A SYMPATHETIC CASE OF MULTIPLE INHALER INTOLERANCES

Abstract

<h3>Introduction</h3> Drug reactions account for a large proportion of complaints evaluated in allergy/immunology clinic. Determining the cause for these drug reactions can often be difficult. In this case, we discuss a rare cause for repeated adverse reactions to multiple inhalers. <h3>Case Description</h3> A 57-year-old male veteran with COPD presented for evaluation of drug allergy. His COPD was previously well-controlled with ipratropium and albuterol inhalers. Over the last several weeks, he has experienced flushing, lightheadedness, and shortness of breath following use of both inhalers. He tolerated inhaled fluticasone and cromolyn for several days before having the same symptoms following each use. Initial testing included skin prick testing to the offending agents, which was negative (Table 1). Drug challenge with budesonide, omalizumab, and albuterol revealed intense flushing, hypertension, and sense of doom within 30 mins. Serum catecholamines, urine metanephrines, urine 5-HIAA, and serum tryptase were normal. 24hr urine cortisol was slightly elevated. Dexamethasone suppression test was normal. In collaboration with endocrinology, he was diagnosed with <i>pseudopheochromocytoma</i> and advised to start an SSRI given the frequency of his paroxysms, which he declined. <h3>Discussion</h3> Non-immunologic drug reactions are suspected when drugs from multiple drug classes incite symptoms. Determining the underlying process is important to allow patients to continue taking life-saving medications. Pseudopheochromocytoma is a rare but important cause of drug reactions that present with paroxysms of hypertension, headache, palpitations, lightheadedness, flushing, and diaphoresis due to somatic sympathetic surges. Treatment includes antidepressants and biofeedback therapy.