P028 Reaction to lactose in an albuterol sulfate dry powder inhaler training device

P028 Reaction to lactose in an albuterol sulfate dry powder inhaler training device

Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96 S25 P027 ADVERSE DRUG REACTIONS TO LAMOTRIGINE HAVING BEEN SPONTANEOUSLY ...

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Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96



(Figure 1A, Top Left panel) Hypochromic lesions in different stages of healing. (Figure 1B, Top Right panel) Blistering. (Figure 1C, Bottom panel) Skin biopsy revealing non-inflammatory subepidermal bullous dermatosis and ribbonlike staining of vessels walls on immunofluorescence.

P026 SEVERE ANAPHYLAXIS TO TRIAMCINOLONE A. Harish*1, S. Brady2, 1. Williamsville, NY; 2. Amherst, NY. Introduction: Glucocorticoid hypersensitivity is rare despite widespread use. Many clinicians are unaware that glucocorticoids can cause IgE-mediated hypersensitivity reactions. We report a case of a severe anaphylaxis to injectable triamcinolone. Case: A 37 year old female with recurrent granulomatous lesions on feet presented for intralesional triamcinolone treatment. Within minutes, she experienced tongue swelling, urticaria, wheezing, dizziness, and the sensation of vision going black. She was given two intramuscular epinephrine and transferred to the emergency room where she was hypoxic, cyanotic, hypotensive and confused. Oxygenation, blood pressure, and level of consciousness improved after another dose of intramuscular epinephrine. Tryptase on admission was 4. She had been previously exposed to intralesional triamcinolone and oral prednisone without incident. Subsequently, she underwent undiluted form skin prick and 1:100 and 1:10 intradermal testing to glucocorticoids: prednisone, methylprednisolone acetate, methylprednisolone succinate, dexamethasone phosphate, hydrocortisone succinate, betamethasone, and triamcinolone. Patient had a positive skin prick test and intradermal 1:100 with triamcinolone 10 mg/ml. All other steroids tested were negative for intradermal and skin prick test. Conclusion: Carboxymethylcellulose, a component of injectable triamcinolone and a common food additive, filler in medications and cosmetics, has been implicated in case reports as a cause of anaphylaxis. Our patient had taken acetaminophen, which contains carboxymethylcellulose, after episode of anaphylaxis on multiple occasions with no subsequent reaction. This highlights that our patient most likely had a true IgE-mediated hypersensitivity reaction to triamcinolone. IgE-mediated reactions to glucocorticoids account for 0.3-0.5% of reactions. Undergoing skin testing with a panel of glucocorticoids can help confirm allergy and identify safe alternatives.

Introduction: Lamotrigine, a promising anticonvulsant and mood stabilizer, has been concerned to cause a serious cutaneous adverse reaction (SCAR). We aimed to evaluate clinical features and the associated factors of lamotrigine-related adverse drug reactions (ADRs) to manage them proactively. Methods: We retrospectively reviewed medical reports of subjects who experienced ADR to lamotrigine from database of regional pharmacovigilance center during the recent 8 years. We gathered information on types and severities of ADRs, on subjects’ age and underlying condition, on prescribed doses and co-prescribed medicine, and the time between the prescription and ADR. Results: Among the 64,008 ADR cases being archived in the regional database, 80 were related to lamotrigine. The skin was most frequently involved (66 cases including a total of 7 [11%] SCAR cases.) Fifteen (19%) cases were associated with co-prescription with other anti-convulsants, and 57 (72%) cases followed the recommended dosing protocol whereas only in 3 cases exceeded the recommended dosage. In 34 (43%) and 28 (35%) cases ADR were notified during the <2 and 2-8 weeks from the first prescription. Finally, there was no significant difference between SCAR cases and the others in terms of the anticonvulsant co-prescription (p¼1.000), ratio of overdose prescription (p¼0.248), and the time from prescription to presentation (median of days [interquartile range], 22.0 [9.0-54.5] vs 13.0 [10.021.5], p¼0.377). Conclusion: ADR to lamotrigine happens mostly on the skin, among them SCAR comprises a significant portion. High index of suspicion and urgent intervention should be warranted to minimize damages of these unpredictable adverse reactions.

