D3.258 - Probable drug- induced Enterocolitis Syndrome (DIES) caused by Amoxicillin
Case report
Background: Drug-induced enterocolitis syndrome (DIES) is a non IgE mediated hypersensitivity reaction, characterized by symptoms that typically resemble those of FPIES (food protein induced enterocolitis syndrome) after drug intake. To date, only ten cases of DIES have been described. Aminopenicillins are the drugs more frequently implicated. Physiopathological mechanisms are still unknown.
Case report:
A three years old patient who was referred to our allergy department presented two adverse reactions after treatment with amoxicillin. She had history of reactive airway disease, recurrent ear and urinary tract infections.
At two years of age, on the 5th day of treatment with amoxicillin for acute otitis, she developed a rash and self-limited vomiting which were treated with dexchlorpheniramine. In the emergency department (ED) she was diagnosed with exanthem due to viral infection and the seven days of treatment was completed. Twenty-four hours after finishing the treatment she developed a rash and self-limited vomiting.
One year later, amoxicillin-clavulanic acid was prescribed for urinary tract infection (E. Coli). After the first dose of treatment she presented only with persistent vomiting and diarrhea. She was treated in the ED with intravenous (IV) saline solution (SS) and ondansetron. No exanthem, lethargy nor hypotension were observed. The hemogram blood test and triptase's value were normal. Cefuroxime was prescribed and she completed the treatment without adverse reactions. Due to different clinical presentations related to amoxicillin treatment within infection we decided to rule out allergy to this drug.
Results:
Prick and intradermal tests with amoxicillin and specific IgE were negative.
After 90 minutes of finishing the drug challenge test with 350 mg of amoxicillin, the patient developed four episodes of vomiting and progressive lethargy. No exanthem, fever, hypotension nor desaturation were reported. Dexchlorpheniramine and methylprednisolone were administered without resolution of symptoms. There was no improvement after treatment with epinephrine. Only after rapid IV SS administration the symptoms were resolved.
Conclusions:
In case of persistent vomiting and lethargy coinciding with treatment with aminopenicillins, DIES must be suspected. Other beta-lactams antibiotics can be tolerated as alternatives.
