Rifampin Hypersensitivity in a 2-year-old Child With Successful Rapid Oral Desensitization
Notice bibliographique
Résumé
To the Editors: Management of tuberculosis is complicated by rising rates of drug-resistant disease for which there are limited therapeutic options.1 Rifampin is the only agent recommended for prophylaxis of isoniazid-resistant, rifampin-sensitive latent tuberculosis infection.2 We describe a child latently infected after household exposure to isoniazid-resistant tuberculosis who developed facial angioedema and pruritic rash within 30 minutes after ingesting the 5th dose of rifampin. Oral antihistamine was administered and symptoms resolved over 2 hours. Rifampin was discontinued. The child was assessed in a tertiary pediatric allergy clinic. Type I hypersensitivity to rifampin was ascertained based on the clinical history and confirmed with epicutaneous and intradermal testing (Table, Supplemental Digital Content 1, https://links.lww.com/INF/B831). The rifampin concentrations used for testing was based on a previously published report of nonirritant concentration of rifampin.3 Rapid desensitization to oral rifampin was performed and adapted from an accepted penicillin desensitization protocol.4 No premedication (antihistamine or corticosteroid) was administered. Incremental doses were administered orally every 15 minutes over a period of 3.25 hours on an inpatient pediatric ward (Table, Supplemental Digital Content 2, https://links.lww.com/INF/B832). The child continued with rifampin twice daily and completed a 3.5-month course of rifampin prophylaxis without adverse reactions before travel out of country. Adverse reactions to rifampin include fever, rash, flu-like syndrome, acute renal failure, hemolytic anemia, thrombocytopenia and anaphylaxis.5 Only a limited number of these effects are because of type 1 hypersensitivity or would be expected to respond to desensitization. Drug desensitization modifies a patient’s response to a drug that allows the patient to tolerate the drug for a temporary period in order for treatment to occur and lasts only for the duration of the treatment period. If the drug is discontinued and required in the future, the desensitization procedure must be repeated. The decision to pursue drug desensitization requires a high likelihood of drug allergy, a documented medical need for the drug, a lack of alternative agents and the benefits of drug desensitization outweigh the potential risks. Contraindications to desensitization include Steven-Johnson Syndrome, toxic epidermal necrolysis, exfoliative dermatitis, drug rash with eosinophilia and systemic symptoms, interstitial nephritis, hepatitis and hemolytic anemia.4 Our case highlights a rare case of rifampin hypersensitivity in a young child complicated by a lack of prophylaxis alternatives given the isoniazid-resistant strain of tuberculosis and crossreactivity among rifamycins.5 Rifampin desensitization protocols previously reported occurred mainly in adults involved premedication and were conducted in the intensive care unit. Premedication with antihistamine or corticosteroids was not used as these medications do not prevent IgE-mediated reactions and have the potential to mask early IgE symptoms at lower doses of the drug, thereby risking more serious reactions at higher doses. Drug desensitization should be performed under the guidance of an Allergy specialist, or at a minimum, a physician capable of treating anaphylaxis. The protocol outlined here may be a useful tool for other practitioners, particularly in areas where tuberculosis is endemic and treatment is essential. Kyla J. Hildebrand, MD, FRCP(C), MSc CH Department of Pediatrics Division of Allergy and Immunology University of British Columbia Vancouver Adelle Atkinson, MD, FRCP(C) Division of Allergy and Clinical Immunology Hospital for Sick Children Department of Paediatrics University of Toronto Ian Kitai, MB, BCh, FRCP(C)1 Division of Infectious Diseases Hospital for Sick Children and University of Toronto Toronto, Ontario, Canada
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Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,001 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,001 | 0,001 |
| Études des sciences et des technologies | 0,001 | 0,000 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,006 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».