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VANCOMYCIN-INDUCED DRESS SYNDROME MASQUERADING AS RED MAN SYNDROME
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
dermatitis with exfoliation and diagnosed with Eczema status post skin biopsy. Increasing her Famotidine dosage showed an exacerbation in her condition. Famotidine was discontinued, however her rash persisted and developed over time, leading to her present condition. The skin rash was found on the trunk, extremities, face, and scalp, soles, and mucosal membranes of the mouth. There was marked neutrophilia and light eosinophilia. The Anti-SSA and SSB came back negative ruling out Sjogren Syndrome as well as a negative skin biopsy ruling out bacterial infection. The patient is currently being treated with ammonium lactate lotion and prednisone. The pustules had disappeared by the 8th day of admission leaving dry skin and some scarring with continuing improvement. Discussion: This case brings attention to an uncommon skin manifestation caused by a drug that does not have many documented cases of causing AGEP. Though rare, AGEP should be considered in patients that develop cutaneous manifestations with Famotidine treatment.
M012 RAPID DESENSITIZATION AFTER A TYPE I HYPERSENSITIVITY REACTION TO CEFTAZIDIME/AVIBACTAM IN A PENICILLIN TOLERANT PATIENT J. Davenport*, D. Smith, JBSA - Lakland AFB, TX Introduction: Cerebral palsy patients are at high risk for developing recurrent pneumonia with increased morbidity and mortality. Frequent requirements of antibiotics have resulted in multidrug resistant (MDR) pathogens. Newer antibiotics can help treat these infections, but many contain beta lactam rings and less information is known about tolerability. This abstract describes a penicillin tolerant cerebral palsy patient who developed a type I hypersensitivity reaction to ceftazidime/avibactam, and his successful treatment with this antibiotic after rapid induction of temporary tolerance. Case Description: A 34-year old male with cerebral palsy was admitted for sigmoidectomy after a diagnosis of colon adenocarcinoma. During his hospitalization, he developed multifocal pneumonia with MDR Klebsiella. Infectious Disease deemed ceftazidime/avibactam the only acceptable antibiotic for treatment. The first infusion of the antibiotic resulted in immediate flushing and urticaria, which was successfully treated with H1 antihistamines. Allergy was consulted for rapid induction of temporary tolerance. A 16-step protocol was successfully completed based on the Journal of Cystic Fibrosis model. The patient continued to tolerate this medication throughout his recovery. He had no prior documented exposure to ceftazidime or aztreonam. Discussion: This is the first reported case in the literature to describe a type I hypersensitivity reaction and rapid intravenous induction of tolerance to ceftazidime/avibactam. Interestingly this patient previously tolerated penicillins and cephalosporins without similar reaction, suggesting the possibility of a non-IgE mediated mechanism to the hypersensitivity reaction. Additional information regarding nonirritating doses of avibactam could help clarify the culprit agent in order to guide further avoidance recommendations.
M013 FLUTTER, FEVER, AND A FIERY RED RASH: A CASE OF AGEP SECONDARY TO DILTIAZEM S. Reddy*1, N. Bade2, S. Hasan1, K. Reddy3, 1. Montgomery, AL; 2. Birmingham, AL; 3. Griffin, GA Introduction: Acute Generalized Exanthematous Pustulosis (AGEP) is a severe cutaneous reaction that is characterized by acute formation of sterile pustules, accompanied with systemic features such as fever and leukocytosis. Case Description: A 39-year old man with a past medical history of diastolic congestive heart failure presented to the hospital in an exacerbation. On day two of admission, he was diagnosed with new
S67
onset Atrial Flutter, and subsequently started on Diltiazem. On day ten of admission; patient noticed a rash in the intertriginous regions and the abdomen which spread to involve the face, chest and extremities. On examination, temperature was 102.7 degrees fahrenheit, heart rate 30 beats/min, blood pressure- 80’s systolic. Examination revealed an erythematous confluent rash with the presence of wide spread pustular lesions. His laboratory investigations were relevant for leukocytosis of 39.5 k/uL with 93% neutrophilia, and mild renal impairment. Skin biopsy demonstrated band like mild to moderate inflammatory infiltrate with scattered pigment laden macrophages. His AGEP validation score was 8 consistent with a definitive AGEP diagnosis. Diltiazem was stopped. He was started on topical triamcinolone cream twice daily. He had complete resolution of his rash within fifteen days of onset. Discussion: Diltiazem is a medication widely used in the treatment of cardiac pathologies ie angina, atrial flutter/fibrillation and supraventricular tachycardia. AGEP has been documented as a rare side effect of this medication. This case highlights the need to increase awareness amongst clinicians of an uncommon adverse effect, as timely diagnosis can lead to complete resolution and favorable outcomes.
