Methylprednisolone-induced anaphylaxis: diagnosis by skin test and basophil activation test

Immediate and delayed hypersensitivity reactions to corticosteroids - prevalence, diagnosis and treatment

BACKGROUND

Corticosteroids, which are anti-inflammatory and immunosuppressive agents used for the treatment of various diseases including allergic disorders, can induce immediate and delayed hypersensitivity reactions. Although these reactions are not common, due to the wide usage of corticosteroid medications, corticosteroid hypersensitivity reactions are clinically important.

OBJECTIVE

In this review, we summarise the prevalence, pathogenetic mechanism, clinical manifestations, risk factors, diagnostic and therapeutic approach for corticosteroid-induced hypersensitivity reactions.

METHODS

An integrative review of the literature was conducted using PubMed searches (mainly large cohort-based studies) regarding the different aspects of corticosteroid hypersensitivity.

RESULTS

Hypersensitivity reactions to corticosteroids can be immediate or delayed and can follow all modes of corticosteroid administration. Prick and intradermal skin tests are useful diagnostic tools for immediate hypersensitivity reactions, patch tests are useful for delayed hypersensitivity reactions. According to the diagnostic tests an alternative (safe) corticosteroid agent should be administered.

CONCLUSION

Physicians of all medical disciplines should be aware that corticosteroids can cause (paradoxically) immediate or delayed allergic hypersensitivity reactions. The diagnosis of such allergic reactions is challenging since it is often difficult to distinguish between hypersensitivity reactions and deterioration of the basic inflammatory disease (e.g., worsening of asthma or dermatitis). Thus, a high index of suspicion is needed in order to identify the culprit corticosteroid.

Immediate hypersensitivity reactions to steroids and steroid containing medications

PURPOSE OF REVIEW

Although rare and counterintuitive, hypersensitivity reactions to corticosteroids have been reported since the 1950s. Delayed hypersensitivity reactions following cutaneous exposure (contact allergy) are well understood and principles of testing, as well as cross-reactivity patterns, have been established. In contrast, understanding of immediate hypersensitivity reactions and delayed hypersensitivity reactions after systemic exposure is evolving more slowly. However, progress has been made in the delineating of underlying pathogenic mechanisms and in the development of testing.

RECENT FINDINGS

IgE-mediated hypersensitivity reactions to corticosteroids have been described. It has been recognized that some, if not all of them, may be due to excipients in steroid formulations. Two excipients, polyethylene glycol and carboxymethylcellulose, seem of particular importance, but cases of reactions to polysorbate 80 and lactose have also been reported. The use of skin testing but also, increasingly, in-vitro methods such as basophil activation test is improving diagnostic accuracy.

SUMMARY

The recognition of the role of excipients is leading to a paradigm shift in our approach to immediate hypersensitivity to corticosteroids. Improved access to in-vivo and in-vitro testing will enhance our understanding of true corticosteroid immediate allergy.

Methylprednisolone-induced anaphylaxis diagnosed by intradermal skin test: a case report

Background

Glucocorticoids rarely cause anaphylaxis. Common methods for the determination of allergens include in vivo skin prick test (SPT) and intradermal skin test (IDST) and the in vitro basophil activation test (BAT). However, to our knowledge, the best strategy for diagnosing glucocorticoid-induced anaphylaxis has not been elucidated.

Case presentation

A 10-year-old boy was admitted to our hospital because of 2 weeks of fever and arthralgia. He had not been treated with glucocorticoids before, including methylprednisolone (mPSL). He was suspected to have bacterial myositis and was treated with ceftriaxone. However, his symptoms persisted for > 2 weeks. Autoinflammatory arthritis was suspected, and he was treated with mPSL sodium succinate (MPS) pulse therapy (30 mg/kg). After 15 min of mPSL injection, he had wheezing and generalized wheal formation with decreased oxygen saturation. As anaphylaxis was suspected, mPSL was discontinued, and olopatadine and oxygen were administered. The symptoms improved considerably without the use of epinephrine and disappeared in 30 min. One month after discharge, SPT, IDST, and BAT were performed without discontinuing his prescribed oral prednisolone. SPTs for MPS, hydrocortisone sodium succinate (HCS), prednisolone sodium succinate (PSS), dexamethasone sodium phosphate (DSP), and betamethasone sodium phosphate (BSP) were negative. IDSTs for MPS, HCS, and PSS were positive, whereas those for DSP and BSP were negative. By contrast, BATs for MPS, HCS, and PSS were negative. Although glucocorticoid-induced hypersensitivity caused by nonmedicinal ingredients such as lactose, carboxymethylcellulose, polyethylene glycol, and hexylene glycol has been reported; the glucocorticoids tested in this patient did not contain any of these nonmedicinal ingredients. As the glucocorticoids that were positive on IDST share a succinate ester, this might have caused MPS-induced anaphylaxis.

