Research Letter
Cefotaxim induced a near fatal anaphylactic shock in an infant
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Gil-Adrados" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Á." "apellidos" => "Moreno-Ancillo" "email" => array:1 [ 0 => "a.morenoancillo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:4 [ "nombre" => "A.C." "apellidos" => "Gil-Adrados" "email" => array:1 [ 0 => "alanaro@telefonica.net" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Alergia. Hospital Nuestra Señora del Prado. Talavera de la Reina, Toledo, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Salud La Solana, Talavera de la Reina, Toledo, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Severe anaphylactic reactions are potentially life-threatening.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In the literature, foods, venom and drugs are the most commonly reported exogenous causative agents.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Symptoms vary widely and can involve multiple organ systems, with skin, gastrointestinal, respiratory and cardiovascular symptoms.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the paediatric population, allergic disorders have reached epidemic proportions, and anaphylaxis is an increasingly common event. However, drug induced life-threatening anaphylactic shock is still very rare in infants under six months of age.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a 4-month-old girl who had a severe anaphylactic reaction within one minute after an intravenous administration of the third dose of cefotaxime (200 mg dissolved in 10<span class="elsevierStyleHsp" style=""></span>ml of specific solvent) given for a bronchial infection. Drug was administered by intravenous “push” over two to four minutes, rather than by a more prolonged intravenous infusion of 30<span class="elsevierStyleHsp" style=""></span>minutes. At the same time, she had just finished the intake of 180<span class="elsevierStyleHsp" style=""></span>ml of cow's milk. It was her second admission at the hospital. She had tolerated intravenous cefotaxime two months before, in her first admission. Symptoms included facial flush with swelling of the lips, urticarial rash on her trunk which progressed to generalised urticaria, intense dyspnoea, shortness of breath, wheezing and cyanosis with severe hypotension and collapse. After adequate treatment with intense anti-shock therapy, which was high flow oxygen, intravenous crystalloid fluid 20<span class="elsevierStyleHsp" style=""></span>mL/kg, intravenous hydrocortisone 25<span class="elsevierStyleHsp" style=""></span>mg, and three doses of intramuscular adrenaline, these symptoms were considerably reduced within one hour; and completely resolved after six hours. The patient had no other medical history.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Skin prick tests were performed with whole cow's milk extract (5<span class="elsevierStyleHsp" style=""></span>mg/ml), with isolated cow's milk proteins: α -lactalbumin (5<span class="elsevierStyleHsp" style=""></span>mg/mL), β -lactoglobulin (5<span class="elsevierStyleHsp" style=""></span>mg/mL), and casein (10<span class="elsevierStyleHsp" style=""></span>mg/mL); and with cefotaxime (2<span class="elsevierStyleHsp" style=""></span>mg/ml after dilution in 9%ClNa). Histamine dihydrochloride (10<span class="elsevierStyleHsp" style=""></span>mg/ml) was used as a positive control, and glycerosaline was used as a negative control. Reactions were read at 15<span class="elsevierStyleHsp" style=""></span>minutes. A net wheal diameter 3<span class="elsevierStyleHsp" style=""></span>mm larger than that produced by the negative control was considered positive. All skin prick tests were negative.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Assays for serum specific IgE to milk, α-lactalbumin, β-lactoglobulin, casein, penicilloyl G, penicilloyl V, ampicilloyl, amoxicilloyl, and latex were performed according to the manufacturer's instructions with UniCAP™ (CAP-FEIA; Pharmacia Diagnostics, Uppsala, Sweden). All these tests were negative. Total serum IgE was 10 IU/ml. The levels of serum tryptase, C3 and C4 were also assessed two months after the reaction and they were normal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Open controlled challenge test with cow's milk was carried out with a formula of cow's milk adapted to the age of the patient. She tolerated the cow's milk without any problem. Her parents rejected the carrying out of any other diagnostic evaluation, including intradermal testing or challenge test with drugs. Latex environment was well tolerated.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is a lack of information on the prevalence and characteristics of anaphylaxis in young infants. Food is the most common eliciting factor of anaphylactic reactions and furthermore a rising prevalence of food hypersensitivity has been reported during the last decades.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The negative results of the diagnostics tests and the low levels of total IgE supported our decision on performing a challenge test with milk. The tolerance of cow's milk and the chronology of the reaction suggested the implication of the cephalosporin.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although a previous administration of cephalosporin existed, the severity of the reaction, the low levels of total IgE and, maybe, the inadequate velocity of the drug administration in the little body of our patient suggest an unspecific mechanism. It is probably a non IgE-mediated anaphylactic reaction. Several cases of life-threatening reaction due to cephalosporin have been reported.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> Some of the reactions have been related to rapid administration of intravenous ceftriaxone coincidentally with a calcium solution.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> In another case caused by cefazidime<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> an IgE-mediated mechanism was suggested, but it could not be demonstrated. We think that most of these reactions should be at least in part associated with histamine release from basophils and mast cells due to a direct membrane effect related to the osmolarity of the drug solution<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> with a possible activation of the complement system. Contributing factors for the infant in our report may include the use of a high dosage and intravenous “push” administration, and administration of the total daily dosage as a single infusion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case, an adequate, quickly and intense treatment with several doses of adrenaline avoided the death of the infant. Severe anaphylactic reaction is a medical emergency requiring immediate recognition and treatment, particularly in young infants. We present the case of a near fatal non IgE-mediated anaphylactic reaction due to cefotaxime in a 4-month-old infant. This case shows that it is very important to control the rate of administration of cephalosporins in very young infants.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fatalities due to anaphylactic reactions to foods" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.A. Bock" 1 => "A. Munoz-Furlong" 2 => "H.A. 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Dallar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1398-9995.2010.02373.x" "Revista" => array:6 [ "tituloSerie" => "Allergy" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "1486" "paginaFinal" => "1487" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20415719" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03010546/0000004000000002/v1_201304101104/S0301054611001558/v1_201304101104/en/main.assets" "Apartado" => array:4 [ "identificador" => "5550" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Research letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03010546/0000004000000002/v1_201304101104/S0301054611001558/v1_201304101104/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0301054611001558?idApp=UINPBA00004N" ]
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| 2013 August | 39 | 8 | 47 |
| 2013 July | 37 | 9 | 46 |
| 2013 June | 21 | 3 | 24 |
| 2013 May | 33 | 8 | 41 |
| 2013 April | 25 | 10 | 35 |
| 2013 March | 14 | 5 | 19 |
| 2013 February | 14 | 6 | 20 |
| 2013 January | 5 | 3 | 8 |
| 2012 December | 5 | 3 | 8 |
| 2012 November | 1 | 2 | 3 |
| 2012 October | 1 | 1 | 2 |
| 2012 September | 1 | 1 | 2 |
| 2012 March | 246 | 0 | 246 |
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