D3.376 - Drug Allergy Related to Chemotherapy and Premedication: Anaphylaxis Induced by Carboplatin and Methylprednisolone

Background

Hypersensitivity reactions related to chemotherapy represent serious adverse events that may significantly affect oncological treatment. Platinum-based agents, such as carboplatin and cisplatin, are the most frequently implicated drugs; however, premedication agents, including corticosteroids, may also cause severe allergic reactions and are often overlooked.

Case Report

A 57-year-old woman receiving carboplatin and paclitaxel chemotherapy for recurrent ovarian cancer developed throat tightness, severe dyspnea, and loss of consciousness shortly after carboplatin infusion. She required endotracheal intubation and intensive care unit admission and was extubated the following day. Carboplatin was discontinued, and the treatment regimen was revised to cisplatin plus paclitaxel.

The patient was referred for allergy evaluation prior to the new protocol. Three weeks after the reaction, skin prick testing with cisplatin was negative, whereas intradermal testing at a 1/100 dilution was positive. Serum tryptase level was measured as 2.88 µg/L.

Off-label omalizumab was administered as part of premedication. The following day, during hospitalization for chemotherapy preparation, intravenous methylprednisolone was administered in the evening. Within minutes, the patient developed generalized urticaria, throat tightness, dyspnea, hypotension, and bradycardia, consistent with anaphylaxis, and was treated immediately. During intensive care follow-up, fexofenadine was administered using a graded challenge protocol without any adverse reaction.

One week later, after confirming a positive histamine control response, skin testing with dexamethasone was performed, including prick and intradermal tests at 1/100 and 1/10 dilutions; all results were negative. Subsequently, intramuscular placebo, followed by 1/4 and 3/4 dose provocations, was administered without any allergic reaction.

Approximately one week later, the patient was recalled for chemotherapy planning. At eight weeks after the initial reaction, repeat skin testing revealed a positive intradermal test to cisplatin at a 1/100 dilution. Based on these findings, cisplatin desensitization was successfully performed using a 13-step protocol with three solutions and three dilutions, delivering a total dose of 90 mg. Premedication included dexamethasone 8 mg and fexofenadine 180 mg administered at 13, 7, and 1 hours before chemotherapy. No allergic reactions occurred during desensitization.

Conclusion

This case highlights that hypersensitivity reactions during chemotherapy may be triggered not only by antineoplastic agents but also by premedication drugs. Comprehensive allergy evaluation and individualized management strategies, including desensitization, are essential to ensure the safe continuation of oncological treatment.