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OIT triggered life-threatening anaphylaxis in teenagers with asthma

Teenagers with persistent asthma, high milk- or egg-specific IgE levels and noncompliant behavior were a high-risk group for oral immunotherapy and experienced life-threatening reactions to the treatment, according to recent study results.

Researchers studied 130 patients, aged 5 to 18 years, who had undergone oral immunotherapy (OIT) at a Barcelona hospital. Standard treatment for the patients (cow’s milk allergy, n=80; egg allergy, n=50) included OIT protocols from the Spanish Society of Pediatric Allergy. OIT induction was begun at the hospital for 2 days, followed by once-daily dosing at home.

Forty-five patients (13 adolescents) were on the third and fourth steps of asthma treatment. Twenty-two children required intramuscular epinephrine for anaphylaxis to OIT. Three males with asthma developed life-threatening anaphylaxis to OIT.

Patient No. 1 had completed 17 months of cow’s milk OIT and entered maintenance phase. Immediate dyspnea and dizziness developed after ingesting 6 g cow’s milk protein, followed by hypotension, unconsciousness and respiratory arrest, and erythema. Intubation and ventilation and two 0.5-mg doses intramuscular epinephrine were required, followed by 28 hours of invasive ventilation in an ICU.

Researchers said he had poorly controlled asthma and required salbutamol two to three times weekly. He exhibited poor compliance, however, and had recently begun smoking. OIT protocol compliance also was suboptimal.

A second patient experienced vomiting, urticaria, severe bronchoconstriction and hypotension with decreased hypoxia after taking 3.5 g cow’s milk protein at home at 5 months into OIT. He received epinephrine via auto-injector, then two additional 0.3-mg doses, volume expansion, inotropes, intravenous salbutamol, steroids and invasive ventilation for 48 hours. He had skipped the previous 3 days of OIT doses (100 mL milk [3 g cow’s milk protein]). Because the patient disliked milk, his parents had given him 100 mL custard (3.5 g/100 mL cow’s milk protein). He also had persistent asthma and suboptimal compliance with medication.

One hour after a weekly dose increase (1.8 g) in month 4 of an egg OIT, a third patient experienced severe bronchoconstriction and hypotension with hypoxemia and dizziness followed by urticaria. Three consecutive 0.3-mg doses intramuscular epinephrine, nebulized salbutamol, intravenous hydroxyzine and intravenous saline were administered, followed by 8 hours of noninvasive ventilation.

Possible co-factors included fasting and mild exercise, and the patient reported that he had noticed dyspnea for 10 minutes without notifying his parents or health care workers. He also had persistent, partly controlled asthma.

“Teenagers with persistent asthma and high milk- or egg-specific IgE levels should be considered a particularly high risk group for OIT,” the researchers concluded.

Disclosure: The researchers report no relevant financial disclosures.