Conclusions

We report the case of MPS-induced anaphylaxis diagnosed by IDST but not BAT. In case reports of glucocorticoid-induced anaphylaxis in the literature, most patients were diagnosed with SPT or IDST. These results suggest that BAT should be considered when IDST and SPT are negative. Further studies are necessary to clarify the best strategy for diagnosing glucocorticoid-induced anaphylaxis.

Basophil Reactivity as Biomarker in Immediate Drug Hypersensitivity Reactions-Potential and Limitations

Immediate drug hypersensitivity reactions (DHRs) resemble typical immunoglobulin E (IgE)-mediated symptoms. Clinical manifestations range from local skin reactions, gastrointestinal and/or respiratory symptoms to severe systemic involvement with potential fatal outcome. Depending on the substance group of the eliciting drug the correct diagnosis is a major challenge. Skin testing and in vitro diagnostics are often unreliable and not reproducible. The involvement of drug-specific IgE is questionable in many cases. The culprit substance (parent drug or metabolite) and potential cross-reacting compounds are difficult to identify, patient history and drug provocation testing often remain the only means for diagnosis. Hence, several groups proposed basophil activation test (BAT) for the diagnosis of immediate DHRs as basophils are well-known effector cells in allergic reactions. However, the usefulness of BAT in immediate DHRs is highly variable and dependent on the drug itself plus its capacity to spontaneously conjugate to serum proteins. Stimulation with pure solutions of the parent drug or metabolites thereof vs. drug-protein conjugates may influence sensitivity and specificity of the test. We thus, reviewed the available literature about the use of BAT for diagnosing immediate DHRs against drug classes such as antibiotics, radio contrast media, neuromuscular blocking agents, non-steroidal anti-inflammatory drugs, and biologicals. Influencing factors like the selection of stimulants or of the identification and activation markers, the stimulation protocol, gating strategies, and cut-off definition are addressed in this overview on BAT performance. The overall aim is to evaluate the suitability of BAT as biomarker for the diagnosis of immediate drug-induced hypersensitivity reactions.

Immediate hypersensitivity reactions to corticosteroids

OBJECTIVE

To review the literature on immediate hypersensitivity reactions to corticosteroids and classify them according to manifestations, routes of exposure, causative preparations, diagnostic tests, and management.

DATA SOURCES

PubMed search for English-language publications from January 1, 2004 through December 31, 2014 using search terms corticosteroid, glucocorticoid, or steroid combined with hypersensitivity, allergy, or anaphylaxis.

STUDY SELECTION

Only reports of immediate hypersensitivity reactions that occurred sooner than 24 hours after administration of a corticosteroid were included. Excluded were reports on patients with delayed reactions, including contact dermatitis.

RESULTS

Forty-eight articles fulfilled the criteria, reporting 120 reactions in 106 patients 2 to 90 years of age (55 male and 51 female). The most commonly reported manifestation was anaphylaxis in 60.8% (73 of 120) followed by urticaria and/or angioedema in 26.7%. Exposure to corticosteroid was through any route, with intravenous being the most common (44.2%, 53 of 120), followed by oral in 25.8% and intra-articular in 11.7%. Methylprednisolone was the most commonly implicated (40.8%) followed by prednisolone (20.0%). Some reacted to more than 1 preparation. Pharmacologically-inactive ingredients were implicated in 28.3%. Diagnosis was based primarily on medical history and in most cases was confirmed by challenge testing. Skin tests were positive in 74.1%. The vast majority of patients tolerated at least 1 alternative preparation, and very rarely desensitization was required.

CONCLUSION

Corticosteroids seem to be rare causes of immediate hypersensitivity reactions but possibly are misdiagnosed or under-reported relative to their worldwide use. Physicians should be cognizant of this entity and identify safe alternative preparations.

