Management of Hypersensitivity to Trimethoprim-Sulfamethoxazole With an Ultrarapid Desensitization Protocol in HIV Infection.

Abstract

Prophylaxis for opportunistic infections has been a major advance in the treatment of HIV-infected patients, significantly decreasing morbidity and mortality. Nevertheless, these improved treatment options have been accompanied by an increase in reports of hypersensitivity reactions (HSRs) to sulfonamides. The most common cutaneous manifestations of the reactions are as follows: maculopapular rash (36.6%); fixed drug eruption (22%); and type IV HSRs (urticaria) and type I HSRs (angioedema) (12.6%). Withdrawal of the drug and desensitization are both possible therapeutic approaches following confirmed diagnosis of adverse reactions to cotrimoxazole [1]. Many protocols for desensitization to trimethoprim-sulfamethoxazole in HIVinfected patients are described in the literature. These initially took several days and, more recently, a single day, although few take less than 6 hours [2]. The objective of this study was to report 3 cases of HSR to trimethoprim-sulfamethoxazole in HIV-infected patients and describe their management with a novel ultrarapid 3.25-hour, 13-step oral desensitization protocol. Written informed consent for publication was obtained from the patients. Three HIV-infected men presented clinical manifestations of drug-induced HSR after receiving treatment with trimethoprim-sulfamethoxazole. The first patient was a 30-year-old man with a complicated appendectomy and abdominal collections who had recently been diagnosed with HIV infection (CD4+ 140/μL) and syphilis. Trimethoprim-sulfamethoxazole was started owing to fever and intra-abdominal collection. After administration of the third dose, he developed disseminated dermatosis on the head, face, neck, and thorax. He was diagnosed with maculopapular rash secondary to trimethoprimsulfamethoxazole, and patch testing yielded a positive reaction (+++, vesicles covering 50% of the test site). Premedication with chlorphenamine was given prior to the protocol (3 solutions [A 1:100, B 1:10, C 1:1]), with no adverse events (Table). Raphael Piarroux is currently employed by ldbio diagnostics. The remaining authors declare that they have no conflict of interests.