M014 FACTIOUS DISORDER MASQUERADING AS IDIOPATHIC ANAPHYLAXIS A. Hicks*, M. Bauer, S. Green, Aurora, CO Introduction: Idiopathic anaphylaxis is a diagnosis of exclusion with a broad differential. We present a patient with multiple ICU admissions in a two-month period treated as anaphylaxis but without supportive objective findings. Case Description: A 14-year old female presented with subjective lip angioedema and stridor concerning for anaphylaxis, without a known trigger. Subsequently, she was admitted to an inpatient eating disorder unit given newly discovered significant weight loss. During her hospitalization, 6 codes were called for anaphylaxis resulting in 5 ICU admissions and 1 elective intubation given persistent stridor despite optimal treatment. These episodes consisted of subjective lip swelling with pursing and stridor which coughing resolved. Patient was treated as idiopathic anaphylaxis after reassuring evaluation of other etiologies. She began a long-term prednisone course for frequent idiopathic anaphylaxis which was not effective. When it was noted her episodes occurred with progress in her treatment, she received a diagnosis of factious disorder. With psychiatric treatment, her anaphylactoid episodes resolved. Discussion: This case demonstrates the need to consider nonorganic causes in the differential diagnoses of idiopathic anaphylaxis. The patient’s symptoms were viewed by providers as anaphylaxis and thus were treated without meeting NIAD criteria on several occasions. [1, 2] Ultimately, her symptoms were most consistent with factious disorder. Prior reports have discussed patients with symptoms consistent with anaphylaxis but who do not respond to treatment and whose symptoms are found to be non-organic. [3, 4] These patients can be difficult to manage and respond best to treatments for their underlying psychiatric diseases.
M015 VANCOMYCIN-INDUCED DRESS SYNDROME MASQUERADING AS RED MAN SYNDROME S. Zafar*1, S. Pal2, N. Kanaparthy2, 1. Edison, NJ; 2. Valhalla, NY Introduction: DRESS (drug reaction and eosinophilia with systemic symptoms) syndrome is a severe drug-induced reaction most typically characterized by fevers, lymphadenopathy, transaminitis, kidney injury, and/or rash. We present a case of DRESS syndrome after vancomycin administration masquerading as Red Man syndrome.
S68
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
Case Description: A 63-year old woman with history of Rheumatoid arthritis, hyperlipidemia, and recent right foot osteomyelitis presented to our hospital with fever, malaise, and a diffuse macular, erythematous, blanching rash which started after receiving vancomycin. She had been receiving vancomycin for 4 weeks at the time of presentation for her osteomyelitis. Her symptoms were initially attributed to Red Man Syndrome secondary to rapid infusion of vancomycin, and she was treated with antihistamines with immediate resolution of her rash. The next day, she was noted to have recurrent fevers, worsening rash, transaminitis, and significant eosinophilia. The RegiSCAR (European Registry of Severe Cutaneous Adverse Reaction Criteria) diagnosis score was indicative of “probable” DRESS Syndrome. The diagnosis of DRESS syndrome due to vancomycin was made. She was started on high-dose prednisone and her symptoms resolved soon thereafter. Discussion: Although mild drug reactions are fairly common at approximately 3% of hospitalized patients, there are also rare, potentially fatal cutaneous drug reactions an investigator must consider, such as DRESS Syndrome. Diagnosis of DRESS Syndrome must be considered as a differential when approaching a patient receiving vancomycin who has developed a rash and fever, as it can present with fatal complications and is reversible with rapid initiation of corticosteroid therapy.
