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Yoon, Ahn, Kim, Hwang, Park, and Kang: Successful rapid desensitization to trimethoprim-sulfamethoxazole-induced delayed hypersensitivity
Case Report

Allergy, Asthma & Respiratory Disease 2015; 3(2): 155-158.

Published online: 24 March 2015

DOI: https://doi.org/10.4168/aard.2015.3.2.155

Successful rapid desensitization to trimethoprim-sulfamethoxazole-induced delayed hypersensitivity

Doran Yoon1, Hongkeun Ahn1, Se Yong Kim1, Seong Jun Hwang1, Han-Ki Park1, 2, 3, Hye-Ryun Kang1, 2, 3

1Department of Internal Medicine, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea.

2Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea.

3Regional Pharmacovigilance Center, Seoul National University Hospital, Seoul, Korea.

Correspondence to: Hye-Ryun Kang. Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea. Tel: +82-2-2072-0820, Fax: +82-2-742-3291, helenmed@snu.ac.kr

Received 13 August 2014       Revised 8 December 2014       Accepted 10 December 2014

© 2015 The Korean Academy of Pediatric Allergy and Respiratory Disease; The Korean Academy of Asthma, Allergy and Clinical Immunology

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/).

Abstract

Trimethoprim-sulfamethoxazole (TMP-SMX) is an antibiotic used for the treatment or prophylaxis of Pneumocystis pneumonia and other infectious conditions. Sulfonamide derivatives have been reported to cause delayed hypersensitivity reactions, resulting in switch to less effective second-line antibiotics. Although desensitization is traditionally known to be effective in patients with immediate hypersensitivity, it is also applied to the treatment of delayed hypersensitivity in recent years. A 66-year-old female who had a history of repeated TMP-SMX-induced delayed hypersensitivity presenting as whole body rashes needed to take prophylactic dose of TMP-SMX (80/400 mg daily) before initiation of chemotherapy for multiple myeloma. Intravenous rapid desensitization was performed by using a 11-step, 4-bottle protocol from 1:1,000 to 1:1 solution for 3 hours to reach the target dose for prophylaxis. After successful rapid desensitization of TMP-SMX, 1-month prophylaxis was completed without any complications until the patient recovered normal immunity. We herein reported a case of delayed hypersensitivity reaction to TMP-SMX in an about-to-be immunocompromised host with planned chemotherapy who successfully completed 1-month prophylaxis with the drug without any complications through rapid desensitization.

Keywords: Sulfamethoxazole, Trimethoprim, Delayed hypersensitivity, Immunologic desensitization

Figures and Tables

Table 1

The preparation of 4-bottle tenfold increasing solutions (A, B, C, and D) used in the rapid desensitization protocol

aard-3-155-i001
Solution Dilution TMP/SMX (mg) DW (mL) Preparation protocol Concentration (mg/mL)
A 1:1 480 100 480 mg + DW 100 mL 4.8
B 1:10 48 200 A solution 22 mL in DW 200 mL 0.47568
C 1:100 4.8 200 B solution 22 mL in DW 200 mL 0.04714
D 1:1,000 0.48 200 C solution 22 mL in DW 200 mL 0.00467

TMP/SMX, trimethoprim/sulfamethoxazole; DW, dextrose 5% water.

Table 2

The 11-step desensitization protocol used in the present case of the TMP/SMX induced delayed hypersensitivity

aard-3-155-i002
Solution Concentration (mg/mL) Infusion Rate (mL/hr) Duration (min) Dose (mg) Volume (mL)
1:1,000 0.00467 100 20.0 0.156 33.3
250 15.0 0.292 62.5
500 15.1 0.589 126.2
1:100 0.04714 100 20.0 1.571 33.3
250 15.0 2.946 62.5
500 12.5 4.910 104.2
1:10 0.47568 100 20.0 15.856 33.3
250 15.0 29.730 62.5
500 12.5 49.550 104.2
1:1 4.80000 100 20.0 160.0 33.3
250 10.7 214.4 44.7
Total 175.9 480.0 700.0

TMP/SMX, trimethoprim/sulfamethoxazole.

Notes

This research was supported by a grant from Ministry of Food and Drug Safety to operation of the regional pharmacovigilance center in 2014.

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