Wedad Awad, BCPS, PharmD
Critical Care Clinical Pharmacist
King Hussein Cancer Center
Amman, Jordan
Disclosure information not submitted.
Lama Nazer, BCPS, PharmD, FCCM (she/her/hers)
Clinical Pharmacy Specialist
King Hussein Cancer Center
Amman, Jordan
Disclosure information not submitted.
Farah AlSheyyab, PharmD
Clinical Pharmacist
King Hussein Cancer Center (Jordan)
Amman, 'Amman, Jordan
Disclosure information not submitted.
Naser Mahmoud, MD
Pulmonary and Critical Care Consultant
King Hussein Cancer Center (Jordan)
Amman, Jordan
Disclosure information not submitted.
Title: A Case of a Severe Delayed Hypersensitivity Reaction associated with Intravenous Colistin
Case Report Body
Introduction: Delayed hypersensitivity reactions have been reported with antimicrobial therapy, mostly beta-lactams. We describe a case of a severe delayed hypersensitivity reaction associated with colistin.
Description: A 20-year old male patient with acute myeloid leukemia was transferred to the ICU with severe hypokalemia and arrhythmias. The patient was on a prolonged course of intravenous colistin for the treatment of carbapenem-resistant Escherichia coli bacteremia, with the source being a rectocecal abscess that was deemed un-resectable due to severe thrombocytopenia. On day 2 of ICU admission and day 28 of colistin therapy, the patient developed a severe hypersensitivity reaction during the administration of colistin. The patient exhibited facial flushing, tachycardia, and tachypnea. Colistin was held and adrenaline, chlorpheniramine, and hydrocortisone were administered. Shortly after that, the patient became hypotensive and required norepinephrine for the next 24 hours. On the day of the reaction, the patient was febrile, and laboratory changes included leukocytosis and acute kidney injury. Given the lack of other treatment options and the uncertainty about the adverse reaction, it was decided to re-challenge the patient. No hypersensitivity reactions were reported with the colistin re-challenge and therefore, treatment was resumed. However, two days later, the patient developed a more severe hypersensitivity reaction during colistin administration. He exhibited facial flushing, extensive skin rash, tachycardia, tachypnea, redness and hotness in the upper limbs, and hypotension that required vasopressors for the next 24 hours. Adrenaline, chlorpheneramine, and hydrocortisone were administered and colistin was discontinued. On that day, the patient was febrile and the laboratory changes included leukocytosis, acute kidney injury and an acute increase in bilirubin. Over the next 24 hours, vasopressors were discontinued and the hypersensitivity reaction resolved.
Discussion: To our knowledge, this is the first report of a colistin-associated delayed hypersensitivity reaction. Clinicians should be aware of such reactions that may occur several weeks after the initiation of treatment. In addition, a successful re-challenge may not necessarily rule out such a reaction and close monitoring is needed.