ALEMTUZUMAB SKIN TESTING: TO DILUTE OR NOT TO DILUTE; IRRITANT OR NON-IRRITANT

Abstract

Introduction Perioperative anaphylaxis is infrequent with an incidence of 1 in 2,000 – 20,000 procedures. Alemtuzumab is a humanized anti-CD52 monoclonal antibody (mAb) used as an off-label anti-rejection therapy in renal transplantation. Case description A 60-year-old non-atopic African American male with end-stage renal disease (ESRD) secondary to nephrosclerosis developed profound hypotension (35/20 mmHg), bradycardia (35 beats per minute), ST depression on EKG, oxygen desaturation (81%), and generalized urticaria 37 minutes after induction of general anesthesia. Resuscitation was successful after administration of methylprednisolone, epinephrine, atropine, vasopressin, famotidine, and diphenhydramine. Tryptase was elevated (134.0 ng/mL; ref Discussion Perioperative hypersensitivity should include a comprehensive allergy evaluation to all agents used peri-operatively. A previous report recommended intradermal mAbs testing at dilutions of 1:100 and 1:10. Intradermal alemtuzumab has the potential to produce an irritant reaction at a 1:1000 concentration. Further studies are needed to determine nonirritant concentrations for alemtuzumab AST during allergy evaluation. Perioperative anaphylaxis is infrequent with an incidence of 1 in 2,000 – 20,000 procedures. Alemtuzumab is a humanized anti-CD52 monoclonal antibody (mAb) used as an off-label anti-rejection therapy in renal transplantation. A 60-year-old non-atopic African American male with end-stage renal disease (ESRD) secondary to nephrosclerosis developed profound hypotension (35/20 mmHg), bradycardia (35 beats per minute), ST depression on EKG, oxygen desaturation (81%), and generalized urticaria 37 minutes after induction of general anesthesia. Resuscitation was successful after administration of methylprednisolone, epinephrine, atropine, vasopressin, famotidine, and diphenhydramine. Tryptase was elevated (134.0 ng/mL; ref Perioperative hypersensitivity should include a comprehensive allergy evaluation to all agents used peri-operatively. A previous report recommended intradermal mAbs testing at dilutions of 1:100 and 1:10. Intradermal alemtuzumab has the potential to produce an irritant reaction at a 1:1000 concentration. Further studies are needed to determine nonirritant concentrations for alemtuzumab AST during allergy evaluation.