A 4y/o male with anaphylaxis after multivitamin infusion 張均豪醫師 / 林應然主任

A 4y/o male with anaphylaxis after multivitamin infusion

張均豪醫師張均豪醫師 / / 林應然主任林應然主任

Basic Data

Name: Name: 劉劉 X X 昀昀 Age: 4-year-5-month-oldAge: 4-year-5-month-old Sex: maleSex: male Chart number: 6269XXChart number: 6269XX

Chief Problem

Fever for two daysFever for two days

Present Illness

The 4The 4++y/o boy patient was suffering y/o boy patient was suffering from fever for 2 days. Besides, Cough, from fever for 2 days. Besides, Cough, rhinorrhea, abdominal pain, vomiting and rhinorrhea, abdominal pain, vomiting and poor appetite were noted since yesterday.poor appetite were noted since yesterday.

Due to these symptoms, he was Due to these symptoms, he was brought to our ER for help. Primary brought to our ER for help. Primary physical examination showed tonsil physical examination showed tonsil enlargement with exudate . Therefore , he enlargement with exudate . Therefore , he was admitted to our ward for further was admitted to our ward for further management. management.

Birth history , past history and family history GA 36weeksGA 36weeks C/SC/S Birth body weight 2500gmBirth body weight 2500gm Drug and food allergy: nilDrug and food allergy: nil Other systemic disease: deniedOther systemic disease: denied Admission history: 90.01 AGE with Admission history: 90.01 AGE with

dehydrationdehydration No special family history No special family history

Physical examination

Vital sign : HRVital sign : HR 100 100 1/min, RR 1/min, RR 3030 1/min , 1/min ,

BP BP 106/60106/60 mm-Hg, BT mm-Hg, BT 39.739.7 。。 cc HEENT : throat : HEENT : throat : injectedinjected ; ;

tonsil : tonsil : enlarged with pus enlarged with pus coatingcoating; ;

ear drum: not injectedear drum: not injected Neck: suppleNeck: supple

Physical examination

Chest: symmetric expansion ; Chest: symmetric expansion ;

Breath sound: clear; Breath sound: clear;

Heart sound: regular heart beat without Heart sound: regular heart beat without murmurmurmur

Abdomen: soft and flat ,normal activeAbdomen: soft and flat ,normal active Extremity: freely movableExtremity: freely movable Skin: no rashSkin: no rash

Admission impression

Acute suppurative tonsillitisAcute suppurative tonsillitis G-I upsetG-I upset

Admission plan

CBC/DC, CRP, ASLO, B/C CBC/DC, CRP, ASLO, B/C Throat culture Throat culture Empiric antibiotics treatment (Cephradine)Empiric antibiotics treatment (Cephradine) Supportive treatment (Taita No2)Supportive treatment (Taita No2)

Laboratory Data (Day 1)

CBC/DC : WBC CBC/DC : WBC 1799017990 (Neu (Neu 81.481.4 %, Lym %, Lym 9.89.8 %) RBC 4.66 (Hb 13.0 Ht 36.7 MCV %) RBC 4.66 (Hb 13.0 Ht 36.7 MCV 78.8) PLA 290K 78.8) PLA 290K

生化生化 : GLU 73, BUN 9, Cr 0.4, AST 21, : GLU 73, BUN 9, Cr 0.4, AST 21, ALT 14ALT 14

CRP : CRP : 2.842.84mg/dl (0~0.8)mg/dl (0~0.8) ASLO : <25.0 IU/ml(0~200)ASLO : <25.0 IU/ml(0~200)

Hospital course (Day 1~2)

Day 1-2 : persistent high fever,Day 1-2 : persistent high fever, Day 3: gum swellingDay 3: gum swelling Day 3 PM 04:00: Day 3 PM 04:00: Skin rashSkin rash , , dyspnea , dyspnea ,

ccyanosisyanosis and and conscious disturbanceconscious disturbance were were noted after OMV injected a few minutes noted after OMV injected a few minutes later (Otsuka multivitamin)later (Otsuka multivitamin)

Stop OMV ivdStop OMV ivd

Hospital course (Day 3) Bosmin (1:1000) 0.3cc iv stBosmin (1:1000) 0.3cc iv st Solumedrol 1 vial (40mg) iv stSolumedrol 1 vial (40mg) iv st N/S 250 cc challenge N/S 250 cc challenge Ambu baggingAmbu bagging BP 140/90 (after Bosmin iv) BP 140/90 (after Bosmin iv) monitor BP (monitor BP (90/5090/50 mmHg), EKG ( mmHg), EKG (120120

1/min,WNL) and SpO2 (1/min,WNL) and SpO2 (9898 %) %) PM 05:00 BP PM 05:00 BP 90/60 90/60 mmHgmmHgkeep N/S ivd, keep N/S ivd,

Hospital course (Day 4)

