CATAMENIAL ANAPHYLAXIS PRESENTING PRIOR TO ONSET OF MENSES

Abstract

Introduction Catamenial anaphylaxis is an uncommon, heterogeneous disorder related to type 1 hypersensitivity to endogenous progesterone. We report a twelve-year old premenstrual female who presented with recurrent episodes of anaphylaxis with improvement after starting an oral contraceptive. Case Description A twelve-year old female presented with six episodes of anaphylaxis that occurred monthly. Her symptoms included nausea, vomiting, diarrhea, urticaria, dizziness, and facial angioedema all requiring hospitalization. She was treated with intramuscular epinephrine, antihistamines, and systemic steroids. Her third episode occurred thirty-six hours after she had received her first dose of omalizumab. Her symptoms were uncontrolled despite treatment with prednisone, cromolyn, ketotifen, anti-leukotrienes and antihistamines. Her work-up for anaphylactic triggers, systemic mastocytosis, and carcinoid syndrome was negative. Her lab-work showed an elevated tryptase to 13.2 ug/L from a baseline of 2.0 ug/L. There was concern for catamenial anaphylaxis given the cyclical nature of her symptoms, however the patient had not started menstruation. She underwent an oral challenge with progesterone with no reaction. She was started on low-ogestrel and did not have any subsequent episodes of anaphylaxis. Discussion Catamenial anaphylaxis is described as recurrent episodes of multi-system allergic reactions occurring around the time of menstruation. This case is the first description of a premenstrual female who presented with catamenial anaphylaxis. The patient had no further episodes of anaphylaxis following initiation of an oral contraceptive as opposed to previous therapies. It is important to consider catamenial anaphylaxis in the differential diagnosis of idiopathic anaphylaxis prior to the onset of menses.