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Trubiano JA. New Pathways to Navigate an Old Problem of Tuberculosis Therapy-Associated Adverse Drug Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3450-3451. [PMID: 34507712 DOI: 10.1016/j.jaip.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases (Austin Health), Heidelberg, Victoria, Australia; Department of Medicine (Austin Health), University of Melbourne, Parkville, Victoria, Australia.
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Kim TO, Shin HJ, Kim YI, Lim SC, Koh YI, Kwon YS. Cutaneous adverse drug reactions in patients with peripheral blood eosinophilia during antituberculosis treatment. Korean J Intern Med 2019; 34:1050-1057. [PMID: 30879290 PMCID: PMC6718751 DOI: 10.3904/kjim.2018.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 07/25/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/AIMS Peripheral eosinophilia during tuberculosis (TB) treatment is common, but has not been fully evaluated. The aim of this study was to determine the prevalence and clinical significance of peripheral blood eosinophilia in patients undergoing anti-TB treatment. METHODS We retrospectively reviewed the clinical and laboratory data of patients who received anti-TB treatment and had peripheral blood eosinophilia (> 5% of the total white blood cell count) at the Chonnam National University Hospital between January 2010 and December 2014. RESULTS Of all 2,234 patients with TB who received anti-TB treatment, 397 (17.8%) had peripheral blood eosinophilia. Of the 397 with eosinophilia, we reviewed the data of 262 (66%), and cutaneous adverse drug reactions (CADRs) were observed in 161 (61.5%). Of the 161 with CADRs, itching (47.2%) and skin rash (47.8%) were common. Older age, abnormal liver function, and higher peak blood eosinophil percentage were associated with CADRs in multivariate analysis. There was a significant relationship between increased peak eosinophil counts and the degree of severity of CADRs. CONCLUSION Peripheral blood eosinophilia is a relatively common occurrence during anti-TB treatment. Peripheral blood eosinophil counts were higher according to the degree of severity of CADRs.
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Affiliation(s)
- Tae-Ok Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hong-Joon Shin
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yu-Il Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung-Chul Lim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Young-Il Koh
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
- Correspondence to Yong-Soo Kwon, M.D. Department of Internal Medicine, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea Tel: +82-62-220-6575 Fax: +82-62-225-8578 E-mail:
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Abstract
PURPOSE OF REVIEW Tuberculosis (TB) is the commonest infectious cause of death globally. Adverse reactions to first-line tuberculosis antibiotics are common and have a major impact on the outcomes of patients as second-line antibiotics are less effective and more toxic. The present review addresses the most recent literature regarding epidemiology, investigating reactions, and reintroducing treatment in patients who have had their treatment interrupted. RECENT FINDINGS Studies have demonstrated that up to 60% of patients experience adverse reactions to TB treatment; around a third of these are idiosyncratic and may relate to immune sensitization. There is an increased risk in patients with HIV. For patients with severe cutaneous reactions patch testing has an important role; however, systemic reactions to patch testing are common in patients with HIV. In-vitro testing remains limited to specialist centers but studies have identified drug-specific lymphocyte responses in patients with cutaneous and liver reactions. Desensitization of patients with severe cutaneous reactions have been demonstrated to be possible, albeit at high risk. SUMMARY Management of these patients remains suboptimal. Better identification of predisposing factors, such as HLA alleles, are needed to identify patients at risk. Improved in-vitro diagnostics will reduce the need to re-expose the patient to the drug and optimized desensitization regimens will improve patient safety when drugs have to be re-introduced.