P028 REACTION TO LACTOSE IN AN ALBUTEROL SULFATE DRY POWDER INHALER TRAINING DEVICE P. Maini*, M. Makhija, Chicago, IL. Background: Lactose monohydrate is the predominant carrier in most available dry powder inhaler (DPI) products. There are few reports detailing anaphylactic reactions to lactose in DPI asthma medications in patients with IgE-mediated milk allergy. We describe a reaction to lactose in the albuterol sulfate (ProAir Respiclick) training device, which contains lactose but does not contain active medication. Case Presentation: A 17-year-old male with a past medical history of asthma, multiple food allergies including milk, allergic rhinitis, atopic dermatitis, intermittent urticaria and a previous reaction to ibuprofen presented for a follow-up. He reported an episode of hives, throat swelling and chest tightness after having a sip of coffee with milk. His last milk sIgE was 0.87 IU/ml. His asthma controller therapy was twice daily fluticasone/salmeterol Diskus (Advair), which contains lactose. He refused to carry his spacer device for use with his as needed albuterol. A discussion of the albuterol sulphate DPI device ensued. He demonstrated use with the trainer, and within a few minutes reported that his tongue was itchy. On exam, his tongue tip was erythematous, and his upper right lip was swollen; his lungs were clear. He was treated with both cetirizine and diphenhydramine. One hour after symptom onset, he reported chest tightness, and was given 2 inhalations of albuterol. His symptoms subsequently resolved. Discussion: This report describes a rare situation in which a patient with IgE-mediated milk allergy, who had used inhalers containing


Abstracts: Poster Sessions / Ann Allergy Asthma Immunol 119 (2017) S17eS96

lactose regularly with no adverse effect, experienced a reaction while using a training device for a lactose-containing DPI asthma medication.

P029 ANAPHYLAXIS: IMPACT OF A TARGETED EDUCATIONAL INTERVENTION ON THE KNOWLEDGE AND PRACTICES OF PEDIATRIC RESIDENTS M. Chitty Lopez1, A. Goyal*2, D. Vellaichamy Manian2, E. Pollak-Christian2, M. Vastardi2, 1. Stamford, CT; 2. Brooklyn, NY. Introduction: Prevention of anaphylaxis mortality depends on correct diagnosis and early epinephrine injection. Our study sought to evaluate pediatric resident knowledge regarding anaphylaxis recognition and management. Methods: An anonymous multiple choice survey was distributed to pediatric residents. A teaching intervention of a didactic lecture with demonstration of epinephrine auto-injectors use was performed. Anaphylaxis guidelines posters were distributed in resident continuity clinic, inpatient ward and pediatric emergency department (ED). Post-intervention survey was distributed one week and three months after intervention. Results: 42 residents responded to the pre-intervention survey. 35 responded to one week post-intervention survey. 36 responded to three month post-intervention survey. 50% were PGY1, 26% PGY 2 and 10% were PGY3 or above. Prior to intervention, 38% have seen a case of anaphylaxis, 24% had an Allergy and Immunology (A&I) rotation and 62% had two or more weeks of ED rotation. There was no significant difference in knowledge scores between residents with prior anaphylaxis case exposure, emergency room or A&I rotation. There was a positive correlation between PGY level and who answered correctly (r¼0.378). The mean composite knowledge score was 66% pre-intervention, 82% one week post-intervention (p< 0.001), and 79% three months post intervention (p< 0.001). Conclusions: Our study demonstrated a knowledge gap among pediatric residents regarding anaphylaxis recognition and management, indicating need for educational intervention. Lecture discussing anaphylaxis with hands on training in the use of epinephrine auto-injectors made a significant difference in residents knowledge of identifying and preventing life threatening anaphylaxis.