Case Discussion: 7 years old male with Attention Deficit Hyperactivity Disorder started on risperidone 0.25 mg and subsequently 0.5 mg once daily after a week. On third week, patient developed generalized purpuric, confluent, maculopapular patches. Although he did not have any sign and symptoms of a viral illness, he was diagnosed with viralinduced exanthema and continued risperidone. On day 28, he developed extremities swelling, angioedema, lymphadenopathy, arthralgia and arthritis in ankles, knees, hands and elbows with no fever. Investigations showed normal C3 and C4 (mostly remains normal in serum sickness to medication). C1 esterase inhibitor, anti-nuclear antibody and urinalysis were normal. ESR, CRP and leukocytes were elevated. The diagnosis of serum sickness to risperidone was made and patient was treated with citerizine, hydrocortisone and prednisone with significant improvement. Skin biopsy suggested vasculitic urticaria which lasted 6 weeks. Challenge to risperiodone was not considered because of clear suggestive history and ethical consideration. Discussion: Psychotropic medications are known to cause cutaneous eruptions. Serum Sickness can happen upon exposure to risperidone. The clinicians should be aware of this potential adverse reaction that can develop weeks after therapy initiation and be encouraged to discontinue risperidone when the suggestive symptoms emerges.
M016
M018
OCTREOTIDE SKIN TESTING: A FALSE POSITIVE S. Sussman*, C. Patel, B. Kaplan, Great Neck, NY
PERIPHERAL EOSINOPHILIA ATTRIBUTED TO INHALED HEPARIN IN A 5-YEAR-OLD BEING TREATED FOR PLASTIC BRONCHITIS H. Duffey*, Aurora, CO
Introduction: Allergic reactions to octreotide are rarely reported in the literature and nonirritating skin testing concentrations have not been established. We present a patient with false-positive skin testing to octreotide. Case Description: The patient is a 67 year old female with a pancreatic neuroendocrine tumor who was started on octreotide for control of symptoms related to elevated gastrin secretion. For her first octreotide treatment, patient received 100 mcg subcutaneously. Within ten minutes, patient developed redness at the site of injection and complaints of feeling hot with subsequent development of facial flushing, scalp and ear erythema and epigastric pain. Patient reported that six hours later she developed severe abdominal pain, reflux and bloating. Octreotide skin testing, including prick testing (SPT) and intradermal (ID), was performed. SPT at 50mcg/mL was negative and ID was negative at 0.5 mcg/mL and positive at 5 mcg/mL on patient. ID was repeated on 4 controls at 5 mcg/mL with 2 positive and 2 negative results. The patient underwent a three step graded challenge and subsequently continued monthly doses without further reaction. Discussion: Octreotide skin testing has been reported as useful (up to 5 mcg/mL). This case demonstrates that ID octreotide skin testing at 5 mcg/mL can be falsely positive as we had both positive and negative results on control subjects. This highlights the importance of careful clinical history gathering when evaluating patients with drug allergy. Graded challenge is a useful procedure for patients with history of drug allergy, inconclusive skin testing results and low risk of hypersensitivity reaction.
M017 SERUM SICKNESS, CAN IT HAPPEN SECONDARY TO ATYPICAL ANTIPSYCHOTICS? P. Kashani*1, S. Lavi2, 1. Toronto, ON, Canada; 2. Thornhill, Canada Introduction: Serum sickness is a type III hypersensitivity reaction. The deposition of immune complexes activates complement pathways and cause fever, vasculitic rash, arthritis and lymphadenopathy. Medications are known to trigger serum sickness. Risperidone is an atypical antipsychotic and to our knowledge, this is the first report presenting a case of serum sickness to risperidone in paediatric population.