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Roy M, Ahmad S, Roy AK. Successful rapid oral desensitization for dual hypersensitivity to isoniazid and rifampin while treating central nervous system tuberculosis. J Community Hosp Intern Med Perspect 2018; 8:345-348. [PMID: 30559942 PMCID: PMC6292347 DOI: 10.1080/20009666.2018.1545516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 10/30/2018] [Indexed: 11/21/2022] Open
Abstract
Tuberculosis of the central nervous system (CNS-TB) is a critical disease with poor prognosis if not diagnosed and treated early. A regimen of drugs with good CNS penetration is required for treatment. Treatment options are limited in case of hypersensitivity reaction of the recommended regimen. We are reporting a rare instance where a patient developed hypersensitivity to both first line agents (isoniazid and rifampin) for CNS-TB and was successfully desensitized against both these medications to complete the treatment course using the rapid desensitization process. There have been reported cases of desensitization to anti tuberculous medications in cases with pulmonary tuberculosis and hypersensitivity reaction. In this review article we discuss the prior used methods of slow and rapid desensitization in case on non-CNS tuberculosis infections. This is the first reported case to use similar method of rapid desensitization in treatment of central nervous system infection.
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Affiliation(s)
- Moni Roy
- Adult Hospitalist, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Sharjeel Ahmad
- Section of Infectious Diseases, Department of Medicine, University of Illinois College of Medicine, Peoria, IL, USA
| | - Ashish Kumar Roy
- Adult Hospitalist, OSF Saint Francis Medical Center, Peoria, IL, USA
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Collado-Chagoya R, Hernández-Romero J, Eliosa-Alvarado GA, Cruz-Pantoja RA, Campos-Gutiérrez RI, Velasco-Medina AA, Velázquez-Sámano G. Tolerance Induction to Antituberculosis Drugs in a Patient With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Overlap. ALLERGY & RHINOLOGY 2018; 9:2152656718783618. [PMID: 30083412 PMCID: PMC6071158 DOI: 10.1177/2152656718783618] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tolerance induction and desensitization in Stevens-Johnson syndrome (SJS) or in toxic epidermal necrolysis (TEN) have been described as an absolute contraindication by some authors, but there are cases where there is no treatment alternative. Tuberculosis (TB) remains a leading cause of morbidity and mortality in developing countries and ranks alongside HIV as a leading cause of death worldwide. Severe drug reactions, such as SJS and TEN, occurring in these individuals are lifethreatening. Since alternative therapies for TB are limited, the role of desensitization and reintroduction becomes essential. We describe a case of tolerance induction to anti-TB drugs in a patient with SJS/TEN overlap syndrome using a specifically designed premedication, comedication, and desensitization protocol.
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Affiliation(s)
- Rodrigo Collado-Chagoya
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Javier Hernández-Romero
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Gumaro A Eliosa-Alvarado
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Rubén A Cruz-Pantoja
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Rosa I Campos-Gutiérrez
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Andrea A Velasco-Medina
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
| | - Guillermo Velázquez-Sámano
- Allergy and Clinical Immunology Department, Hospital General de México "Dr. Eduardo Liceaga", Mexico City, Mexico
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Siripassorn K, Ruxrungtham K, Manosuthi W. Successful drug desensitization in patients with delayed-type allergic reactions to anti-tuberculosis drugs. Int J Infect Dis 2018; 68:61-68. [PMID: 29410254 DOI: 10.1016/j.ijid.2018.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/07/2017] [Accepted: 01/11/2018] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To evaluate the outcomes of anti-tuberculosis drug desensitization. METHODS This was a retrospective study. Inclusion criteria were as follows: age >18years, documented tuberculosis infection, a previous cutaneous allergic reaction to anti-tuberculosis drugs, and having undergone drug desensitization between January 2003 and March 2014. The definition of allergic reaction to anti-tuberculosis drugs included (1) a temporal relationship between drug use and the allergic reaction; (2) improvement in the allergic reaction after drug withdrawal; (3) recurrence of the allergic reaction after reintroduction of only the offending drug; and (4) absence of other causes. RESULTS A total of 19 desensitization procedures were performed. The drugs used for these procedures were isoniazid (n=7), rifampicin (n=6), or ethambutol (n=6). Of note, severe allergic reactions (Stevens-Johnson syndrome (n=4), erythema multiforme (n=3), and drug rash with eosinophilia and systemic syndrome (n=1)) were included. All patients underwent resolution of the previous allergic reactions before desensitization. The median duration of desensitization was 18 days. The success rate was 78.9%. The allergic reactions following failed desensitization were not severe; most were maculopapular rashes. CONCLUSIONS The desensitization protocol for anti-tuberculosis drugs was associated with a high success rate, and the individuals who failed desensitization experienced mild allergic reactions.
