Anaphylaxis to 6-alpha-methylprednisolone in an eight-year-old child

Hypersensitivity reactions to corticosteroids

PURPOSE OF REVIEW

To describe the clinical entities, underlying mechanisms and diagnostic approach of hypersensitivity reactions to corticosteroids, emphasizing new data concerning hypersensitivity reactions to systemically administered corticosteroids.

RECENT FINDINGS

Reactions after topical corticosteroid administration to the skin have been known for decades, appearing as an eczematous lesion and with diagnosis by patch testing. However, new data have appeared about cutaneous symptoms after inhaled and systemically administered corticosteroids. In fact, T-cell involvement in a generalized maculopapular exanthema induced by inhaled budesonide has recently been demonstrated by lymphocyte transformation tests. Moreover, T-cell involvement has also been shown in skin biopsies from a group of patients with urticaria and maculopapular exanthema after systemically administered corticosteroids, with detection of a significant increase in the expression of interferon-gamma (IFN-gamma) and tumor necrosis factor-alpha (TNF-alpha), and a significant decrease in interleukin-4 and GATA-3 when samples obtained during the drug provocation test reaction were compared with samples from the resolution phase. In immediate allergic reactions to corticosteroids, an immunoglobulin E (IgE) response has recently been shown by skin testing, ImmunoCAP and basophil-activation tests.

SUMMARY

Generalized cutaneous symptoms after corticosteroid administration occur with both IgE and T-cell involvement. Skin testing, in-vitro testing and drug provocation tests are useful diagnostic tools.

Nonimmediate reactions to systemic corticosteroids suggest an immunological mechanism

BACKGROUND

Administration of corticosteroids (CS) by different routes may cause varying types of allergic reactions, thereby hampering their further use in affected patients. In order to verify an immunological involvement we evaluated a group of patients with symptoms compatible with nonimmediate allergic reactions to CS.

METHODS

Studies included patch and intradermal tests, immunohistochemical studies and controlled administration to reproduce the response. The cytokines interleukin (IL)-4, interferon (IFN)-gamma and tumor necrosis factor (TNF)-alpha were quantified in peripheral blood during the response.

RESULTS

Of 32 subjects evaluated presenting nonimmediate urticaria or exanthema, 21 were finally considered positive after re-exposure. The drugs most frequently involved were betamethasone and dexamethasone. Fewer than half the patients responded to prednisolone whilst some responded to three or more CS. Hydrocortisone and deflazacort were well tolerated by all the patients. Subjects with a positive intradermal or patch test had a perivascular mononuclear cell infiltrate with the presence of CD4 and CD8 lymphocytes positive for CD45RO+ (memory) and CD69 (activation marker) cells. Monitoring peripheral blood during the acute response showed expression of IFN-gamma and TNF-alpha, with downregulation of IL-4.

CONCLUSION

Adverse systemic responses to different CS are suggestive of a nonimmediate reaction. The symptoms elicited together with the immunlogical studies suggest a T-cell mediated response. The response to closely related CS was especially marked between betamethasone and dexamethasone, whereas hydrocortisone and deflazacort were well tolerated.

[Skin allergy to hydrocortisone hemisuccinate in a patient with asthma]

INTRODUCTION

Corticosteroids are the basis of treatment of asthma; they interrupt the development of inflammation. However, corticosteroids can also be at the origin of severe allergical reactions.

CASE REPORT

A 40 Year-old woman, during hospitalisation for severe acute asthma, presented with an allergy to hydrocortisone hemisuccinate (HCHS) in the form of generalised pruritus with, on examination, cutaneous mucosal lesions in the form of purpura and ecchymoses on the abdomen and the upper and lower limbs. The substitution of HCHS led to the return to normal.

COMMENTS

Allergic reactions to corticosteroids, generally paradoxical, were for many Years ignored and their existence was controversial. They were usually secondary to the administration of injectable substances containing hydrocortisone hemisuccinate or methylprednisolone. Their physiopathology remains a mystery. Their management requires the immediate and permanent withdrawal of the product implied, antihistamine and adrenalin in the case of shock and symptomatic treatment.

An anaphylactic reaction to intra-articular triamcinolone: a case report and review of the literature

OBJECTIVE

The primary objective was to report a case of triamcinolone-induced anaphylaxis and review the proposed mechanisms of corticosteroid-associated hypersensitivity reactions.

DATA SOURCES

Articles in French and English were identified from references in relevant articles and from articles retrieved from the PubMed web site. Indexing terms consisted of corticosteroids in conjunction with the terms anaphylaxis, hypersensitivity reactions, asthma, urticaria, and angioedema.

STUDY SELECTION

We reviewed all articles that described a case or cases of allergic-type reaction in association with corticosteroid use and for which we could obtain the full text of the article (>95%).

RESULTS

We report an anaphylactic reaction occurring after an intraarticular injection of triamcinolone in a 75-year-old man who had positive prick skin tests to triamcinolone and negative tests to lidocaine, methylprednisolone, and hydrocortisone.

CONCLUSIONS

To date, there have been approximately 100 published reports of immediate hypersensitivity reactions occurring after oral and parenteral administration of corticosteroids. Both immunologic and nonimmunologic mechanisms are proposed, but there is no definitive evidence in favor of either hypothesis. Our patient demonstrated positive prick skin tests to triamcinolone in a dose-response manner, suggesting the likelihood that an immunoglobulin E-mediated hypersensitivity mechanism may play a role.

Allergic-type reactions to corticosteroids

OBJECTIVE

To review reported cases of suspected allergic reactions to various corticosteroids.

DATA SOURCES

A MEDLINE search (January 1966-December 1997) was performed to obtain case reports and review articles on allergic-type reactions to corticosteroids. Further references were obtained from these publications.

STUDY SELECTION

Reports involving allergic or allergic-type reactions to systemic administration of corticosteroids were chosen for this review. An allergic-type reaction was defined as any reaction after administration of the drug that involved the appearance of adverse symptoms that are characteristic of unwanted immune responses. These symptoms include rash, sneezing, dyspnea, edema, bronchospasm, or death. Articles were excluded from the evaluation if they described reactions to topical, intraarticular, or ophthalmic corticosteroid administration.

DATA SYNTHESIS

Corticosteroids are medications that are often used to treat allergic reactions. However, it appears that patients can also have allergic-type reactions to these agents. The severity of the reaction can vary from a rash to anaphylaxis or death. Both immediate and delayed reactions can occur. Allergic-type reactions are reported to occur more frequently in asthmatic and renal transplant patients than other patient populations. However, it is questionable whether all of these are true allergic responses, as there is conflicting evidence regarding the mechanism of the reaction. The most commonly implicated corticosteroids are methylprednisolone and hydrocortisone, but reactions have also occurred with others. Intradermal skin testing can help determine cross-sensitivity, although its value has not been conclusively demonstrated.

CONCLUSIONS

Clinicians should be aware that allergic reactions to corticosteroids are possible. Worsening of symptoms may not always mean treatment failure, but may indicate an allergic reaction. High doses of corticosteroids (> or = 500 mg) should be given over 30-60 minutes, and patients should be observed after administration for at least the same time period. Asthmatics, renal transplant patients, and hemodynamically unstable patients may be at higher risk for adverse events. If a patient is found to be allergic to one corticosteroid, intradermal skin testing may help identify another corticosteroid that can be tolerated.