Introduction: Peripheral eosinophilia in critically ill patients with an unclear underlying diagnosis can be particularly concerning. Allergists can assist inpatient teams in determining the underlying etiology. Case Description: A 5-year-old female with hypoplastic left heart syndrome and recent presumed plastic bronchitis presented with respiratory failure. Inhaled heparin was started one month prior to admission for plastic bronchitis and was continued on admission. The patient worsened while on therapy for plastic bronchitis. The diagnosis was questioned, and the inhaled heparin was discontinued. In evaluations of alternative etiologies, a significant peripheral eosinophilia of 5680/uL was noted with a value of 500/uL two months earlier, which was prior to starting inhaled heparin. Given her lack of improvement there was concern her peripheral eosinophilia was contributing to her clinical status. Detailed history and laboratory evaluations were performed to evaluate for causes of peripheral eosinophilia with the clinical picture ultimately being consistent with drug-induced eosinophilia to inhaled heparin. This is supported by a continual downtrend of eosinophilia to 130/uL five days after discontinuation of therapy. However, resolution of peripheral eosinophilia did not correspond with clinical improvement, indicating the peripheral eosinophilia was unlikely to be contributing to her underlying pulmonary status. Discussion: Based on our evaluation, we deduced that her eosinophilia was likely drug-induced from inhaled heparin. There have been reports of intravenous formulations of heparin causing eosinophilia but not inhaled forms. This case demonstrates the importance of taking a thorough drug history and considering any drug as a cause of eosinophilia.
M019 THE FIRST PATHOLOGICAL SPECIMEN FROM A RARE LOCAL REACTION AFTER SUBCUTANEOUS ALLERGEN IMMUNOTHERAPY T. Atchley*, LBSA Lackland, TX Introduction: Local reactions in the form of injection site tenderness, pain, induration, and erythema are frequently experienced in
dermatitis with exfoliation and diagnosed with Eczema status post skin biopsy. Increasing her Famotidine dosage showed an exacerbation in her condition. Famotidine was discontinued, however her rash persisted and developed over time, leading to her present condition. The skin rash was found on the trunk, extremities, face, and scalp, soles, and mucosal membranes of the mouth. There was marked neutrophilia and light eosinophilia. The Anti-SSA and SSB came back negative ruling out Sjogren Syndrome as well as a negative skin biopsy ruling out bacterial infection. The patient is currently being treated with ammonium lactate lotion and prednisone. The pustules had disappeared by the 8th day of admission leaving dry skin and some scarring with continuing improvement. Discussion: This case brings attention to an uncommon skin manifestation caused by a drug that does not have many documented cases of causing AGEP. Though rare, AGEP should be considered in patients that develop cutaneous manifestations with Famotidine treatment.
M012 RAPID DESENSITIZATION AFTER A TYPE I HYPERSENSITIVITY REACTION TO CEFTAZIDIME/AVIBACTAM IN A PENICILLIN TOLERANT PATIENT J. Davenport*, D. Smith, JBSA - Lakland AFB, TX Introduction: Cerebral palsy patients are at high risk for developing recurrent pneumonia with increased morbidity and mortality. Frequent requirements of antibiotics have resulted in multidrug resistant (MDR) pathogens. Newer antibiotics can help treat these infections, but many contain beta lactam rings and less information is known about tolerability. This abstract describes a penicillin tolerant cerebral palsy patient who developed a type I hypersensitivity reaction to ceftazidime/avibactam, and his successful treatment with this antibiotic after rapid induction of temporary tolerance. Case Description: A 34-year old male with cerebral palsy was admitted for sigmoidectomy after a diagnosis of colon adenocarcinoma. During his hospitalization, he developed multifocal pneumonia with MDR Klebsiella. Infectious Disease deemed ceftazidime/avibactam the only acceptable antibiotic for treatment. The first infusion of the antibiotic resulted in immediate flushing and urticaria, which was successfully treated with H1 antihistamines. Allergy was consulted for rapid induction of temporary tolerance. A 16-step protocol was successfully completed based on the Journal of Cystic Fibrosis model. The patient continued to tolerate this medication throughout his recovery. He had no prior documented exposure to ceftazidime or aztreonam. Discussion: This is the first reported case in the literature to describe a type I hypersensitivity reaction and rapid intravenous induction of tolerance to ceftazidime/avibactam. Interestingly this patient previously tolerated penicillins and cephalosporins without similar reaction, suggesting the possibility of a non-IgE mediated mechanism to the hypersensitivity reaction. Additional information regarding nonirritating doses of avibactam could help clarify the culprit agent in order to guide further avoidance recommendations.
