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Genis C, Sengul Emeksiz Z, Buyuk Yaytokgil S, Ginis T, Islamoglu C, Dibek Misirlioglu E. Successful rapid liposomal amphotericin B desensitization in pediatric case series. Allergy Asthma Proc 2024; 45:201-206. [PMID: 38755786 DOI: 10.2500/aap.2024.45.240008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: Liposomal amphotericin B (LAMB) is a crucial agent in the treatment of invasive fungal diseases caused by a wide variety of yeasts and molds. In the presence of an infection caused by a fungal agent resistant to alternative antifungal drugs, desensitization may be the only option to continue treatment. However, there is insufficient information and consensus with regard to amphotericin B desensitization protocols in the pediatric age group. Objective: We present our experience with five cases of patients in whom successful desensitization protocols were applied with LAMB, along with a review of the literature on pediatric cases. We also provide a sample desensitization protocol that we successfully applied. Methods: Pediatric patients who continued their treatment with the successful rapid desensitization protocol conducted at the Paediatric Allergy and Immunology Clinic of the Ministry of Health Ankara City Hospital between September 2019 and September 2023 were examined. Desensitization protocols were applied based on Castells' desensitization protocol. Results: Five patients ages between 5 and 12 years were referred to us due to the development of anaphylaxis during their treatment with LAMB. Anaphylaxis is diagnosed clinically, according to the European Academy of Allergy and Clinical Immunology guidelines: anaphylaxis (2021 update). A 16-step desensitization protocol was prepared by using LAMB solutions at four different dilutions (0.001, 0.01, 0.1, and 1 mg/mL). Each solution consisted of four steps, with a 15-minute infusion for each step. The patients were premedicated with 1 mg/kg/dose methylprednisolone and an antihistamine. Conclusion: The data we present on the successful application of a sample protocol to five cases, particularly in a pediatric setting, are noteworthy valuable contributions to the field, which demonstrates the feasibility and success of rapid desensitization with LAMB in pediatric patients. This can provide important insights and potentially serve as a reference for medical professionals working with similar cases in the future.
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Affiliation(s)
- Cankat Genis
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Zeynep Sengul Emeksiz
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Sule Buyuk Yaytokgil
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Tayfur Ginis
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Candan Islamoglu
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- From the Department of Paediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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Milosevic K, Malinic M, Plavec D, Lekovic Z, Lekovic A, Cobeljic M, Rsovac S. Diagnosing Single and Multiple Drug Hypersensitivity in Children: A Tertiary Care Center Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121954. [PMID: 36553397 PMCID: PMC9776612 DOI: 10.3390/children9121954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 11/29/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are a type of adverse drug reactions with heterogeneous pathophysiological mechanisms and a broad spectrum of clinical manifestations. Since over-diagnosing is common in children, a complete allergy work-up is needed. A cross-sectional study was conducted at a tertiary care institution, covering the five-year period. Five hundred and four patients of both sexes, mean age 7.5 and with a medical history suggestive of DHR were evaluated. ENDA/EAACI guidelines were used for a diagnostic algorithm. Single drug hypersensitivity was registered in 375 patients and multiple drug hypersensitivity in 129. The main culprits in medical history were antibiotics (83%), non-steroidal anti-inflammatory drugs (NSAIDs) (8.4%) and analgoantipyretics (3.8%). Skin involvement was registered in 96.2%. DHRs were confirmed in 4.4% patients-six patients had positive skin tests and 13 had a positive drug provocation test. In the proven DHRs group, the main agents were antibiotics (72.7%), followed by NSAIDs (8.3%), and of all the skin manifestations, urticaria was most common (78.2%), followed by exanthema (10.5%) and angioedema (5.3%). Considering the above, anticipating DHRs and a proper referral of children to an allergologist is a key step in the assessment of drug hypersensitivity. A complete allergy work-up prevents unnecessary drug exclusion and allows most children to safely continue the use of first-line medications when needed.
