Anaphylaxis Induced by Glucocorticoids

Abstract

Glucocorticoids are frequently used to treat allergic reactions. Therefore, allergic reactions to systemic glucocorticoids in particular are considered most unlikely and are not well known. We report on a 23-year-old woman with atopic dermatitis who had an anaphylactic reaction after oral administration of prednisolone. On treatment with epinephrine, antihistamines and volume symptoms resolved. Skin testing with a panel of glucocorticoids showed immediate type reactions to prednisolone, prednisolone hydrogen succinate, prednisone, and betamethasone dihydrogen phosphate. In challenge testing the patient tolerated methyl prednisolone and dexamethasone. There is increasing evidence that true allergic immediate type reactions to glucocorticoids exist. The severity of the reaction can vary from a rash to anaphylaxis. However, a patient sensitized to one or a group of glucocorticoids does not have to refrain from all types of glucocorticoids. Careful challenge testing is by far the best way to select glucocorticoids that are safe for future treatment. Clinicians should be aware that allergic reactions to glucocorticoids can occur and that worsening of symptoms does not always mean treatment failure. (J Am Board Fam Pract 2005;18:143-6.)Since the early 1950s, glucocorticoids have been used extensively for pharmacotherapy. Glucocorticoids are applied topically, orally, or intravenously and, if administered in higher doses, show immunosuppressive, antiproliferative, anti-inflammatory, and antiallergic effects.1 The antiallergic properties of glucocorticoids would seem to contradict their capacity to induce allergic reactions. However, a few severe adverse reactions, including life-threatening reactions caused by systemic glucocorticoids, have been reported over the past decades.2-6 Because the risk of anaphylactic reactions caused by glucocorticoids is not taken into consideration by most clinicians, severe complications may occur, particularly in the treatment of status asthmaticus or in anaphylactic reactions attributable to high doses (ie, if increasing symptoms are thought to be caused by insufficient therapy, even higher doses of glucocorticoids may be applied).We report a patient with an immediate and delayed type hypersensitivity to several glucocorticoids, the diagnostic work-up, including challenge testing, and the options for future treatment with glucocorticoids in patients with glucocorticoid allergy. Case ReportA 23-year-old woman was prescribed prednisolone (Decortin H) because of worsening of atopic dermatitis. Thirty minutes after taking the first oral dose of 40 mg of prednisolone, she developed palmoplantar paraesthesia, tightness of the chest, dizziness, and nausea, and she finally collapsed. In the emergency department, she was treated with epinephrine, antihistamines, and fluid; however, no glucocorticoid was applied because of the clinical history. Within a few hours all symptoms resolved. Two years before at the dentist's office, the patient had shown the same symptoms, albeit less severe, 15 minut...

Side Effects of Short-Term Oral Corticosteroids

“…43 Erdmann and colleagues reviewed anaphylaxis induced by CS and reported a case of a 22-year-old woman with atopic dermatitis who had an anaphylactic reaction after oral administration of prednisone. 44 Subsequent skinprick testing showed immediate-type hypersensitivity to prednisolone, prednisone, and betamethasone but not to methylprednisolone or dexamethasone. Patch testing in this same patient showed delayed-type hypersensitivity to prednisolone, amcinonide, and clobetasol propionate.…”

Immediate-Type Hypersensitivity to Succinylated Corticosteroids

“…In recent years, immediate-type hypersensitivity reactions to succinylated corticosteroids have been described quite frequently [3,4,6,7,9,11,12,14,15,16,18,24,25,26,34,35,36,37,38,39,40,41] whereas such reactions to succinate-free corticosteroids seem to be less frequent [2,5,10,19,20,42,43,44]. A number of patients had positive skin prick tests to the eliciting and related corticoidsteroids [11,26,45,46].…”

“…Approximately 100 cases of immediate-type hypersensitivity to corticosteroids have been reported [1,2,3]. The pathomechanism of these reactions has remained unclear in most patients, but positive skin test reactions or specific IgE antibodies to the suspected elicitors were found in some patients [3,4,5,6,7,8,9,10,11,12,13,14,15,16,17]. Challenge tests were performed in just a few cases, and most of them were positive [5,8,14,18,19,20].…”

Allergic hypersensitivity to topical and systemic corticosteroids: a review

“…With regard to immediate allergic reactions, two authors failed to detect any cross-reactivity between betamethasone and dexamethasone (agents with identical chemical structure, differing only in the position of the C16 methyl group) (137,138).…”