A COMMON THERAPY FOR ALLERGIC REACTION YET A RARELY SUSPECTED CAUSE OF HYPERSENSITIVITY

Abstract

Introduction While corticosteroid allergy is uncommon, reactions have been described. Increasing reports suggest the frequency of steroid reactions may be increasing, though the exact incidence is unknown. Case Description A 10-year-old girl with bronchiolitis obliterans presented for evaluation of corticosteroid allergy. She had been started on weekly methylprednisolone infusions 2 years prior. During her most recent infusion, she developed acute hives, wheezing, and hypoxia within minutes of infusion onset and was treated for anaphylaxis. Further review revealed four additional reactions associated with prior methylprednisolone infusions. Two episodes had required epinephrine. Subsequent tolerance of a methylprednisolone challenge had been achieved and therefore she continued to receive infusions with cetirizine premedication. The patient underwent skin prick testing (SPT), which was negative. Intradermal (ID) testing to methylprednisolone was positive at a 1:1 concentration (W/F 7/25). Both SPT and ID were negative to dexamethasone, which she has been tolerating since. Discussion While corticosteroid allergy is rare, evaluation should be pursued if history is suggestive. Given the wide use of corticosteroids for many different conditions, including allergic reactions, diagnosis can often go unmissed or be attributed to other etiologies. Further, while in vivo testing lacks validation at this time, skin testing can provide useful information supporting the diagnosis of corticosteroid hypersensitivity. Skin testing may also be helpful in identifying alternative corticosteroids for therapy. Several studies have demonstrated the absence of cross reactivity between different steroids despite their structural similarities. As corticosteroid hypersensitivity is increasingly recognized, further work is needed to standardize testing and guidance on selection of alternative therapy.