ALLERGOL. ET IMMUNOPATHOL., 1998;26(4):199-200
CLINICAL CASES
Anaphylaxis to paracetamol
P. A. Galindo, J. Borja, P. Mur*, F. Feo, E. Gómez and R. García
Allergy Section. Ciudad Real Hospital Complex. * Allergy Section. Hospital of Puertollano. Ciudad Real, Spain.
SUMMARY
We hereby present a patient suffering several episodes of anaphylaxis (generalized urticaria, dyspnea, wheezing and intense cough) a few minutes after taking different drugs containing paracetamol. Intradermal test with pure paracetamol (100 mg/ml) was positive. It was negative in six controls. Serum specific IgE anti-paracetamol (by RIA) was negative. Anaphylaxis from paracetamol is rare but has been reported. Positive skin test with paracetamol have only been rarely described.
Key words: Acetaminophen. Drug Allergy. Inmediate hypersensitivity. Paracetamol. Skin test. Anaphylaxia.
Allergol et Immunopathol 1998;26:199-200.
INTRODUCTION
Paracetamol or acetaminophen is a widely used analgesic-antipyretic. Paracetamol intolerance can occur in any aspirin-sensitive subject as result of inhibition of cyclooxygenase. Nevertheless allergic-like adverse reactions without aspirin-sensitivity are more infrequent. Urticaria and angioedema have been reported (1-4). Anaphylactic reactions also have been reported (4-11). To our knowledge, positive skin test with paracetamol are rarely described (2, 3, 5) and only one patient showed IgE against paracetamol (2).
CASE REPORT
A 20-year old woman, with a personal history of rhinoconjuntivitis and bronchial asthma due to pollen allergy. 2 years ago she took a tablet of Termalgin® 500 mg containing 500 mg of paracetamol, for a headache. After 15 mins. she developed generalized itching, facial erithema and cought; after two hours the symptoms disappeared spontaneously. Eight hours later, she took another tablet of the same drug and after 10 mins. she developed generalized urticaria, dyspnea, wheezing and intense cough. The picture resolved with metilprednisolone and clorfeniramine IV in an emergency unit. Posteriously, similar pictures repeated in two ocassions with other different drugs containing paracetamol. She tolerated aspirin and other non-steroidal antiinflammatory drugs (NSAIDs).
We carried out skin tests with pure paracetamol (kindly supplied by laboratories FUNK. Barcelona. Spain) diluted in saline serum with the following results: Skin prick test (100 mg/ml) was negative. Intradermal tests (1 and 10 mg/ml) were negative. Intradermal tests (100 mg/ml) showed a wheal of 9 x 9 mm (erithema 39 x 36 mm with pruritus). Intradermal test with histamine (0,1 mg/ml) showed a wheal of 11 x 12 mm (erithema 40 x 45 mm), it was negative with saline serum. Intradermal test with paracetamol at 100 mg/ml in six controls that tolerated paracetamol were negative.
Serum specific IgE anti-paracetamol, measured by a radio immunoassay (RIA) according to the manufacturer''s instruction (Hycor. Irvine. California. USA), was negative.
The challenge test with paracetamol was not carried out for ethical reasons and the clinical picture had repeated in several occasions with the same drug.
DISCUSSION
We hereby present a patient suffering several episodes of anaphylaxis from paracetamol. The most frequent causes of anaphylaxis are drugs, and especially penicillins and analgesics (12). Anaphylaxis from paracetamol is rare but has been reported (4-11). To our knowledge, positive skin tests with paracetamol have only been described in a few cases, two by prick (2, 5) and three by patch test (3). Only one patient showed IgE against paracetamol (2). Our patient had suffered anaphylactic reactions in several occasions a few minutes after taking paracetamol, and she showed positive intradermal test with pure paracetamol at 100 mg/ml. Inhibition of cyclooxygenase as mechanism implicated was excluded because the patient tolerated aspirin, a more potent inhibitor of cyclooxygenase, and other NSAIDs. Although specific IgE to paracetamol was not detected, we think the adverse reaction was due to IgE-mediated hypersensitivity to paracetamol because the clinical characteristics of the reaction and the positive sking tests results.
Conclusions: Immediate hypersensitivity to paracetamol without NSAIDs intolerance can occur and skin tests may be useful to diagnose it.
ACKNOWLEDGEMENTS
We thank the nurses of our allergy section Adela Delicado and Rosalía Fernández-Pacheco, and the auxiliary nurses M.ª Carmen Cid, M.ª Cruz Rabadán and Rosa Valera, for their excellent collaboration in this study.
RESUMEN
Presentamos el caso de una paciente que presentó varios episodios de anafilaxia (urticaria generalizada con tos, disnea y sibilantes) a los pocos minutos de tomar diferentes fármacos que contenían paracetamol. Se realizaron test cutáneos en PRICK e intradermorreacción con paracetamol puro, siendo positivo la intradermorreacción a una concentración de 100 mg/ml. Fue negativa en 6 controles. Se determinaron los niveles séricos de IgE específica frente a paracetamol por técnica de RIA, fueron negativos. La anafilaxia producida por paracetamol es rara pero ha sido descrita. Test cutáneos positivos con paracetamol se han descrito raramente.
Palabras clave: Acetaminofen. Alergia a medicamentos. Anafilaxia. Hipersensibilidad inmediata. Paracetamol. Tests cutáneos.
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Correspondence:
Pedro A. Galindo Bonilla
C/ Azucena, 10 - 3º B
13003 Ciudad Real, Spai
