Q:

12/16/2013
I have a 14 year old girl with symptomatic pan sinusitis/multiple air fluid levels on CT which ENT has cultured and is pan sensitive h flu. She has multiple antibiotic allergy syndrome and has had a pruritic lacy reticular rash and lip angioedema to oral biaxin, ciprofloxacin, doxycycline, azithromycin, cephalexin, amoxicillin, and septra after 2 - 3 doses each drug. I tried tobramycin nasal washes and she developed urticaria face, neck and trunk after 3 doses. I attempted desensitization (without any premedication) to amoxicillin orally but around total dose of 160 mg she developed lip angioedema and lacy rash upper body.

My current plan is to bring her in for aztreonam, to give IM in a graded fashion with a prep to prevent reaction used for contrast allergy on board before she gets to clinic. If she does well, my question is whether to continue steroids (30 mg daily or other dose) and antihistamines as an outpatient while she takes the IM aztreonam at home. Her mother is an RN and will be given the injections q 12 h and I am planning a 2 week course of therapy. Is there a better way to treat this patient? ENT does not think surgery is needed.

A:

Thank you for your inquiry.

The questions you pose have no definitive answers, and my guess is that you would get different responses from various allergists-immunologists. I do not believe there is any literature which we could use to substantiate a response. Thus, I can only give you an opinion. This opinion would be neither right nor wrong, but only represent how I might deal with this difficult situation.

First of all I think your approach is reasonable and have no "better way".

Having said this, I would not continue preventive therapy once your patient leaves your office, but would simply observe her closely during the treatment.

I of course cannot tell for sure, but based upon your description, the side effects she has had to date have not been threatening, and I believe you would have time to institute therapy if symptoms did occur. If these symptoms were mild and responded to treatment with antihistamines and/or corticosteroids, I would consider treating through the reaction.

So in summary, I would personally not pretreat, but observe for a reaction; and if the reaction was not threatening, continue therapy until the full course of antibiotics had been administered.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology