Immunoglobulin E-mediated hypersensitivity reaction after intraperitoneal administration of vancomycin

Abstract

Intraperitoneal (IP) vancomycin is widely used to treat Gram-positive peritonitis associated with peritoneal dialysis. There have been two cases of red man syndrome (RMS), a vancomycin-specific nonimmunologic reaction, associated with IP vancomycin. However, immune-mediated hypersensitivity reaction to IP vancomycin has not yet been reported. A 49 year old woman on continuous ambulatory peritoneal dialysis developed her first peritonitis episode. The patient was treated with IP vancomycin once/wk for 4 weeks. She experienced mild itching and flushing throughout her body for 1 day after the second treatment. Whenever vancomycin was administered, generalized urticaria and a prickling sensation developed, and the intensity increased gradually; however, these symptoms improved after vancomycin was discontinued. An allergic skin test was performed 6 weeks after the previous urticarial episode, and an intradermal skin test revealed a positive response to vancomycin. To our knowledge, this is the first case report of immunoglobulin E-mediated hypersensitivity reaction to IP vancomycin administration.

"Getting Under Your Skin”: First Reported Case of Transient Reactive Phlebitis Involving Vancomycin Infusion Therapy

“…Vancomycin-associated cutaneous drug reactions are associated with two types of reactions, with both attributed to the direct or indirect mediation of histamine release [2][3][4]. The first is due to the direct induction of histamine release by mast cells due to the antibiotic molecule and its metabolic products [2].…”

“…One well-documented example is "Red-Man Syndrome" which is associated with a rapid rate of vancomycin infusion. The second type of cutaneous drug reaction secondary to vancomycin infusion is a hypersensitivity reaction mediated by immunoglobulin E (IgE) that results in histamine release and has been associated with eosinophilia [2][3][4]. This type of reaction is seen in up to 5% of patients receiving vancomycin [2].…”

“…Twenty-nine percent of cutaneous drug reactions attributed to vancomycin occurred only during the administration of the antibiotic [3]. Treatment of these adverse cutaneous reactions is typically supportive, and symptoms usually resolve with cessation of vancomycin therapy [2][3][4]. One caveat with "Red-Man Syndrome" is that symptoms typically resolve after the IV vancomycin infusion rate is titrated down or stopped completely [2,3].…”

Systemic Toxicity of Intraperitoneal Vancomycin

“…We feel it is unlikely that ceftazidime was the culprit drug and subsequently the patient has been challenged with cephalosporins without any reaction. There has only been one previous report of intraperitoneal vancomycin induced hypersensitivity with systemic symptoms, a recent report from South Korea where a patient developed throat tightness and rash [3] (Table 2). In that report, there was no hypotension and the rash was not biopsied.…”