M013 FLUTTER, FEVER, AND A FIERY RED RASH: A CASE OF AGEP SECONDARY TO DILTIAZEM S. Reddy*1, N. Bade2, S. Hasan1, K. Reddy3, 1. Montgomery, AL; 2. Birmingham, AL; 3. Griffin, GA Introduction: Acute Generalized Exanthematous Pustulosis (AGEP) is a severe cutaneous reaction that is characterized by acute formation of sterile pustules, accompanied with systemic features such as fever and leukocytosis. Case Description: A 39-year old man with a past medical history of diastolic congestive heart failure presented to the hospital in an exacerbation. On day two of admission, he was diagnosed with new
S67
onset Atrial Flutter, and subsequently started on Diltiazem. On day ten of admission; patient noticed a rash in the intertriginous regions and the abdomen which spread to involve the face, chest and extremities. On examination, temperature was 102.7 degrees fahrenheit, heart rate 30 beats/min, blood pressure- 80’s systolic. Examination revealed an erythematous confluent rash with the presence of wide spread pustular lesions. His laboratory investigations were relevant for leukocytosis of 39.5 k/uL with 93% neutrophilia, and mild renal impairment. Skin biopsy demonstrated band like mild to moderate inflammatory infiltrate with scattered pigment laden macrophages. His AGEP validation score was 8 consistent with a definitive AGEP diagnosis. Diltiazem was stopped. He was started on topical triamcinolone cream twice daily. He had complete resolution of his rash within fifteen days of onset. Discussion: Diltiazem is a medication widely used in the treatment of cardiac pathologies ie angina, atrial flutter/fibrillation and supraventricular tachycardia. AGEP has been documented as a rare side effect of this medication. This case highlights the need to increase awareness amongst clinicians of an uncommon adverse effect, as timely diagnosis can lead to complete resolution and favorable outcomes.
M014 FACTIOUS DISORDER MASQUERADING AS IDIOPATHIC ANAPHYLAXIS A. Hicks*, M. Bauer, S. Green, Aurora, CO Introduction: Idiopathic anaphylaxis is a diagnosis of exclusion with a broad differential. We present a patient with multiple ICU admissions in a two-month period treated as anaphylaxis but without supportive objective findings. Case Description: A 14-year old female presented with subjective lip angioedema and stridor concerning for anaphylaxis, without a known trigger. Subsequently, she was admitted to an inpatient eating disorder unit given newly discovered significant weight loss. During her hospitalization, 6 codes were called for anaphylaxis resulting in 5 ICU admissions and 1 elective intubation given persistent stridor despite optimal treatment. These episodes consisted of subjective lip swelling with pursing and stridor which coughing resolved. Patient was treated as idiopathic anaphylaxis after reassuring evaluation of other etiologies. She began a long-term prednisone course for frequent idiopathic anaphylaxis which was not effective. When it was noted her episodes occurred with progress in her treatment, she received a diagnosis of factious disorder. With psychiatric treatment, her anaphylactoid episodes resolved. Discussion: This case demonstrates the need to consider nonorganic causes in the differential diagnoses of idiopathic anaphylaxis. The patient’s symptoms were viewed by providers as anaphylaxis and thus were treated without meeting NIAD criteria on several occasions. [1, 2] Ultimately, her symptoms were most consistent with factious disorder. Prior reports have discussed patients with symptoms consistent with anaphylaxis but who do not respond to treatment and whose symptoms are found to be non-organic. [3, 4] These patients can be difficult to manage and respond best to treatments for their underlying psychiatric diseases.
