Glucocorticoids can cause allergic reaction in rare cases. A ten year old boy, known asthmatic, was treated with intramuscular injection of glucocorticoids, followed by nausea, vomiting and abdominal pain. His lips turned pale along with palpitation and light headache. His right eye lid and lower lip were swollen. Heart rate was 177/min, and BP was 66/46 mmHg,. Patient spontaneously improved and symptoms resolved. IV fluids bolus, antihistamines or epinephrine were not required. The case was seen in September 2012

Ahmed, Shakeel

Siddiqui, Emad Uddin

English

eCommons@AKU

eCommons@AKUDepartment of Emergency Medicine Medical College, PakistanDecember 2013Glucocorticoids induced allergic reactionEmad Uddin SiddiquiAga Khan UniversityShakeel AhmedAga Khan University, emaduddin.siddiqui@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_medPart of the Emergency Medicine CommonsRecommended CitationSiddiqui, E. U., Ahmed, S. (2013). Glucocorticoids induced allergic reaction. Journal of Pakistan Medical Association, 63(12),1547-1548.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_emerg_med/225Vol. 63, No. 12, December 20131547AbstractGlucocorticoids can cause allergic reaction in rare cases. Aten year old boy, known asthmatic, was treated withintramuscular injection of glucocorticoids, followed bynausea, vomiting and abdominal pain. His lips turned palealong with palpitation and light headache. His right eyelid and lower lip were swollen. Heart rate was 177/min,and BP was 66/46 mmHg,. Patient spontaneouslyimproved and symptoms resolved. IV fluids bolus, anti-histamines or epinephrine were not required. The casewas seen in September 2012. Keywords: Allergic reaction, Glucocorticoids, Children.IntroductionAlthough the glucocorticoids have been extensivelyused for numerous medical problems, they are knownfor their anti-allergic and anti-inflammatory propertiesother than immunosuppression in high doses.1 Howeverrecent literature has shown a reaction contrary to whatsteroids are known for. These contradicting reactionsrange from mild allergic reaction to life threateninganaphylaxis.2-4 Nevertheless glucocorticoids are used incommon practice, and physicians usually ignore thepossibility of allergic reaction, which may lead to seriousconsequences. Although considered rare, the trueextent of glucocorticoid induced reactions is unknownand no uniform mechanism has been identified.Steroidinduced allergic reactions has been documented as farback as 1962.5The immune-pathogenesis of allergic reaction isproposed to be IgE mediated against glucocorticoidmolecules. Glucocorticoid is a hapten molecule, whichbinds irreversibly to other proteins and convert it to acomplete antigenic structure. Cortisol in aqueous solutionis degraded into steroid-glyoxal, with an aldehyde groupin the C21 position, and is able to bind covalently withguanidine groups of the protein, thus establishing apotentially immunogenic steroid-protein compound.Succinate as an ingredient is more prone to have allergicreaction as compared to Sodium phosphate, because ofhigh affinity of succinate esters to different serumproteins, and this could favour the immunogenic role ofsuccinates and may promote an IgE mediated reaction.6Case Report This was the case of a ten year old boy seen in Septmeber2012, who presented to the paediatric clinic withshortness of breath and cough for the last 15 days. He wasa known asthmatic for the last three years, and was onintermittent treatment on nebulizer or MDI (meter doseinhaler) salbutamol, and never had steroids before. Therewas no associated fever or headache, no cyanosis or chesttightness. One month back he had a similar episodewhich improved after inhaled bronchodilator. He wasnever admitted to the hospital and never used systemicsteroids for his asthma. There was no other significantmedical illness in the past. He was taking salbutamol andipratropium and inhaler along with montelukastintermittently for the last 2 months. For the previous twodays he was only on salbutamol. Family history of allergywas significant as father had allergic rhinitis, one eldermale sibling had asthma, and sister was allergic to dust.There was no history of steroid allergy. They were living ina spacious house within the center of city but away fromindustrial pollution. He was not exposed to any newallergen or even no definitive allergen was known. No onesmoked at home.In the clinic he was given intra muscular hydrocortisone(100 mg), as he had already taken adequate puffs beforecoming to the clinic. When examined, there was anoccasional wheeze but the child was clinically stable, withasthma score of 2-3. Physicians decided to give him aninitial dose of parenteral steroid which would be followedby a short