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Affiliation(s)
| | - Kiat Ruxrungtham
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Manzini TC, Gosnell BI, John MAA, Moosa MYS. Efavirenz challenge in patients with nevirapine induced Stevens-Johnson Syndrome. S Afr J Infect Dis 2015. [DOI: 10.1080/23120053.2016.1156874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Thong BYH, Chia FLA, Tan SC, Tan TC, Leong KP, Tan JWL, Tang CY, Hou JF, Chan GYL, Chng HH. A retrospective study on sequential desensitization-rechallenge for antituberculosis drug allergy. Asia Pac Allergy 2014; 4:156-63. [PMID: 25097851 PMCID: PMC4116042 DOI: 10.5415/apallergy.2014.4.3.156] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 06/29/2014] [Indexed: 12/13/2022] Open
Abstract
Background Antituberculosis (anti-TB) drug allergy often involves multiple concurrently administered drugs which subsequently need to be reinitiated as no better alternatives exist. Objective To describe the results of tailored sequential desensitization-rechallenge (D-R) for anti-TB drug allergy. Methods Consecutive patients who had undergone D-R to anti-TB drugs between 1 September 1997 and 31 January 2012 were recruited. Following resolution of the acute reaction, anti-TB drug was restarted at 1:6,000 to 1:3 of the final daily dose (FDD), with gradual single or multiple step daily dose escalation to the FDD. Subsequent drugs were sequentially added ≥3 days later when the preceding drug was tolerated. Full blood count and liver function tests were monitored prior to addition of each new drug. Results There were 11 patients of whom 10 were male, predominantly Chinese (8 patients). Regimens comprised at least 3 drugs: isoniazid (INH), rifampicin (RIF), ethambutol (EMB), pyrazinamide (PZA), or streptomycin. All patients had nonimmediate reactions, with cutaneous eruptions, where maculopapular exanthema (MPE) was the most common (8 patients). Drug-induced hypersensitivity syndrome (DIHS) occurred in 6 patients, and Stevens Johnson syndrome (SJS) in 2 patients. D-R to INH was successful in 7/9 patients (77.8%) and to RIF/EMB/PZA/streptomycin in all. Of the 2 patients who failed INH D-R, 1 developed fever and MPE on day 3, the other MPE on day 8. D-R with INH and RIF respectively was successful in 2 patients with SJS. Among DIHS patients, 1 failed D-R with INH (fever and MPE on day 3). There were 23/25 (92%) successful D-R among the 11 patients. All patients completed TB treatment of ≥5 months' duration with no cases of drug-resistant TB. Conclusion Tailored sequential TB drug D-R is successful where no better alternative therapies are available, with careful dose escalation and close monitoring, and after a careful risk-benefit assessment.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Faith Li-Ann Chia
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Sze-Chin Tan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Teck-Choon Tan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Khai-Pang Leong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Justina Wei-Lyn Tan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Chwee-Ying Tang
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jin-Feng Hou
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Grace Yin-Lai Chan
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Hiok-Hee Chng
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433, Singapore
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Sánchez-Borges M, Thong B, Blanca M, Ensina LFC, González-Díaz S, Greenberger PA, Jares E, Jee YK, Kase-Tanno L, Khan D, Park JW, Pichler W, Romano A, Jaén MJT. Hypersensitivity reactions to non beta-lactam antimicrobial agents, a statement of the WAO special committee on drug allergy. World Allergy Organ J 2013; 6:18. [PMID: 24175948 PMCID: PMC4446643 DOI: 10.1186/1939-4551-6-18] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/18/2013] [Indexed: 01/12/2023] Open
Abstract
Antibiotics are used extensively in the treatment of various infections. Consequently, they can be considered among the most important agents involved in adverse reactions to drugs, including both allergic and non-allergic drug hypersensitivity [J Allergy Clin Immunol 113:832–836, 2004]. Most studies published to date deal mainly with reactions to the beta-lactam group, and information on hypersensitivity to each of the other antimicrobial agents is scarce. The present document has been produced by the Special Committee on Drug Allergy of the World Allergy Organization to present the most relevant information on the incidence, clinical manifestations, diagnosis, possible mechanisms, and management of hypersensitivity reactions to non beta-lactam antimicrobials for use by practitioners worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico-Docente La Trinidad, Caracas, Venezuela.