M015 VANCOMYCIN-INDUCED DRESS SYNDROME MASQUERADING AS RED MAN SYNDROME S. Zafar*1, S. Pal2, N. Kanaparthy2, 1. Edison, NJ; 2. Valhalla, NY Introduction: DRESS (drug reaction and eosinophilia with systemic symptoms) syndrome is a severe drug-induced reaction most typically characterized by fevers, lymphadenopathy, transaminitis, kidney injury, and/or rash. We present a case of DRESS syndrome after vancomycin administration masquerading as Red Man syndrome.
S68
Abstracts: Medically Challenging Cases / Ann Allergy Asthma Immunol 121 (2018) S63−S134
Case Description: A 63-year old woman with history of Rheumatoid arthritis, hyperlipidemia, and recent right foot osteomyelitis presented to our hospital with fever, malaise, and a diffuse macular, erythematous, blanching rash which started after receiving vancomycin. She had been receiving vancomycin for 4 weeks at the time of presentation for her osteomyelitis. Her symptoms were initially attributed to Red Man Syndrome secondary to rapid infusion of vancomycin, and she was treated with antihistamines with immediate resolution of her rash. The next day, she was noted to have recurrent fevers, worsening rash, transaminitis, and significant eosinophilia. The RegiSCAR (European Registry of Severe Cutaneous Adverse Reaction Criteria) diagnosis score was indicative of “probable” DRESS Syndrome. The diagnosis of DRESS syndrome due to vancomycin was made. She was started on high-dose prednisone and her symptoms resolved soon thereafter. Discussion: Although mild drug reactions are fairly common at approximately 3% of hospitalized patients, there are also rare, potentially fatal cutaneous drug reactions an investigator must consider, such as DRESS Syndrome. Diagnosis of DRESS Syndrome must be considered as a differential when approaching a patient receiving vancomycin who has developed a rash and fever, as it can present with fatal complications and is reversible with rapid initiation of corticosteroid therapy.
Case Discussion: 7 years old male with Attention Deficit Hyperactivity Disorder started on risperidone 0.25 mg and subsequently 0.5 mg once daily after a week. On third week, patient developed generalized purpuric, confluent, maculopapular patches. Although he did not have any sign and symptoms of a viral illness, he was diagnosed with viralinduced exanthema and continued risperidone. On day 28, he developed extremities swelling, angioedema, lymphadenopathy, arthralgia and arthritis in ankles, knees, hands and elbows with no fever. Investigations showed normal C3 and C4 (mostly remains normal in serum sickness to medication). C1 esterase inhibitor, anti-nuclear antibody and urinalysis were normal. ESR, CRP and leukocytes were elevated. The diagnosis of serum sickness to risperidone was made and patient was treated with citerizine, hydrocortisone and prednisone with significant improvement. Skin biopsy suggested vasculitic urticaria which lasted 6 weeks. Challenge to risperiodone was not considered because of clear suggestive history and ethical consideration. Discussion: Psychotropic medications are known to cause cutaneous eruptions. Serum Sickness can happen upon exposure to risperidone. The clinicians should be aware of this potential adverse reaction that can develop weeks after therapy initiation and be encouraged to discontinue risperidone when the suggestive symptoms emerges.
