key: cord-0872617-fttrhozh
authors: Breidenbaugh, M.
title: M044 POLYETHYLENE GLYCOL ALLERGY TESTING AN ADOLESCENT WITH ANAPHYLAXIS TO PEG-ASPARAGINASE BEFORE ADMINISTERING PFIZER-BIONTECH COVID-19 VACCINE
date: 2021-11-30
journal: Annals of Allergy, Asthma & Immunology
DOI: 10.1016/j.anai.2021.08.218
sha: 54ac38b9324d6d0a96919c70c804577f2b62e516
doc_id: 872617
cord_uid: fttrhozh

nan

SUCCESSFUL SUBCUTANEOUS SARGRAMOSTIM DESENSITIZATION S. Qayum*, H. Valdin, Z. LeBlanc, A. Abreo, E. Wisner New Orleans, LA Introduction: Sargramostim is a recombinant human granulocyte-macrophage colony-stimulating factor used in the treatment of high-risk neuroblastoma as part of immunotherapy to stimulate cytotoxic activity against GD2-positive neuroblastoma cells. Patients receiving the anti-GD2 monoclonal antibody dinutuximab are treated concomitantly with GM-CSF with favorable cure rates. There is no suitable alternative for GM-CSF. We present a patient enrolled in the ANBL1221 trial who presented with anaphylaxis to sargramostim. Hypersensitivity to GM-CSF and desensitization protocols are not well described in the literature. This case describes a successful subcutaneous desensitization protocol after multiple failed attempts at intravenous desensitization. Case Description: A 16-year-old male with refractory neuroblastoma presented with anaphylaxis to sargramostim. We designed an intravenous 15-step desensitization protocol with four 10-fold dilutions given over 3.5 hours. Baseline tryptase level was 3.3 ug/L. The patient was premedicated with H 1 -and H 2 -receptor antagonists and a leukotriene receptor antagonist. During the final step, the patient developed urticaria and diarrhea associated with an elevated tryptase of 18 ug/L. He again developed urticaria with an elevated tryptase despite slowing the infusion rate of the final step. Due to continued hypersensitivity reactions via intravenous route, we designed a 12-step subcutaneous desensitization protocol with 20-minute intervals between steps. He subsequently tolerated this protocol during multiple rounds of treatment without evidence of an IgE-mediated reaction. Discussion: Although rare, hypersensitivity reactions to GM-CSF have been reported. While most desensitization protocols are performed intravenously, this case highlights a successful subcutaneous protocol to GM-CSF. This protocol may be considered in patients who have repeated hypersensitivity reactions to intravenous desensitization.

GUMMY MULTIVITAMIN ANAPHYLAXIS FROM NIACIN PSEUDOALLERGY J. Wong* 1 , D. Levy 1 , Y. Hsieh 2 , T. Jean 1 , 1. Orange, CA; 2. Long Beach, CA Introduction: Niacin commonly causes flushing, but rarely progresses to a life-threatening reaction. We present a rare case of anaphylaxis to niacin in her gummy multivitamin (GMVI). Case Description: A 57-year-old woman presented with a history of anaphylaxis to GMVI. Previously, she reacted to Centrum GMVI with an immediate diffuse, pruritic rash and difficulty breathing. She required steroids, albuterol, and diphenhydramine. Subsequently, she tried a standard (non-gummy) multivitamin and developed a pruritic rash on her back and arms. She had no reactions with gummy bears or gelatin. We performed a skin prick test (SPT) which was positive to yellow GMVI (5 mm induration), and negative to the orange and purple GMVI. She was first challenged with the purple GMVI, but developed anaphylaxis with flushing, hives, and difficulty breathing. She required epinephrine, steroids, and diphenhydramine. We further evaluated the GMVI excipients via SPT, which was 3 mm induration for pectin and niacin. Pectin oral challenge was negative. We then performed an oral challenge to niacin 500 mg, which resulted in flushing, lip tingling and swelling. She received steroids, aspirin, and diphenhydramine.

Discussion: Our patient had non-immunologic systemic reactions to niacin, which likely explains her GMVI anaphylaxis. Niacin-triggered reactions are due to PGD2 and PGE2 production by Langerhan cells and keratinocytes. We ruled out gelatin, pectin, and dyes (turmeric, annatto) as potential sources of allergy with GMVI. Clinicians should consider niacin as a culprit when presented with a history of multivitamin flushing and systemic reactions. -19) pandemic has resulted in the deaths of millions of people worldwide. The current mechanism of the Pfizer-BioNTech COVID-19 vaccine allergy and the causative antigen is not known. The FDA Emergency Use Authorization for Pfizer-BioNTech vaccine recommends against administration in those with a history of severe allergic reaction to components of the vaccine. We present a patient with previous anaphylactic reaction to PEG-asparaginase who successfully received the Pfizer-BioNTech vaccine. Case Description: A 13 year-old male with a history of T-cell Lymphoma and severe anaphylaxis to IV PEG-asparaginase presented to allergy clinic for evaluation and allergy testing with hopes to receive the Pfizer-BioNTech vaccine. Prior signs and symptoms of allergic reaction to PEG-asparaginase included wheezing, urticaria, hypotension, and vomiting. Due to a desire to obtain protection during this pandemic, patient underwent skin prick and intradermal testing using the protocol published by Banerjee et al, which was negative. He successfully received two doses of the Pfizer-BioNTech vaccine without allergic reaction. Discussion: It has been suggested that allergic reactions to the Pfizer-BioNTech vaccine could be due to the PEG component. PEG in Pfizer-BioNTech has a molecular weight of 2000. PEG in PEG-asparaginase has a molecular weight of 5000. It may be that patients who react to PEG at molecular weights greater than the COVID-19 vaccines, including MiraLax and PEG-asparaginase, can tolerate the COVID-19 vaccines. While caution is needed, vaccination should be considered in individuals with prior allergic reactions to PEG containing products which differ in molecular weight.

Up to 60% hypersensitivity reactions (HSR) to L-aspraginase and 25% to PEGasparaginase have been reported, in these cases it is recommended to change to the form of asparaginase derived from E. chrysanthemi. However, these presentations are not available worldwide. Case Description: A 3-year-old male patient with no history of atopy and diagnosis of B-cell ALL. During the induction phase chemotherapy, 5 minutes after the administration of intramuscular L-asparaginase the patient developed moderate anaphylaxis (generalized rash, abdominal pain, nausea, and vomiting). A dose of IM epinephrine, hydrocrotisone