David Hummel

Anaphylactic Reaction to Oral Cefaclor in a Child

Adverse drug reactions are a common clinical problem. It has been estimated1 that 6% to 15% of hospitalized patients experience some sort of adverse drug reaction. Clinical manifestations of adverse drug reactions include skin rash; a serum sickness-like reaction; drug fever; pulmonary, hepatic, and renal involvement; and systemic anaphylaxis. Many of these adverse events are not immunologically mediated. Actual allergic or immunologic drug reactions probably account for <25% of adverse drug reactions overall.1 Antibiotics are one of the major contributors to drug hypersensitivity. Cefaclor, an oral second-generation cephalosporin with a β-lactam ring, is used against various infectious diseases of the respiratory tract, especially in children. Several cases of cefaclor hypersensitivity have been reported.2 ,3 The most common presentations are either erythematous or papular eruptions, although serum sickness-like reactions have also been described. Anaphylactic reactions, although rare, have been observed in adults. Here we report a case of anaphylactic reaction to cefaclor in a 2½-year-old patient.

No systemic reactions to influenza vaccination in egg-sensitized tertiary-care pediatric patients

BackgroundThere are numerous, disparate guidelines for influenza vaccination in egg-allergic patients. We aimed to describe the outcome of selectively applied guidelines, based on risk-stratification, to our high risk, egg-allergic, tertiary-care pediatric population.MethodsEgg allergy was confirmed with skin testing. The vaccine administered was an adjuvunated 2009 H1N1 influenza A vaccine with < 0.165 mcg/ml ovalbumin. Patients with mild egg allergy were to receive the vaccination in 1 dose, those with severe egg allergy were to receive 2 split doses, and patients with exquisite egg allergy or significant co-morbidities were to be skin tested with the vaccine (prick full strength, intradermal 1:100 of final concentration without adjuvant) and had 5 step desensitization if the testing was positive, or 1-2 step administration if negative. Patients were observed for 60 minutes after the final dose and anaphylaxis treatment was available. We report the frequency of allergic reactions.ResultsNinety-nine patients were referred and 79 had positive egg testing. Asthma was present in 67% and 30% had prior anaphylaxis to egg. We vaccinated 77 of 79 patients: 71 without performing vaccine skin testing. Two refused vaccination. No patient had a systemic reaction or required treatment. Two patients experienced positive testing to the adjuvanated intradermal vaccine, but were negative without adjuvant.ConclusionsOur results suggest that most egg-allergic tertiary care pediatric patients can be vaccinated with a low ovalbumin content influenza vaccine without prior vaccine testing. Vaccine skin testing, if used at all, can be reserved for special circumstances. The squalene adjuvant may cause an irritant reaction with intradermal testing.

Anaphylaxis to Milk After Elimination Diet for Eosinophilic Gastrointestinal Disease

To the Editor: Eosinophilic gastrointestinal diseases (EGID), which include eosinophilic esophagitis (EoE), eosinophilic gastroenteritis, and eosinophilic colitis, have become increasingly recognized ( 1 ). Cow’s milk has been implicated as being a causative factor in EGID ( 1,2 ) and exclusion diets may be prescribed for all of these conditions ( 2 ). We describe a previously milk-tolerant child who developed anaphylaxis to cow’s milk aft er only a year of avoidance for EGID from age 6 to 7 years old. To the best of our knowledge, the description of anaphylactic allergy aft er avoidance for EGID is novel. Elimination diets for EGID can lead to anaphylactic allergy, even in school-aged children. A 6-year-old male with a history of asthma, atopic dermatitis, and food allergy developed recurrent vomiting. He had a clinical history of allergies to eggs, bananas, fi sh, shellfi sh, peanuts, tree nuts, and peaches confi rmed by positive skin prick tests (SPTs). However, he had always clearly tolerated dairy products and had a negative SPT to milk. He had consistently high eosinophil counts (>3.5×10 9 /l) and very high IgE levels (>8,000 IU). Endoscopy and biopsy showed features of EGID of the esophagus and stomach ( Figure 1 ). Aft er his diagnosis of EGID, an SPT was again negative for milk. He was started on an exclusive elemental formula diet. Foods were gradually reintroduced into his diet with strict milk elimination maintained for 1 year. At the age of 7 years, he consumed cheese and immediately developed urticaria, respiratory diffi culty, and vomiting treated with auto-injectable epinephrine. Aft er this event, SPTs and IgE to milk were strongly positive and corroborated the development of an IgE-mediated allergy to cow’s milk (24×14 mm wheal to milk extract, 30×15 mm wheal to fresh milk, 20×10 mm wheal to boiled milk, and IgE to milk >100 kU/l). At the last visit, he was 14 years old and continued to avoid all forms of milk. Food allergies are strongly associated with EoE as well as other EGID ( 1,2 ). Food elimination diets are helpful in 40–100% of patients ( 1,2 ). To mitigate the risk of reintroduction, the TIGERS consensus ( 2 ) recommends performing SPT and serum IgE CONFLICT OF INTEREST Financial support: None. Potential competing interests: None.