course of oral steroids. Child developed nauseaand vomited once, his lips turned pale and he startedcomplaining of abdominal pain (5-6/10) along withpalpitation, and light headache. The right eye lid andlower lip were swollen. His vitals at that time showedsignificant tachycardia with hypotension (HR 177/min, BPwas 66/46mmHg), and he looked pale. He was rushed toEmergency after starting oxygen through a nasal prong.At triage his vitals were; temp. 36.5°C, RR 20, HR 99 O2 satCASE REPORTGlucocorticoids induced allergic reactionAzeem Khan,1 Emad Uddin Siddiqui,2 Shakeel Ahmed31Department of Paediatric Medicine, 2Department of emergency Medicine,3Department of Paediatrics and Child Health, Aga Khan University Hospital,Karachi.Correspondence: Emad Uddin Siddiqui. Email: emaduddin.siddiqui@aku.edu98%, BP 76/62 mmHg and weight 29 kg. The patient didnot need fluid boluses, anti-histamine or epinephrine.Though his symptoms slowly regressed in the next 3-4hours, he was hospitalized for observation. The childremained stable during the stay of 24 hours in thehospital and his asthma symptoms also improved oninhaled bronchodilators and ipratropium. He wasfollowed in the clinic after 2 days and at that time heremained stable and was asymptomatic. Discussion There are approximately 100 published reports ofimmediate hypersensitivity reactions occurring after oraland parenteral corticosteroid administration.7To date the data on glucocorticoids induced allergy islimited, but increasing number of cases are being addedto literature.2-4 The active ingredient of glucocorticoidsuccinate has previously been documented in literature ofproducing allergic and anaphyletic reactions.8-10Although considered rare, the true extent of suchreactions is unknown and no uniform mechanism hasbeen identified.4 Other than succinate, other ingredientslike Phosphate containing corticosteroid preparations arenot considered to be associated with systemic allergicreactions.6As evidenced by our case, the allergic reaction of anyvariety can occur by any dose or route of administration ofglucocorticoids, and can occur with even a very smallquantity. This case might be an important reminder to allmedical personnel, that any patients can have allergicreactions to parenteral corticosteroids containingsuccinate. Worsening symptoms may not be due totreatment failure, but could be due to allergic reaction toany one of the medications or its constituent/ ingredients.To find a safe and effective alternate for glucocorticoids isthus required. The usefulness of intradermal test forselection of safe alternative corticosteroids should bepracticed. Little is known about the epidemiology andpathophysiology of steroid-induced hypersensitivity, asmost data are derived from case reports. Clinicalheterogeneity of steroid-induced hypersensitivity doesexists. More studies are needed to know the extent ofadverse reactions so as to have an effective therapeuticinterventions.References1. Erdmann SM, Abuzabra F, Merk HF. Anaphylaxis induced byglucocorticoids. J Am Board FamPract 2005; 18: 143-6.2. Escribano-Rodriguez MM, Gonzalez-Pol J, Munoz- Bellido FJ, de laCalle-Toral A, Velazquez-Amor E, Conde-Hernandez J. Immediatereaction to methylprednisolone with tolerance of othercorticosteroids. Allergy 1997; 52: 677-8.3. Kamm GL, Hagmeyer KO. Allergic-type reactions tocorticosteroids. Ann Pharmacother 1999; 33: 451-60.4. Burgdorff T, Venemalm L, Vogt T, Landthaler M, Stolz W. IgE-mediated anaphylactic reaction induced by succinate ester ofmethylprednisolone. Ann Allergy Asthma Immunol 2002; 89: 425-8.5. Butani L. Corticosteroid-induced hypersensitivity reactions. AnnAllergy Asthma Immunol 2002; 89: 439-45.6. Calogiuri L, Muratore E, Netti MT, Ventura AF, Tursi A. Anaphylaxis tohydrocortisone hemisuccinate with cross-sensitivity to relatedcompounds in a paediatric patient. Br J Dermatol 2004; 151: 707-30.7. Rodrigues-Alves R, Spínola-Santos A, Pedro E, Branco-Ferreira M,Pereira-Barbosa M. Immediate hypersensitivity to corticosteroids:finding an alternative. J Investig Allergol Clin Immunol 2007; 17:284-5.8. Nakamura H, Matsuse H, Obase Y, Mitsuta K, Tomari S, Saeki S, etal. Clinical evaluation of anaphylactic reactions to intravenouscorticosteroids in adult asthmatics. Respiration 2002; 69: 309-13.9. Dajani BM, Sliman NA, Shubair KS, Hamzeh YS. Bronchospasmcaused by intravenous hydrocortisone sodium succinate (Solu-Cortef ) in aspirin-sensitive asthmatics. J Allergy ClinImmunol1981; 68: 201-4.10. Kawane H. Anaphylactoid reaction to intravenous hydrocortisonesodium succinate. Med J Aust 1991; 154: 783-4.J Pak Med Assoc1548 A. Khan, E. U. Siddiqui, S. Ahmed

Glucocorticoids induced allergic reaction

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