P030 LITHIUM-INDUCED DRUG REACTION WITH EOSINOPHILIA AND SYSTEMIC SYMPTOMS PRESENTING AS SEVERE HEADACHE C. Muglia*1, M. Crippen2, A. Wolff3, E. Capitle4, 1. Washington, NJ; 2. Morristown, NJ; 3. East Orange, NJ; 4. Marlboro, NJ. Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) presents a diagnostic challenge due to significant variability in presentation and long latent period following exposure to the offending agent. Classic features include a morbilliform rash, inflammatory response with eosinophilia, and systemic involvement; typically hepatic, renal, and/or pulmonary. We present a unique case of DRESS in which severe headache was the initial manifestation and lithium was the cause. Case Presentation: 16 year-old female with bipolar disorder presented with a one-week history of severe, unremitting headache with photophobia, nausea, and vomiting which began two weeks after starting lithium. While hospitalized, she developed a maculopapular, pruritic rash and myalgias. Lab abnormalities during her hospitalization included AST 86, ALT 141, creatine up to 1.7, creatine kinase up to 4116 and urinalysis with eosinophils, RBCs and WBCs. EKG revealed non-specific ST/T wave changes. CT head was unremarkable. On hospital day #6, absolute eosinophil count was 1,200/mL and she developed

worsening of her maculopapular rash with new onset angioedema of the face. She developed fever on hospital day #7, at which time Allergy/Immunology was consulted, DRESS was diagnosed, and treatment was initiated with methylprednisolone and intravenous immunoglobulin. She experienced rapid resolution of headache and marked improvement in clinical status within the first 24 hours. Discussion: The patient’s development of fever, rash, myositis, acute interstitial nephritis, myocarditis, and transaminitis are consistent with known complications of DRESS. Our patient represents a rare case of lithium-induced DRESS and, to the best of our knowledge, is the first case of DRESS presenting initially as headache.

P031 A CASE OF CEFEPIME IGE-MEDIATED REACTION WITH NEGATIVE SKIN TESTING. SHOULD CURRENT CONCENTRATIONS BE RECONSIDERED? I. Carrillo-Martin*1, K. Molony2, K. Reddy3, D. Youssef2, A. Gonzalez-Estrada2, 1. Madrid, Spain; 2. Johnson City, TN; 3. Griffin, GA. Introduction: Patients with cystic fibrosis (CF) are at an elevated risk for beta-lactam allergy. Skin testing concentrations for evaluation of cephalosporin allergy vary between US (10-33 mg/dL) and European (2 mg/dL) guidelines. Case Description: A 45-year-old female with history of CF was admitted with acute-on-chronic P. aeruginosa meropenem-resistant sinus disease. She was started on cefepime and within 3 hrs of the second dose she developed non-pruritic urticaria on her lower extremities and abdomen. She denied other symptoms such as angioedema, wheezing, or anaphylaxis. Her rash improved within 24 hrs of diphenhydramine, corticosteroids, and discontinuation of cefepime. She was started on inhaled colistin and piperacillin-tazobactam but developed a similar rash on her lower extremities, abdomen, back and ears. She denied other symptoms. Her symptom resolved within two days of diphenhydramine, corticosteroids and discontinuation of piperacillin-tazobactam and was started on linezolid and inhaled tobramycin. We perform skin testing (prick and intradermal) to penicillin G, penicilloylpolylysine, and, cefepime (0.2, 2, and 20 mg/mL). Skin testing was negative after which she underwent cefepime desensitization based on current US guidelines. After developing a generalized pruritic rash (Fig 1) during desensitization, the protocol had to be suspended due to patient’s preference. The patient was discharged on meropenemen and colistin without further adverse reactions. Discussion: We present a case of IgE-mediated reaction to cefepime clearly proven by the presence of pruritic urticaria during cefepime desensitization despite negative skin tests to commonly used concentrations for cephalosporins. Should we be rethinking our current concentrations for cephalosporin skin testing?

Pruritic urticaria on lower extremities during cefepime desensitization