M016
M018
OCTREOTIDE SKIN TESTING: A FALSE POSITIVE S. Sussman*, C. Patel, B. Kaplan, Great Neck, NY
PERIPHERAL EOSINOPHILIA ATTRIBUTED TO INHALED HEPARIN IN A 5-YEAR-OLD BEING TREATED FOR PLASTIC BRONCHITIS H. Duffey*, Aurora, CO
Introduction: Allergic reactions to octreotide are rarely reported in the literature and nonirritating skin testing concentrations have not been established. We present a patient with false-positive skin testing to octreotide. Case Description: The patient is a 67 year old female with a pancreatic neuroendocrine tumor who was started on octreotide for control of symptoms related to elevated gastrin secretion. For her first octreotide treatment, patient received 100 mcg subcutaneously. Within ten minutes, patient developed redness at the site of injection and complaints of feeling hot with subsequent development of facial flushing, scalp and ear erythema and epigastric pain. Patient reported that six hours later she developed severe abdominal pain, reflux and bloating. Octreotide skin testing, including prick testing (SPT) and intradermal (ID), was performed. SPT at 50mcg/mL was negative and ID was negative at 0.5 mcg/mL and positive at 5 mcg/mL on patient. ID was repeated on 4 controls at 5 mcg/mL with 2 positive and 2 negative results. The patient underwent a three step graded challenge and subsequently continued monthly doses without further reaction. Discussion: Octreotide skin testing has been reported as useful (up to 5 mcg/mL). This case demonstrates that ID octreotide skin testing at 5 mcg/mL can be falsely positive as we had both positive and negative results on control subjects. This highlights the importance of careful clinical history gathering when evaluating patients with drug allergy. Graded challenge is a useful procedure for patients with history of drug allergy, inconclusive skin testing results and low risk of hypersensitivity reaction.
M017 SERUM SICKNESS, CAN IT HAPPEN SECONDARY TO ATYPICAL ANTIPSYCHOTICS? P. Kashani*1, S. Lavi2, 1. Toronto, ON, Canada; 2. Thornhill, Canada Introduction: Serum sickness is a type III hypersensitivity reaction. The deposition of immune complexes activates complement pathways and cause fever, vasculitic rash, arthritis and lymphadenopathy. Medications are known to trigger serum sickness. Risperidone is an atypical antipsychotic and to our knowledge, this is the first report presenting a case of serum sickness to risperidone in paediatric population.
Introduction: Peripheral eosinophilia in critically ill patients with an unclear underlying diagnosis can be particularly concerning. Allergists can assist inpatient teams in determining the underlying etiology. Case Description: A 5-year-old female with hypoplastic left heart syndrome and recent presumed plastic bronchitis presented with respiratory failure. Inhaled heparin was started one month prior to admission for plastic bronchitis and was continued on admission. The patient worsened while on therapy for plastic bronchitis. The diagnosis was questioned, and the inhaled heparin was discontinued. In evaluations of alternative etiologies, a significant peripheral eosinophilia of 5680/uL was noted with a value of 500/uL two months earlier, which was prior to starting inhaled heparin. Given her lack of improvement there was concern her peripheral eosinophilia was contributing to her clinical status. Detailed history and laboratory evaluations were performed to evaluate for causes of peripheral eosinophilia with the clinical picture ultimately being consistent with drug-induced eosinophilia to inhaled heparin. This is supported by a continual downtrend of eosinophilia to 130/uL five days after discontinuation of therapy. However, resolution of peripheral eosinophilia did not correspond with clinical improvement, indicating the peripheral eosinophilia was unlikely to be contributing to her underlying pulmonary status. Discussion: Based on our evaluation, we deduced that her eosinophilia was likely drug-induced from inhaled heparin. There have been reports of intravenous formulations of heparin causing eosinophilia but not inhaled forms. This case demonstrates the importance of taking a thorough drug history and considering any drug as a cause of eosinophilia.
M019 THE FIRST PATHOLOGICAL SPECIMEN FROM A RARE LOCAL REACTION AFTER SUBCUTANEOUS ALLERGEN IMMUNOTHERAPY T. Atchley*, LBSA Lackland, TX Introduction: Local reactions in the form of injection site tenderness, pain, induration, and erythema are frequently experienced in