202 The Canadian Journal of Hospital Pharmacy - Volume 45, No. 5, October, 1992

CASE REPORT ~

Hypersensitivity Reaction to Chlorobutanol-Preserved Thiamine

Major Regis Vaillancourt, Captain Roxanne A. Kearns and Commander Michael Buchholz

Adverse drug reactions are a com­ managed with lorazepam IV or po. test using thiamine with and without mon problem encountered by clini­ On day seven of hospitalization, the preservative (Sabex) was performed cians. Approximately 30 percent of patient developed an urticarial ery­ with the patient's informed consent. all hospitalized medical patients ex­ thematous rash predominantly af­ With immediate resuscitative equip­ perience at least one adverse drug fecting upper limbs and truncal re­ ment at hand in a controlled envir­ reaction during their hospitaliza­ gion. Despite the use of diphenhy­ onment, the intradermal test was tion.1 This case report illustrates the dramine po and an elimination pro­ performed on the forearms. An ery­ importance of considering inactive cess excluding common foods, soap, thematous pruritic 2 cm papule was ingredients as potential allergen. bed linens, the medications except formed on the volar surface with the lorazepam, the patient persisted with thiamine and preservative mixture. CASE new urticarial lesions. Dermatology No reaction was observed with the Mr. J.C. is a 52 year old Caucasian consultation confirmed the diagnosis mixture which was preservative free. man who was admitted to the Na­ of delayed allergic reaction - the tional Defence Medical Centre with most probable etiology being thia­ DISCUSSION a diagnosis of alcohol withdrawal mine injections. Hypersensitivity with thiamine has syndrome. He had a 26 year history The patient was discharged on the been reported and typically present of alcohol abuse with subsequent 23rd day with persistent urticaria. as an urticarial rash and pruritis. The partial gastrectomy for adenocarci­ Discharge medications included ci­ intradermal test dose is a recom­ noma. He required B 12 replacement metidine 300 mg po qid, hydro­ mended procedure to rule out a sen­ therapy for documented B12 defi­ xyzine 25 mg po qam and 50 mg sitivity reaction to thiamine.2 The ciency of mixed etiology. He had po qhs for three weeks, MoistureIdiphenhydramine 50 the intradermal test to determine the Bl 2 therapy for at least two months mg po qhs for one week. offending agent as chronic replace­ prior to admission. The patient had The clinical pharmacist involved ment therapy would be necessary. a known allergy to penicillin with in this case raised the possibility of Chlorobutanol is a preservative local hives. the preservative, chlorobutanol util­ used in topical, ophthalmic, paren­ On admission, the patient received ized in the thiamine injection manu­ teral, and otic preparations.3A Hyper­ thiamine hydrochloride 100 mg factured by Sabex as the etiological sensitivity reactions to chlorobu­ (Sabex) I.M. daily for three days, agent rather than thiamine. tanol, when used as a preservative multivitamins 1 tablet po daily, folic Forty-five days after the onset of have been reported.5-7 One other acid 5 mg po daily, and sucralfate the reaction, when the patient's skin reaction followed the use of chloro­ 1 g po qid. His delirium tremens was rash resolved, the intradermal skin butanol-preserved heparin which

Major Regis Vaillancourt, CD B.Pharm. was Pharmacy Clinical Services Officer at the National Defence Medical Centre at the time of preparation of this case report. Currently Major Vaillancourt is the Commanding Officer of the Regional Medical Equipment Depot of Canadian Forces Base, Chilliwack, BC. Captain Roxanne A. Kearns, B.S.P.M. was a Pharmacy Resident at the National Defence Medical Centre at the time of preparation of this case report. Currently Captain Kearns is an Assistant Head of Pharmacy at Canadian Forces Hospital, Halifax, NS. Commander Michael Buchholz, CD, M.D., F.R.C.P. is the head of Internal Medicine at Canadian Forces Hospital, Halifax, N.S. Address correspondence to: Major Regis Vaillancourt, Commanding Officer, Regional Medical Equipment Depot, Canadian Forces Base, Chilliwack, BC VOX 2EO. Acknowledgements: The authors wish to thank Richard Wagner for his professional support. The Canadian Journal of Hospital Pharmacy - Volume 45, No. 5, October, 1992 203

presented as an erythematous skin Table I: List of Canadian Products which contain chlorobutanol'0 rash. The hypersensitivity to chloro­ Brand Name Generic name formulation butanol was confirmed by an intra­ dermal test.5 Chlorobutanol-pre­ AK-CHLOR CHLORAMPHENICOL ophthalmic solution BACIGUENT BACITRACIN topical served ODA VPCR) was also im­ AK-SULF SULF ACET AMIDE ophthalmic solution 6 plicated in one rash. Chlorobutanol BETAXIN THIAMINE injection has been reported to cause mild CHLOROPTIC (Rl CHLORAMPHENICOL ophthalmic solution conjunctivitis following the immer­ CHLOROPTIC(Rl S.O.P. CHLORAMPHENICOL ophthalmic solution sion of gel lenses in a solution con­ DDAVPCRl DESMOPRESSIN nasal solution taining this preservative.7 DELATESTRYURl TESTOSTERONE injection DELESTROGENCRl ESTRADIOL injection The rash developed seven days DEMO-CINEOURl CINEOL-GUAIACOL injection after initial exposure. This is in a DOPRAMCRl DOXAPRAM injection normal range for newly developed FLURESSCRl FLUORESCEIN-BENOXINATE ophth. solution allergic response. 8 The half-life of ISUPREURl ISOPROTERENOL solution for inhalation LACRI-LUBECRl chlorobutanol is approximately 10 to PETROLATUM-MINERAL OIL ophth. ointment LACRIURl METHYLCELLULOSE ophthalmic solution 4 13 days. This explains why the NEO-CORTEF chloral hydrate.9 Ta­ XTRA POLYVINYL ALCOHOL-POVIDONE ophth. sol. ble I is the list of Canadian products PMS ESTRADIOL VALERA TE ESTRADIOL injection that the patient should avoid because PONTOCAINECRl TETRACAINE injection PRESSYN