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A case of poor negative predictive value of antibiotic specific IgE test for cefuroxime skin hypersensitivity

Background and aims: A 42-year-old woman was admitted to the Division of Clinical Pharmacology of the University Hospital Centre Zagreb on August 14., 2020. due to the need for antibiotic hipersensitivity testing. The CAST ELISA test for specific IgE antibodies directed against antibiotics performed before the hipersensitivity evaluation came back completely negative to: Penicilillin-G, Penicilillin-V, benzyl penicilloyl-polylysine (PPL), minor determinant mixture (MDM), Amoxicilli, Cephalosporins I generation, Cefuroxime, SMZ and TMP. Summary of work and outcomes: Her history showed that 3 months ago she took one 500 mg tablet of cefuroxime axetil orally and 1 minute later she felt itching on her palms, burning of the tongue and lips, dizziness and then she lost consciousness and fell to the floor. The condition was understood as anaphylaxis, so adrenalin, chloropyramine and methylprednisolone were administered parenterally. Following therapy, her consciousness recovered and the erythema of the skin improved. Her personal history was remarcable only for sacroileitis, irritable bowel syndrome and recurrent UTIs. Up to that point, she has been taking all antimicrobial medicines without difficulty and she reported no known allergies. Except for several stools per day, her functions were otherwise unremarcable. Her chronic medication included only mebeverine 2x1 tbl and on presentation, she was generally feeling well. After signing the informed consent form and setting up the peripheral venous access, prick tests were performed on: penicillin G, ampicillin, cefazolin, cefuroxime, ceftriaxone and gadoterate meglumine which were clearly positive to cefuroxime and ceftriaxone. Next, an intradermal test was performed with the same 5 antimicrobial drugs and the contrast agent administered for magnetic resonance imaging and cefuroxime and ceftriaxone again tested clearly positive. Five minutes after the first intradermal application of antimicrobial drugs, the patient started feeling an itch of her palms, which in the next 30 minutes progressed to erythema and itching of the skin of the whole body, so in order to control the symptoms and signs of an acute cutaneous hypersensitivity reaction, we decided to administer chloropyramine 20mg and methylprednisolone 80mg parenterally in 100ml of saline. The signs and sympotms of acute hypersensitivity regressed completely over the next 4 hours. Discussion: After discharge, we prescribed loratadine 10 mg per day for the next 7 days and advised avoiding future use of cefuroxime and ceftriaxone, as well as other beta-lactam antibiotics until their tolerability has been tested under controlled conditions. Conclusion: CAST ELISA results in this case appear to indicate poor negative predicitve value of this test, warranting further investigation on a larger patient cohort.

hypersensitivity reaction ; cefuroxime ; CAST ELISA

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