[CIS PIDD] [cis-pidd] challenging patient for IVIG/SCIG

[Richard Wasserman]

About 15 years ago I had a patient who developed epinephrine non-responsive
hypotension with IGIV. When I gave it SC, the hypotension developed about
48 hours after the infusion. He had to be treated in the hospital with
fluids and steroids for several days. On investigation his levels of TNF
were normal at baseline but went off the charts with IGIV. Pretreatment
with Remicade eliminated the problem. You might check cytokine production
during the reactions.
Richard Wasserman
Dallas


On Tue, Nov 5, 2013 at 11:09 AM, Perez, Elena <e.perez13 at med.miami.edu>wrote:


> Dear All,

>

> Anyone have strategies beyond the normal premedication and the usual

> routine, etc for patients who fail multiple IVIG products for signs/sx of

> anaphylaxis?

>

> The patient is a cardiac transplant patient who is almost 13yo, chronic

> immunosuppression, very low T cells, normal B cells. Reactions reportedly

> happen within minutes of infusion, and involve increased heart rate,

> swelling of face, "glassy eyed" pale, and itchy throat, and feels that she

> will pass out.

>

> I am seeing her now for the first time, after she has failed at least 5

> therapies (adjusting hydrocortisone, solumedrol, antihistamines before and

> during infusion etc.) under the care of outside immunologist.

>

>

>

> She often tolerated 4-5x then with subsequent infusions becomes sick and

> pale, HR increased,

>

> SC Hizentra -- tolerated for a while then started with signs of allergy.

>

> Gammagard and Hizentra: glazed look, pale, itchy throat, swelling of eye

> within one two minutes. VSS HR went up a little. She had been on hizentra

> for a while and reactions kept mounting. Despite benadryl and hct up dosing.

>

> Privigen--pale, lower back pain. Ran over 36hours.

>

>

>

> I was thinking to try Octagam (no volume issues), in house OR try small

> doses of subcutaneous daily.

>

>

>

> Appreciate others experience with difficult infusion reactions or patients

> with allergies to multiple products. In my experience this is very rare....

> and usually solved by switching products or usual premeds. She definitely

> needs the therapy it is just a question of how to give it.

>

>

>

> Thanks!

>

> Elena

>

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-- 
Richard L. Wasserman, MD, PhD
DallasAllergyImmunology
7777 Forest Lane, Suite B-332
Dallas, Texas 75230
Office (972) 566-7788
Fax (972) 566-8837
Cell (214) 697-7211

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