Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge

Luca Delli Colli; Sofianne Gabrielli; Elissa M Abrams; Andrew O'Keefe; Jennifer L P Protudjer; Elana Lavine; Tracy Pitt; Adelle Atkinson; Thomas Eiwegger; Christine McCusker; Moshe Ben-Shoshan

doi:10.1016/j.jaip.2020.08.047

Differentiating Between β-Lactam-Induced Serum Sickness-Like Reactions and Viral Exanthem in Children Using a Graded Oral Challenge

J Allergy Clin Immunol Pract. 2021 Feb;9(2):916-921. doi: 10.1016/j.jaip.2020.08.047. Epub 2020 Sep 6.

Authors

Affiliations

¹ Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada. Electronic address: [email protected].
² Department of Pediatrics, Division of Allergy and Clinical Immunology, Montreal Children's Hospital, Montreal, Quebec, Canada.
³ Department of Pediatrics, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, British Columbia, Canada; Meadowood Medical Center, Winnipeg, Manitoba, Canada.
⁴ Department of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland, Canada.
⁵ Department of Pediatrics, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; George and Fay Yee Center for Healthcare Innovation, Winnipeg, Manitoba, Canada; The Children's Health Research Institute of Manitoba, Winnipeg, Manitoba, Canada; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre of Allergy Research, Karolinska Institutet, Stockholm, Sweden; Food and Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
⁶ Department of Pediatrics, Division of Allergy and Clinical Immunology, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Queen's University, Kingston, Ontario, Canada; Department of Pediatrics, Humber River Hospital, Toronto, Ontario, Canada.
⁷ Department of Pediatrics, Queen's University, Kingston, Ontario, Canada; Department of Pediatrics, Humber River Hospital, Toronto, Ontario, Canada; Department of Pediatrics, St Joseph's Hospital, Toronto, Ontario, Canada.
⁸ Department of Pediatrics, Division of Allergy and Clinical Immunology, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
⁹ Department of Paediatrics, Division of Allergy and Clinical Immunology, Food allergy and Anaphylaxis Program, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada; Reseach Institute, Hospital for Sick Children, Translational Medicine program, Toronto, Ontario, Canada; Department of Immunology, University of Toronto, Toronto, Ontario, Canada.

PMID: 32898711
DOI: 10.1016/j.jaip.2020.08.047

Abstract

Background: Serum sickness-like reactions (SSLRs) are defined by the presence of rash (primarily urticaria) and joint complaints (arthralgia/arthritis) that are believed to occur due to a non-IgE-mediated response to medications. However, similar reactions can occur due to viral infections, and it can be difficult to distinguish between the two. This may lead to unnecessary avoidance of the culprit antibiotic.

Objective: We aimed to evaluate children presenting with suspected SSLRs through a graded oral challenge (GOC).

Methods: All children referred to the Montreal Children's Hospital for potential antibiotic allergy (β-lactam or other antibiotics) and a clinical presentation compatible with SSLR were recruited for the study between March 2013 and February 2020. A standardized survey with questions on treatment, symptoms, and associated factors was completed, and a GOC (10% and subsequently 90% of the oral antibiotic dose) was conducted. Patients with a negative GOC were contacted annually to query on subsequent antibiotic use.

Results: Among 75 patients presenting with suspected SSLRs, the median age was 2.0 years and 46.7% were males. Most reactions were attributed to amoxicillin. Among the 75 patients, 2.7% reacted immediately (within 1 hour) to a GOC and 4.0% had a nonimmediate reaction. Of the 43 patients successfully contacted, 20 reported subsequent culprit antibiotic use of whom 25.0% had a subsequent mild reaction (macular/papular rash).

Conclusions: This is the first and largest pediatric study to assess SSLR using a GOC. Our findings suggest that using a GOC is safe and appropriate for differentiating between β-lactam-induced SSLR and viral exanthem in this population.

Keywords: Amoxicillin; Antibiotic reaction; GOC; Graded oral challenge; Joint complaints; SSLR; Safety; Serum sickness–like reaction; Urticaria.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Amoxicillin / adverse effects
Anti-Bacterial Agents / adverse effects
Child
Child, Preschool
Drug Hypersensitivity* / diagnosis
Drug Hypersensitivity* / drug therapy
Exanthema* / diagnosis
Exanthema* / drug therapy
Female
Humans
Male
Serum Sickness*
Skin Tests
Virus Diseases* / diagnosis
Virus Diseases* / drug therapy
beta-Lactams / adverse effects

Substances

Anti-Bacterial Agents
beta-Lactams
Amoxicillin