ALLERGIC TO THE TREATMENT

Abstract

SESSION TITLE: Medical Student/Resident Allergy and Airway Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Corticosteroids are frequently used for their anti-inflammatory and immunosuppressive effects. While, clinicians are well aware of their side effect profile, allergic reactions to steroids also occurs and have not been widely documented. We discuss a case of sixty-year-old female who presented with chronic obstructive pulmonary disease (COPD) exacerbation and developed an anaphylactic reaction to corticosteroids leading to PEA arrest. CASE PRESENTATION: A sixty-year-old female with past medical history of COPD and depression presented to the emergency department with shortness of breath. She was diagnosed with a COPD exacerbation and given a single dose of intravenous (IV) solumedrol 40mg. Immediately after, she developed itching, hot flashes and worsening respiratory distress. She was given intramuscular (IM) epinephrine 0.3 mg and 50mg of IV Benadryl. However, she did not improve and was urgently intubated following which she had cardiac arrest. Cardiopulmonary resuscitation was started and she achieved return of spontaneous circulation after 1 cycle of chest compressions. The patient eventually recovered and followed up in the Allergy clinic on discharge. Since she had advanced COPD and would be requiring steroids in the future, she was recommended to undergo desensitization. One week later, the patient was admitted to the intensive care for prednisone desensitization. She was given 1mg prednisone. She did not develop any symptoms after 30 minutes. She was then given a 10mg prednisone dose. Within 30 minutes the patient developed diffuse itching, nausea and vomiting. She was given diphenhydramine 25mg and 0.5mg IM epinephrine, prednisone desensitization discontinued, and patient discharged home. Of note, she has had multiple COPD exacerbations since, requiring steroids, and she has gone into anaphylaxis multiple times over the years since. DISCUSSION: The incidence of steroid allergy varies between 2.9-4.8%1 and even in those cases, there is some disagreement on whether the reactions are truly allergic or merely a side effect of the drug. Currently there are no clear guidelines or protocols on steroid desensitization, in part due to the sparse amount of data available in understanding the underlying pathophysiology. This case highlights the fact that much more investigation needs to be done to understand the pathophysiology, and clinicians must be prepared to treat anaphylaxis from corticosteroid use. CONCLUSIONS: Increased awareness of the physiology along with development of a validated protocol will help physicians understand and manage patients with steroid allergy especially when they present in emergent situations like anaphylactic shock. Reference #1: Dooms-Goossins A, Morren M. Results of routine patch testing with corticosteroid series in 2073 patients. Contact Dermatitis. 1992;26(3):182-191. DISCLOSURES: No relevant relationships by Kareem Godil, source=Web Response No relevant relationships by Sara Godil, source=Web Response