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Affiliation(s)
- Katarina Milosevic
- Department of Pulmonology and Allergology, University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
| | - Marija Malinic
- Clinic of Dermatovenereology, University Clinical Center of Serbia, Deligradska 34, 11000 Belgrade, Serbia
| | - Davor Plavec
- Medical Faculty Osijek, J. J. Strossmayer University of Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Srebrnjak Children’s Hospital, Srebrnjak 100, 10000 Zagreb, Croatia
| | - Zoran Lekovic
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
- Department of Gastroenterology, University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia
| | - Aleksa Lekovic
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
| | - Mina Cobeljic
- Department of Pediatric and Neonatal Intensive Care, University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-645390030
| | - Snezana Rsovac
- Faculty of Medicine, University of Belgrade, Dr. Subotica 8, 11000 Belgrade, Serbia
- Department of Pediatric and Neonatal Intensive Care, University Children’s Hospital, Tirsova 10, 11000 Belgrade, Serbia
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Costa Carvalho J, Alen Coutinho I, Matos AL, Alves P, Ramos L, Gonçalo M. Patch testing for cutaneous adverse drug reactions in a paediatric population: A retrospective review. Contact Dermatitis 2022; 87:373-376. [PMID: 35638861 DOI: 10.1111/cod.14167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/02/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jóni Costa Carvalho
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Iolanda Alen Coutinho
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Ana Luísa Matos
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Pedro Alves
- Allergy and Clinical Immunology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Leonor Ramos
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
| | - Margarida Gonçalo
- Dermatology Department, Coimbra University Hospital Center, Coimbra, Portugal
- Dermatology Department, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Tsabouri S, Atanaskovic-Markovic M. Skin eruptions in children: Drug hypersensitivity vs viral exanthema. Pediatr Allergy Immunol 2021; 32:824-834. [PMID: 33621365 DOI: 10.1111/pai.13485] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 12/11/2022]
Abstract
Childhood rashes or exanthemas are common and are usually relatively benign. There are many causes of rash in children, including mainly viruses, and less often bacterial toxins, drugs, allergens and other diseases. Viral exanthema often appears while children are taking a medication in the course of a viral infection; it can mimic drug exanthema and is perceived as a drug allergy in 10% of cases. In the vast majority of cases, the distinction between virus-induced and drug-induced skin eruption during the acute phase is not possible. The drugs most commonly implicated are beta-lactams (BL) and non-steroidal anti-inflammatory drugs (NSAIDs). Viruses, commonly Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6) and cytomegalovirus (CMV), and the bacterium, Mycoplasma pneumoniae, may cause exanthema either from the infection itself (active or latent) or because of interaction with drugs that are taken simultaneously. Determination of the exact diagnosis requires a careful clinical history and thorough physical examination. Haematological and biochemical investigations and histology are not always helpful in differentiating between the two types of exanthema. Serological and polymerase chain reaction (PCR) assays can be helpful, although a concomitant acute infection does not exclude drug hypersensitivity. A drug provocation test (DPT) is although considered the gold standard for the diagnosis and is not preferred by the patients. Skin tests are not well tolerated, and in vitro tests, such as the basophil activation test and lymphocyte transformation, are of low sensitivity and specificity and their relevance is debatable. Based on current evidence, we propose a systematic clinical approach for timely differential diagnosis and management of rashes in children who present a cutaneous eruption while receiving a drug.
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Affiliation(s)
- Sophia Tsabouri
- Child Health Department, Medical School, University of Ioannina, Ioannina, Greece
| | - Marina Atanaskovic-Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's Hospital of Belgrade, Belgrade, Serbia
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5
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Atanaskovic-Markovic M. What is new in beta-lactam allergy in children? Pediatr Allergy Immunol 2021; 32:219-222. [PMID: 32955758 DOI: 10.1111/pai.13375] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/13/2020] [Accepted: 08/10/2020] [Indexed: 01/13/2023]
Abstract
This review highlights the novelties in understanding the underlying immunologic mechanisms of drug hypersensitivity reactions (DHRs) with special reference to beta-lactams (BLs) in the pediatric population, as well as tiny changes in clinical classification and diagnosis of DHRs, in the last couple of years. BLs are still the most commonly prescribed and used antibiotics in children. Viral infections are very often in children, and they can provoke skin rashes which are difficult to differentiate from DHRs. The majority of children are incorrectly labeled as "allergic." Therefore, allergy to BLs in children is overdiagnosed. These children often receive suboptimal treatment with second-line broad-spectrum antibiotics, which are less effective, more costly, and associated with an increased risk of antibiotic-resistant infections. This prolongs hospitalization and thus more uses health care. The correct diagnosis of BL allergy in children is still an important and hot topic. This review has outlined the need for correct diagnosis of BL allergy in children and all the controversies encountered by pediatricians and pediatric allergists. It is also necessary to change the paradigm.