Flow cytometric analysis of the basophil cell activating impact of potential drug delivery nanoparticle-candidate

INTRODUCTION

Carbon nanotubes – as artificial nano-size ranged materials –have increasing role in the modern biomedical, diagnostic and therapeutic applications.There is a promising option for their use as more potential drug carriers. Despite the favourable properties, their impact (accumulation, elimination, etc.) on biological systems is largely unknown. The main limiting factor of medical use of nanomaterials in most cases is the potential hypersensitive side effect. It can develop in different route, but the activation of basophil granulocytes may play a central role in this process.

OBJECTIVE

Our aim was to test the direct activation ability of different, surface modified nanotubes on basophil granulocytes in vitro. In parallel we tested the effectiveness of BasoTest planned to use for this study.

MATERIALS AND METHODS

Using the blood samples of allergic and healthy volunteers we examined the basophil degranulation in the presence of nanotubes and the expression level changes of cell-surface CD63 on FACS Calibur instrument. Our results were compared to positive(fMLP, Mite, Grass) and negative control samples.

RESULTS

The test we have chosen proved to be sufficiently sensitive and specific for further study. Significant basophil activation was observed in the presence of carbon nanotubes in healthy persons and allergic patients, as well. The activating effect of nanotubes was more prevailed in allergic population.

CONCLUSION

Our experiments have proven the fact that nanotubes may play a role in the development of hypersensitive allergic reactions through their basophil granulocyte activator effect.

Recent applications of basophil activation tests in the diagnosis of drug hypersensitivity

Immediate-type drug hypersensitivity is an increasingly significant clinical issue; however, the diagnosis is frequently hindered due to lack of safe and precise diagnostic tests. Flow cytometry-assisted basophil activation test is a safe in vitro diagnostic tool for assessing basophil activation upon allergen stimulation. In this review, we have summarized current literature on the diagnostic utilities, new indications, and methodological aspects of the basophil activation test for the diagnosis of drug hypersensitivity.

Update on the performance and application of basophil activation tests

The basophil activation test (BAT) is a flow-cytometry-based functional assay that assesses the degree of cell activation after exposure to a stimuli. Though no standardized technique currently exists, recent advances have improved the performance of this assay, including identification of new basophil-specific markers and comparisons of the expression of CD63 to CD203c during activation. The basophil activation test has also been validated for many IgE-mediated disease conditions, which have been extensively reviewed elsewhere. This review focuses on the most recent applications of this test to the diagnosis of allergy to drugs, foods, venoms, and pollens, and the evolving role of the BAT in monitoring immunotherapy.

Methylprednisolone sodium succinate-associated macroglossia in a critically ill patient

Allergic hypersensitivity reactions are a rare adverse effect of corticosteroids. Previous reports have identified patients who developed symptoms of urticaria, dyspnea, hypotension, bronchospasm, and angioedema occurring within minutes to an hour after corticosteroid administration. A 35-year-old woman is described who developed an atypical reaction of isolated macroglossia after receiving intravenous methylprednisolone sodium succinate for myasthenic crisis. Macroglossia was identified on day 2 of therapy and worsened through day 5. On day 5, she was transitioned to prednisone 50 mg daily administered by feeding tube. Tongue swelling improved by day 7 and on day 10, the patient was extubated. The patient required reintubation due to stridor, but received a tracheostomy and was weaned off mechanical ventilation by day 15. The reaction was not confirmed with skin-prick tests, intradermal tests, or a drug rechallenge; however, she had previously received and tolerated all other drugs administered during this time. Due to the timing of administration and onset of symptoms, we feel this adverse drug reaction was likely due to administration of methylprednisolone. Applying the Naranjo adverse drug reaction probability scale to this case, a score of six was obtained, indicating a probable association between the administration of methylprednisolone and the development of macroglossia. As intravenous corticosteroids are often used in the treatment of allergic reactions, they may be overlooked as a cause of macroglossia and other allergic reactions; therefore, practitioners need to be aware of the possibility of this adverse effect secondary to corticosteroid administration. In the event of methylprednisolone sodium succinate-induced macroglossia, alternative nonesterified corticosteroids, such as dexamethasone or prednisone, should be considered if continuation of therapy is required.