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Anaphylactic Shock Associated with Cefuroxime Axetil: Structure–Activity Relationships

Industrial Pharmacist, EA 3999 "maladies allergiques: diagnostic et thérapeutique," Department of Internal Medicine, Clinical Immunology and Allergology, University Hospital of Nancy, Nancy, France

Samuel Luyasu, MD

Doctor of Internal Medicine and Allergologist, Arlon, Belgium

Jean-Marie Renaudin, MD

General Practitioner and Allergologist, EA 3999 "maladies allergiques: diagnostic et thérapeutique," Department of Internal Medicine, Clinical Immunology and Allergology, University Hospital of Nancy

Philippe Trechot, PharmD PhD

Department of Pharmacovigilance, University Hospital of Nancy

Gisèle Kanny, MD PhD

Professor of Internal Medicine, College of Medicine, University of Nancy; Head of EA 3999 "maladies allergiques: diagnostic et thérapeutique," Department of Internal Medicine, Clinical Immunology and Allergology, University Hospital of Nancy

Reprints: Dr. Kanny, EA 3999 "maladies allergiques: diagnostic et thérapeutique," Department of Internal Medicine, Clinical Immunology and Allergology, Hôpital Central, University Hospital of Nancy, F-54035 Nancy Cedex, France, fax 0033/383852864, g.kanny{at}chu-nancy.fr

OBJECTIVE: To present a predictive model of allergenicity based on a structure–activity relationship analysis of ß-lactam antibiotics using appropriate skin testing procedures.

CASE SUMMARY: A 39-year-old woman was diagnosed with anaphylactic shock a few minutes after taking a 500 mg tablet cefuroxime of axetil and was admitted to the emergency department with dizziness, facial angioedema, generalized skin rash, and inferior cardiac ischemia. Skin testing confirmed the involvement of cefuroxime as the cause of the anaphylactic reaction, and the reaction was defined as probable according to the Naranjo probability scale. We then performed skin testing to study cross-reactivity between different ß-lactam antibiotics. In addition to this initial assessment, a structure–activity relationship (SAR) analysis was done. It showed that the patient was sensitized to ß-lactam antibiotics presenting a methoxyimino group, but not to similar compounds lacking this chemical group (eg, amoxicillin or penicillin G or V). Challenge with amoxicillin under intensive medical monitoring was tolerated up to a cumulated dose of 1 g, administered intravenously over 2 hours.

DISCUSSION: This study demonstrates that SAR analysis could be useful to predict potential adverse reactions to related antibiotics and to select alternative strategies when antibiotic administration is essential.

CONCLUSIONS: An SAR-based approach could help physicians and pharmacists provide allergic patients with relevant advice and propose viable alternatives regarding drug therapy.

Key Words: anaphylactic shock, cefuroxime axetil, drug allergy, structure–activity relationship

Published Online, May 8, 2007. www.theannals.com, DOI 10.1345/aph.1K050