Hypophosphatemia during continuous hemodialysis is associated with prolonged respiratory failure in patients with acute kidney injury

10.1093/ndt/gfr075Nephrology Dialysis Transplantation26113508-3514NDTR

A case of coronavirus disease 2019 messenger RNA vaccine tolerance and immune response despite presence of anti-polyethylene glycol antibodies

The role of anti-polyethylene glycol (PEG) immunoglobulin (Ig)M, IgG, or IgE antibodies in coronavirus disease 2019 (COVID-19) messenger RNA (mRNA) vaccine anaphylaxis is unknown. We highlight a case with preexisting anti-PEG antibodies that tolerated vaccination. A 60-year-old woman with debilitating gout experienced HLA-B*58:01-restricted allopurinol drug reaction with eosinophilia and systemic syndrome. After 2 years, following therapeutic failure with febuxostat, pegloticase was trialed. After 12 days from initial infusion, she developed angioedema and a diffuse erythematous pruritic rash. She self-treated with diphenhydramine, but symptoms persisted for 2 days. She then developed shortness of breath and throat constriction, requiring antihistamines and systemic steroids from an outside emergency department. She was later discharged with steroids, and symptoms resolved after 7 days. After 7 months, she had negative results from skin prick test (SPT) and intradermal test (IDT) to PEG3350. She was not tested to higher molecular weight PEG at this time. Of note, we detected anti-PEG IgG and IgE antibodies using a previously reported dual cytometric bead assay,1 which had been negative when assessed from biobanked plasma 2 months after the drug reaction with eosinophilia and systemic syndrome episode (Table 1). The target beads for the assay used high-affinity murine anti-PEG monoclonal antibody-conjugated cytometric bead array beads conjugated with pegloticase as the target antigen.1 The control beads were conjugated with the same anti-PEG antibodies without pegloticase.1 The positive signal criterion is defined as “target beads MFI (median fluorescence intensity) more than or equal to 1.2 times control beads MFI” and “free PEG inhibition reduces more than or equal to 50% of target beads MFI.”