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PDF Full-Text PRACTITIONER’S CORNER products was performed using an IgE dot-blot assay (Bio-Rad, Hercules, California, USA) according to the manufacturer’s instructions, with 53 mg of paclitaxel reconstituted in 500 µL of dimethyl sulfoxide (Sigma-Aldrich, Madrid, Spain) and unmodifi ed macrogolglycerol ricinoleate. A polyvinylidene fluoride transfer membrane was used. Serum was applied with Immunoglobulin E–Mediated Severe a blocking buffer (phosphate buffered saline containing 1% Anaphylaxis to Paclitaxel bovine serum albumin and 0.05% Tween, 1:1 v/v). The antibody was a mouse anti-human IgE (Fc) HRP (Southern Biotech) and the Western Lightning Plus-ECL system (PerkinElmer Life and A Prieto García,1 F Pineda de la Losa2 Analytical Sciences, Shelton, Connecticut, USA) was used as 1Allergy Service, Hospital General Universitario Gregorio substrate. The results were positive for paclitaxel and negative Marañón, Madrid, Spain for macrogolglycerol ricinoleate (Figure). 2DIATER Laboratories, R&D, Madrid, Spain The patient was changed to an alternative chemotherapy Key words: Paclitaxel hypersensitivity reactions. Macrogolglycerol regimen with cisplatin and gemcitabine, with good tolerance ricinoleate. Skin tests. Dot-blot assay. and complete response. Taxanes have been avoided. As a Palabras clave: Reacciones de Hipersensibilidad a paclitaxel. challenge test was not carried out with macrogolglycerol Ricinoleato de macrogolglicero. Prueba cutánea. Dot-blot. ricinoleate, the patient was instructed to avoid drugs containing this excipient (a list was supplied). Paclitaxel-related immediate hypersensitivity reactions occur in up to 30% of patients, with this percentage decreasing to under Immediate hypersensitivity reactions to taxanes have been 10% with the administration of antihistamine and corticosteroid related to nonspecifi c mediator release from mast cells. While premedication [1-3]. Most reactions occur within the fi rst few the excipient macrogolglycerol ricinoleate has been implicated minutes of infusion, usually after the fi rst or second dose, indicating in complement or mast cell activation, an immunoglobulin (Ig) that prior sensitization is not necessary. For this reason these reactions E-mediated mechanism has never been demonstrated. are thought to be non-IgE mediated [1-4]. Macrogolglycerol We report the case of a 49-year-old woman with a history ricinoleate has also been implicated in anaphylactic reactions of isocyanate-induced occupational asthma who presented on the basis that it can induce complement activation, giving with an enlarged supraclavicular lymph node identifi ed as a rise to anaphylotoxins that trigger mast cells and basophils for poorly differentiated adenocarcinoma. The patient was started a secretory response [5]. on carboplatin and paclitaxel and tolerated the fi rst cycle well. The use of premedication and/or the slowing of infusion During the second cycle, however, a few seconds after starting rates are effective but not always successful [6]. A safe and paclitaxel infusion, she presented dizziness, fl ushing, dyspnea, effective standardized protocol for rapid drug desensitization desaturation, hypotension, and collapse requiring orotracheal intubation. Carboplatin was not administered. Intravenous premedication with granisetron, ranitidine, methylprednisolone, Patient and dexchlorpheniramine was used. The paclitaxel administered was Paclitaxel Teva (Teva Genéricos Española S.L., Madrid, Spain), Paclitaxel Macrogoglycerol which contains macrogolglycerol ricinoleate. ricinoleate The allergy study performed 1 month later in the intensive care unit included skin tests consisting Control 1 of prick and intradermal (ID) tests with Paclitaxel Teva (6 mg/mL/0.0001-1 mg/mL), carboplatin (10 mg/mL/0.001-1 mg/mL), ranitidine Paclitaxel Macrogoglycerol (10mg/mL/0.01mg/mL), granisetron ricinoleate (1 mg/mL/0.01 mg/mL), methylprednisolone (20 mg/mL/2 mg/mL), and a latex skin prick test. The results were positive only for Paclitaxel Control 2 Control 3 Teva (ID, 0.0001 mg/mL). Fifteen control patients with cancer and previous adverse reactions to paclitaxel had negative skin tests. DPT DPT Controlled challenge tests were negative for ranitidine, granisetron, methylprednisolone, and dexchlorfeniramine. Figure. Immunoglobulin E dot-blot assay. The patient’s serum was positive to paclitaxel Paclitaxel and macrogolglycerol ricinoleate and negative to macrogolglycerol ricinoleate. Serum from a nonallergic patient was used (in powder and petrolatum, respectively) were as a negative control (control 1). Other controls were performed using Dermatophagoides supplied separately by Teva Genéricos Española pteronyssinus (Dpt) extract, the serum from a patient allergic to Dpt (control 2, positive), S.L. Serum