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Affiliation(s)
- Marina Atanaskovic-Markovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,University Children's hospital of Belgrade, Belgrade, Serbia
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Piccorossi A, Liccioli G, Barni S, Sarti L, Giovannini M, Verrotti A, Novembre E, Mori F. Epidemiology and drug allergy results in children investigated in allergy unit of a tertiary-care paediatric hospital setting. Ital J Pediatr 2020; 46:5. [PMID: 31924232 PMCID: PMC6954623 DOI: 10.1186/s13052-019-0753-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022] Open
Abstract
Background and objective Drug Hypersensitivity Reactions (DHRs) are considered adverse effects of medications that resemble allergy symptoms. The reported positive clinical history of pediatric drug reactions is about 10%, however, after allergy investigations, only a small percent is confirmed as hypersensitivity. The aim of this study was to analyze the clinical history, allergy work-up results and sensitization profile of children and adolescents referred to our Allergy Unit for suspected DHRs. Methods The study evaluated data related to a group of children with a positive history of drug reactions during a two-year period. The allergy work-up consisted of in vivo and in vitro tests, in accordance with the recommendations of the ENDA/EAACI guidelines. Results Data from a group of 637 patients [348 M (54.6%); 289 F (45.4%)] were retrospectively analyzed. Beta lactams (BLs) were the most common drugs involved in the reported clinical history, followed by non-steroidal anti-inflammatory drugs (NSAIDs). Severe cutaneous adverse reactions (SCARs) were most frequently observed during BL treatment. The confirmation of BL hypersensitivity was higher for immediate reactions (IRs) [9.4%; 5.1% through positive skin tests (STs) and 5.5% through drug provocation test (DPT)] compared to non-immediate reactions (non-IRs) (8.1%; 2.2% through STs and 6.2% through DPT). A higher number of positive results was obtained for BLs and macrolides when the tests were performed within 12 months after the index reaction (p < 0.05). During DPTs with amoxicillin-clavulanic acid, four hypersensitivity reactions (including one anaphylaxis) occurred despite negative STs. Conclusion Our data demonstrated that only 9.1% of patients resulted in being positive to allergy tests which is in line with the data in literature. An allergy work-up is mandatory for excluding suspected hypersensitivity.
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Affiliation(s)
- A Piccorossi
- Department of Pediatrics, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - G Liccioli
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy.
| | - S Barni
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - L Sarti
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - M Giovannini
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - A Verrotti
- Department of Pediatrics, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - E Novembre
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy
| | - F Mori
- Allergy Unit, Anna Meyer Children's Hospital, Florence, Italy
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Graham F, Caubet JC. Diagnosis of drug causality in non-immediate drug hypersensitivity in children. Expert Rev Clin Pharmacol 2018; 11:655-658. [DOI: 10.1080/17512433.2018.1494570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- François Graham
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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Norton AE, Konvinse K, Phillips EJ, Broyles AD. Antibiotic Allergy in Pediatrics. Pediatrics 2018; 141:peds.2017-2497. [PMID: 29700201 PMCID: PMC5914499 DOI: 10.1542/peds.2017-2497] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2017] [Indexed: 12/11/2022] Open
Abstract
The overlabeling of pediatric antibiotic allergy represents a huge burden in society. Given that up to 10% of the US population is labeled as penicillin allergic, it can be estimated that at least 5 million children in this country are labeled with penicillin allergy. We now understand that most of the cutaneous symptoms that are interpreted as drug allergy are likely viral induced or due to a drug-virus interaction, and they usually do not represent a long-lasting, drug-specific, adaptive immune response to the antibiotic that a child received. Because most antibiotic allergy labels acquired in childhood are carried into adulthood, the overlabeling of antibiotic allergy is a liability that leads to unnecessary long-term health care risks, costs, and antibiotic resistance. Fortunately, awareness of this growing burden is increasing and leading to more emphasis on antibiotic allergy delabeling strategies in the adult population. There is growing literature that is used to support the safe and efficacious use of tools such as skin testing and drug challenge to evaluate and manage children with antibiotic allergy labels. In addition, there is an increasing understanding of antibiotic reactivity within classes and side-chain reactions. In summary, a better overall understanding of the current tools available for the diagnosis and management of adverse drug reactions is likely to change how pediatric primary care providers evaluate and treat patients with such diagnoses and prevent the unnecessary avoidance of antibiotics, particularly penicillins.
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Affiliation(s)
- Allison Eaddy Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, and
| | - Katherine Konvinse
- Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth J. Phillips
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, and,John A. Oates Institute for Experimental Therapeutics and Department of Pharmacology, School of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee;,Division of Infectious Disease, Departments of Medicine and,Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee;,Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia; and
| | - Ana Dioun Broyles
- Division of Allergy and Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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Management of Children with Hypersensitivity to Antibiotics and Monoclonal Antibodies. Immunol Allergy Clin North Am 2017; 37:713-725. [PMID: 28965636 DOI: 10.1016/j.iac.2017.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Proper management of drug allergy in children is based on a thorough history, in vitro testing (if available), in vivo testing, and drug challenge. This approach has been well developed with beta-lactam drugs but not with non-beta-lactam drugs and monoclonal antibodies. Children commonly develop rashes during an antibiotic course, which can lead to misdiagnosis of drug allergy. Clinical reactions to monoclonal antibodies vary and are managed depending on the type. A better knowledge of drug reactions that can occur in antibiotic allergy and monoclonal allergy can aid a provider in better management of their drug-allergic pediatric patients.
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