Day 4 : no skin rash, but persistent Day 4 : no skin rash, but persistent hypothermia(35.5hypothermia(35.5 。。 C degree), poor activity C degree), poor activity

r/o sepsis r/o sepsis

— —CBC/DC, B/C, CRP, U/C, GOT/GPT, CBC/DC, B/C, CRP, U/C, GOT/GPT, BUN/CrBUN/Cr

— —shift (Flomoxef) shift (Flomoxef)

Laboratory Data (Day 4) blood culture (Day 1) : no growthblood culture (Day 1) : no growth Throat culture (Day 1) : no growthThroat culture (Day 1) : no growth CBC/DC (Day 4) : WBC CBC/DC (Day 4) : WBC 9820 9820 (Neu (Neu 87.187.1%, %,

Lym Lym 9.69.6%) RBC 4.73(Hb 12.9 Ht 36.7 %) RBC 4.73(Hb 12.9 Ht 36.7 MCV 77.6) PLA 221KMCV 77.6) PLA 221K

生化生化 (Day 4) : GLU 146, BUN 9, Cr 0.3, (Day 4) : GLU 146, BUN 9, Cr 0.3, GOT 29, GPT 8, K 4.0, Cl 101GOT 29, GPT 8, K 4.0, Cl 101

CRP (Day 4) :CRP (Day 4) : 4.6 4.6

Hospital course (Day 5~10)

Day 5 : lip , tongue and oral ulcer, gum Day 5 : lip , tongue and oral ulcer, gum swellingswelling

Day 6~9 : persistent lower BT 36~37Day 6~9 : persistent lower BT 36~37 。。 C, C, Day 9 : DC antibiotic (total antibiotic Day 9 : DC antibiotic (total antibiotic

treatment 7 days)treatment 7 days) Day 10 : MBDDay 10 : MBD

Laboratory Data (Day 9)

blood culture (Day 4) : no growthblood culture (Day 4) : no growth

Final diagnosis

Herpetic gingivostomatitisHerpetic gingivostomatitis Anaphylactic shockAnaphylactic shock R/O sepsisR/O sepsis

Discussion (1) OMV (Otsuka multivitamin)(lyophilized OMV (Otsuka multivitamin)(lyophilized

power):power):

Thiamine Thiamine Hcl , Hcl , RiboflavinRiboflavin Sodium Phosphate, Sodium Phosphate, Pyridoxine, Pyridoxine, CyanocobalamineCyanocobalamine, Nicotinamine, , Nicotinamine, Folic acid, Folic acid, Ascorbic acidAscorbic acid, Panthenol, Biotin, , Panthenol, Biotin, Dextran 40 ; (aqueous solution)Vitamin Aoil, Dextran 40 ; (aqueous solution)Vitamin Aoil, Cholecalciferol, Tocopherol acetate, Cholecalciferol, Tocopherol acetate, Phytonadione, Polysorbate 80, Polysorbate 20, Phytonadione, Polysorbate 80, Polysorbate 20, D-Sorbitol, Macrogol 400.D-Sorbitol, Macrogol 400.

Discussion (2) Anaphylactic symptomsAnaphylactic symptoms

— —itching, flushing, general papular rash, itching, flushing, general papular rash, dizziness, nauseadizziness, nausea

— —abdominal cramps, angina pectoris, abdominal cramps, angina pectoris, scotomasscotomas

— —dyspnea, angioedema, tachycardia, dyspnea, angioedema, tachycardia, hypotension, lose consciousness, shockhypotension, lose consciousness, shock

Discussion (3)-Case 11.Procbstle TM et al.1.Procbstle TM et al. Specific IgE and IgG serum antibodies to thiamine Specific IgE and IgG serum antibodies to thiamine

associated with anaphylactic reactionassociated with anaphylactic reaction . J Allergy . J Allergy Clin Immunal 1995 Clin Immunal 1995

A 47 y/o man, treatment of humeral epicondylitis A 47 y/o man, treatment of humeral epicondylitis with paraepicondylar injection of Supertendin with paraepicondylar injection of Supertendin ( Vit B1)( Vit B1)

First time : itching of palms, trunk, neckFirst time : itching of palms, trunk, neck

Second time : 2 weeks later , abdominal cramps,Second time : 2 weeks later , abdominal cramps,

angina pectoris, scotomas, loss of consciousness, angina pectoris, scotomas, loss of consciousness, hypotensionhypotension

Discussion (3)-Case 1 After six weeks and 18 months , a strong After six weeks and 18 months , a strong

positive result by prick testpositive result by prick test Blood serum analysis : The decline of IgE Blood serum analysis : The decline of IgE

and the increase of IgG from 6 to 18 months and the increase of IgG from 6 to 18 months after the test were significant after the test were significant

Discussion (3)-Case 1

Discussion (3)-Case 1-conclusion

Oral intake B1 has never lead to any Oral intake B1 has never lead to any advierseadvierse

Booster effect with aggravating symptoms Booster effect with aggravating symptoms from first to second parenteral application from first to second parenteral application of Supertendin occurredof Supertendin occurred