specific-IgE analysis of the 2 and the serum from a nonallergic patient (control 3, negative). J Investig Allergol Clin Immunol 2010; Vol. 20(2): 170-176 © 2010 Esmon Publicidad Practitioner’s Corner 171 has been reported [2,3]. Both IgE-mediated and non-IgE– 7. Weiss RB, Donehower RC, Wiernik PH, Ohnuma T, Gralla RJ, mediated immediate hypersensitivity reactions of any severity Trump DL, Baker JR Jr, Van Echo DA, Von Hoff DD, Leyland- are amenable to rapid desensitization. Jones B. Hypersensitivity reactions from taxol. J Clin Oncol. We have presented an exceptional case of an IgE-mediated 1990;8:1263-8. reaction to paclitaxel, the fi rst such case to be reported to the best of our knowledge. The reaction, which was severe and ❚ Manuscript received July 21, 2009; accepted for publication produced with a minimum dose, occurred with the second September 30, 2009. exposure (the fi rst cycle was well tolerated). These data suggest a type I hypersensitivity reaction, although most paclitaxel- Alicia Prieto García induced immediate hypersensitivity reactions reported have Servicio de Alergia. Hospital General the same characteristics and an IgE-mediated mechanism has Universitario Gregorio Marañón. Dr. Esquerdo, 46. never been demonstrated. 28007 Madrid, Spain In our patient we proved this IgE-mediated mechanism E-mail: [email protected] using skin and in vitro tests. Although skin tests are assumed to be negative in taxane-induced immediate hypersensitivity reactions, there are few reports of skin test results following such reactions [7]. Our patient has a background of atopy, which has been Nonirritating Concentration for Skin Testing identifi ed as a risk factor for the development of hypersensitivity With Cephalosporins reactions to chemotherapeutic drugs [3]. Lastly, we recommend performing skin tests in patients S Testi, M Severino, ML Iorno, S Capretti, G Ermini, with immediate hypersensitivity reactions to taxanes, D Macchia, P Campi especially in the case of very severe reactions, if a previous Allergy and Clinical Immunology Unit, Azienda Sanitaria di dose has been tolerated and in patients with a history of atopy Firenze, San Giovanni di Dio Hospital, Florence, Italy since an IgE-mediated mechanism is also possible. Key words: ß-Lactams. Cephalosporins. Diagnostic skin tests. Acknowledgments Nonirritating concentration. Palabras clave: Betalactámicos. Cefalosporinas. Pruebas cutáneas We thank Mª Esther Durán (Pharmacology Service, diagnósticas. Concentración no irritativa. Hospital Gregorio Marañón, Madrid, Spain) and Ana Rivas (Teva Genéricos Española S.L., Madrid, Spain) for their collaboration. Although diagnostic skin tests with cephalosporins are still considered experimental because of unknown hapten References determinants, skin testing is a useful tool in evaluating immediate and delayed reactions to these ß-lactams [1]. Skin 1. Price KS, Castells MC. Taxol reactions. Allergy Asthma Proc. testing with drugs should be performed using the highest 2002 ;23:205-8. concentration of drug that does not elicit an irritant skin test 2. Feldweg AM, Lee CW, Matulonis UA, Castells M. Rapid response in an adequate number of healthy control individuals. desensitization for hypersensitivity reactions to paclitaxel and While there is agreement on nonirritating concentrations for docetaxel: a new standard protocol used in 77 successful penicillin tests, the same cannot be said for cephalosporins. treatments. Gynecol Oncol. 2005;96:824-9. Empedrad et al [2] recommend performing skin prick 3. Castells MC, Tennant NM, Sloane DE, Hsu FI, Barrett NA, Hong and intradermal tests using a concentration of 10 mg/mL for DI, Laidlaw TM, Legere HJ, Nallamshetty SN, Palis RI, Rao JJ, cefotaxime, cefuroxime, ceftazidime, and ceftriaxone and of Berlin ST, Campos SM, Matulonis UA. Hypersensitivity reactions 33 mg/mL for cefazolin. The concentration recommended to chemotherapy: outcomes and safety of rapid desensitization for prick and intradermal tests by Torres et al [3] and later by in 413 cases. J Allergy Clin Immunol. 2008;122:574-80. Blanca et al [4] for cephalosporins in general was 1 to 2 mg/mL 4. Lee C, Gianos M, Klaustermeyer WB. Diagnosis and and 2 mg/mL, respectively. management of hypersensitivity reactions related to common The aim of the present study was to ascertain if 20 mg/mL cancer chemotherapy agents. Ann Allergy Asthma Immunol. can be considered a nonirritating concentration for intradermal 2009;102:179-87. skin tests for cephalosporins. 5. Szebeni J. Complement activation-related pseudoallergy: a We have been performing diagnostic skin prick and new class of drug-induced acute immune toxicity. Toxicology. intradermal tests for ß-lactams at our center since 1988 with 2005;216:106-21. benzylpenicilloyl-poly-L-lysine (PPL)
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