (EMCB). However, EMCB may not show patchy inflammation or alter management, and may cause harm. CBC, acute phase reactants, B-type natriuretic peptide (BNP), cardiac enzymes, ECG, echocardiographic fractional shortening (E-FS), and GE-MRI may yield a presumptive diagnosis. We report a 15-yo boy treated for acne with minocycline for 6-weeks, who then developed rash, fever, UGI symptoms, lymphadenopathy, facial swelling, eosinophilia (AEC 4,600), hepatitis (ALT 591, AST 447), and interstitial nephritis (creatinine 1.68). High cardiac output shock without myocarditis (E-FS 44.2 and BNP <10) and rhabdomyolysis (CK 657) ensued, requiring intensive support. High dose corticosteroids (HDCS) yielded improvement. A slow corticosteroid taper followed. Seven weeks after discontinuing minocycline, still on corticosteroids, the patient developed myocarditis and clinical heart failure (E-FS 21%, BNP 1196, troponin-I 7.202) with a normal GE-MRI. HDCS yielded improvement (E-FS 39.8%, BNP 166, troponin-I 4.014). These values rebounded with 2 more corticosteroid taper attempts. IVIG and then cyclosporine were added to the HDCS treatment, with incremental improvement. CONCLUSIONS: DS is a life-threatening multisystem drug reaction, which may cause myocarditis. EMCB is diagnostic, but seldom done because of limited utility and possible harm. E-FS, BNP and troponin-I were useful for diagnosis and therapeutic monitoring in our pediatric patient with minocycline triggered DS myocarditis.
SUNDAY
396