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Lehloenya RJ, Dheda K. Cutaneous adverse drug reactions to anti-tuberculosis drugs: state of the art and into the future. Expert Rev Anti Infect Ther 2012; 10:475-86. [PMID: 22512756 DOI: 10.1586/eri.12.13] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
First- and second-line anti-tuberculosis drugs are associated with a diverse presentation of cutaneous adverse drug reactions (CADR), ranging from mild to life threatening. An individual drug can cause multiple types of CADR, and a specific type of CADR can be due to any anti-tuberculosis drug, which can make the management of tuberculosis (TB) following CADR challenging. The higher incidence of TB and CADR in HIV-infected persons makes TB-associated CADR a burgeoning problem for clinicians, particularly in high HIV-prevalence settings. This review discusses the pathogenesis, epidemiology, clinical presentation, diagnosis and management of TB-associated CADR. Clinical controversies including its impact on treatment outcomes, challenges in restarting optimal anti-tuberculosis therapy and the timing of highly active antiretroviral therapy initiation in those with HIV coinfection are also discussed. Finally, gaps in the current knowledge of TB-associated CADR have been identified and a research agenda has been proposed.
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Affiliation(s)
- Rannakoe J Lehloenya
- Division of Dermatology, Department of Medicine, University of Cape Town, Western Cape, South Africa
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Knowles S, Shear NH. Clinical risk management of Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum. Dermatol Ther 2009; 22:441-51. [DOI: 10.1111/j.1529-8019.2009.01260.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Miller DD, Warshaw EM. Adverse cutaneous reactions to antimicrobials in patients with human immunodeficiency virus infection. Dermatitis 2007; 18:8-25. [PMID: 17303040 DOI: 10.2310/6620.2007.05041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Adverse reactions to medication are significant contributors to morbidity and mortality in patients with human immunodeficiency virus (HIV) infection. Cutaneous events not only constitute a significant portion of these reactions, they may also herald developing systemic reactions such as hemato-, nephro-, and hepatotoxicity. The identification of cutaneous adverse reactions and drug culprits and the proper management of reactions are of paramount importance for these patients. This review focuses specifically on adverse cutaneous reactions to antimicrobials that are commonly used in the management of patients with HIV infection.
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Abstract
Adverse drug reactions (ADRs) are common and mostly avoidable. Some ADRs cannot as yet be predicted, but at-risk populations/patients and high-risk drugs are identifiable. HIV-infected patients are at risk of developing cutaneous ADRs, especially Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug hypersensitivity syndrome. Multiple factors of causation variably present in patients with HIV infection best explain the pathogenesis of these cutaneous ADRs. When no effective alternate therapy is available, drug rechallenge in HIV-infected patients can be attempted with little morbidity or mortality if done according to rationalized protocols.
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Affiliation(s)
- Gail Todd
- Division of Dermatology, University of Cape Town, Faculty of Health Sciences, Nard 623, Cape Town, South Africa.
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