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A PATIENT WITH EROSIVE ESOPHAGITIS WITH AN ALLERGY TO BOTH PPI AND H2RA: A THERAPEUTIC CHALLENGE
K Herba, KA Waschke
Department of Gastroenterology, McGill University Health Center, Montreal, QC
This case report describes a patient with gastroesophageal reflux disease (GERD) who developed allergies to both proton pump inhibitors (PPI’s) and H2 receptor antagonists (H2RA’s) required for treatment of erosive esophagitis. The patient initially presented with heartburn approximately 3-4 times per week, with mild nausea but without vomiting or dysphagia. Her past medical history was significant for mild asthma and mild obesity. She had been previously treated with both ranitidine and pantoprazole for Grade A esophagitis at another institution, but had developed facial swelling without other symptoms. An endoscopy at our institution confirmed the presence of mild (Grade A) esophagitis and biopsies done for eosinophilic esophagitis were negative. The patient was treated with esomeprazole, but immediately developed widespread hives, itching of the throat and swelling of the ears after taking only one tablet. Skin testing (prick and intradermal) revealed a negative reaction to famotidine and questionable reactions to pantoprazole and cimetidine. Double blind placebo challenge tests demonstrated an immediate type allergic reaction to both pantoprazole and famotidine. Despite dietary interventions and adherence to alternative regimens including sodium alginate-aluminum hydroxide and sucralphate, her GERD symptoms did not resolve. Subsequent endoscopy revealed persistent esophagitis.
We conducted a literature search using the MEDLINE (1950 to September 2007) and PubMed databases concerning the occurrence of allergies to PPI’s and H2RA’s. We found limited reports of IgE-type reactions to PPI’s and H2RA’s. We discuss the GERD treatment options in this patient in the context of these known medication allergies (misoprostol, endoscopic and surgical interventions) as well as the possible role of desensitization to proton pump inhibitors.