Specific IgE and IgG antibodies to thiamine Specific IgE and IgG antibodies to thiamine hydrochloride have been demonstrated by hydrochloride have been demonstrated by an ELISAan ELISA


2.Ou LS . Huang JL (2.Ou LS . Huang JL ( 黃璟隆黃璟隆 ) ) Anaphylaxis to riboflavin (vitamin B2)Anaphylaxis to riboflavin (vitamin B2) . Annals of . Annals of

Allergy, Asthma, and Immunology. 2001 NovAllergy, Asthma, and Immunology. 2001 Nov 15 y/o boy anaphylasix (dizziness, lost conscious) 15 y/o boy anaphylasix (dizziness, lost conscious)

several times after drank one soft drink (yellow several times after drank one soft drink (yellow color) or took multivitamin tabletcolor) or took multivitamin tablet

Using single-blind prick skin tests and intradermal Using single-blind prick skin tests and intradermal skin tests with various pure vitamin componentsskin tests with various pure vitamin components



Discussion (3)-Case 2-conclusion

Thiamine (vitamin B1) is the vitamin that Thiamine (vitamin B1) is the vitamin that most frequently induces allergic reactions most frequently induces allergic reactions and sometimes causes anaphylactic shockand sometimes causes anaphylactic shock

Vitamin B2, B12, A, C may also induce Vitamin B2, B12, A, C may also induce anaphylactic reactionanaphylactic reaction

Free-form vitamin B2 could be a stronger Free-form vitamin B2 could be a stronger haptenhapten

IgE-specific antibodies to riboflavin-IgE-specific antibodies to riboflavin-conjugated proteinconjugated protein

Conclusion

Paper number-not muchPaper number-not much Severity-mild ~ emergentSeverity-mild ~ emergent Experiment-dangerExperiment-danger Mechanism-not clearMechanism-not clear Treatment-epinephrine, steroidTreatment-epinephrine, steroid

Reference1.Wrenn KD , Murphy F.Slovis CM. A toxicity study of 1.Wrenn KD , Murphy F.Slovis CM. A toxicity study of

parenteral thiamine hydrochloride. Ann Emerg Med parenteral thiamine hydrochloride. Ann Emerg Med 1989;18:867~8701989;18:867~870

2. Pollitt NT. Large intravenous dosage of thiamine. JAMA 2. Pollitt NT. Large intravenous dosage of thiamine. JAMA 1968; 203:1531968; 203:153

3.Assem ES. Anaphylactic reaction to thiamine . Practitioner 3.Assem ES. Anaphylactic reaction to thiamine . Practitioner 1973;211:5651973;211:565

4.Fernandez M, Barcelo M, Munoz C. et al. Anaphylaxis to 4.Fernandez M, Barcelo M, Munoz C. et al. Anaphylaxis to thiamine (vitamin B1). Allergy 1997; 52: 985~960thiamine (vitamin B1). Allergy 1997; 52: 985~960

5.Procbstle TM . Gall H. Jugert FK ,et al. Specific IgE and 5.Procbstle TM . Gall H. Jugert FK ,et al. Specific IgE and IgG serum antibodies to thiamine associated with IgG serum antibodies to thiamine associated with anaphylactic reaction . J Allergy Clin Immunal 1995; anaphylactic reaction . J Allergy Clin Immunal 1995; 95:1059~1060. 95:1059~1060.

Reference

6. Ou LS . Kuo ML . Huang JL(6. Ou LS . Kuo ML . Huang JL( 黃璟隆黃璟隆 ) Anaphylaxis to ) Anaphylaxis to riboflavin (vitamin B2) . Annals of Allergy, Asthma, and riboflavin (vitamin B2) . Annals of Allergy, Asthma, and Immunology. 87(5):430-433, 2001 NovImmunology. 87(5):430-433, 2001 Nov

7. Severoa EI. Anaphylactic shock due to sensitization to 7. Severoa EI. Anaphylactic shock due to sensitization to ascorbic acid . (in Russian) . Klin Med 1972;50:130~131ascorbic acid . (in Russian) . Klin Med 1972;50:130~131

8. Danilov LN, Finogenov LN. Anaphylactic shock 8. Danilov LN, Finogenov LN. Anaphylactic shock following administration of vitamin A. (in Russian) . following administration of vitamin A. (in Russian) . Klin Med 1977;55:122~123Klin Med 1977;55:122~123

9. Tordjman R . Genereau T. Guinnepain MT. Weyer A. 9. Tordjman R . Genereau T. Guinnepain MT. Weyer A. Lortholary O. Royer I . Casassus P. Guillevin L. Lortholary O. Royer I . Casassus P. Guillevin L. Reintroduction of vitamin B12 in 2 patients with prior Reintroduction of vitamin B12 in 2 patients with prior B12-induced anaphylaxis. European Journal of B12-induced anaphylaxis. European Journal of Haematology. 60(4):269~270, 1998 Apr. Haematology. 60(4):269~270, 1998 Apr.

Documents

A 4y/o male with anaphylaxis after multivitamin infusion 張均豪醫師 / 林應然主任