"Pseudoallergic reaction" to albuterol

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

A 6-month-old boy, who has a history of bronchiolitis, developed urticaria after the first dose of treatment with albuterol syrup 2 weeks ago. The symptoms have since resolved with the administration of Benadryl. He has no history of food allergies and no history of asthma. He has some occasional sneezing and congestion which started recently. He has no history of eczema.

He is not on any medications. Family history is positive for seasonal allergies in his mother.

On physical examination, this is a well-developed, well-nourished male in no apparent distress. The physical examination is normal.

What would you suggest?

Procedures: He had a drug challenge test with nebulized albuterol. He received 1 dose and we observed him for 30 minutes after that without any evidence of urticaria or any drug allergic reaction.

What is the most likely diagnosis?

This is a child with a history of bronchiolitis with suspected drug allergic reaction to albuterol syrup. He had urticaria which was most likely related to a viral infection. He had a negative drug challenge with nebulized albuterol which makes a drug allergic reaction to albuterol syrup considerably less likely.

What is the next step?

We suggested the use of nebulized albuterol in the future if needed for respiratory symptoms instead of albuterol syrup. Considering that he has some evidence of sneezing, nasal congestion and visible mold in the house, we can perform skin prick testing for environmental allergens, including dust mite, cat, dog, cockroach and mold when he is approximately 9-12 months of age. The testing for environmental allergens is one of the major criteria in the modified asthma predictive index (mAPI) and it would be helpful to determine his risk of developing asthma later in life.

Published: 11/12/2010
Updated: 12/10/2010

Food Allergy Management Guidelines by the NIH

The first Food Allergy Clinical Practice Guidelines were published in 2010 by the National Institute of Allergy and Infectious Disease (NIAID), part of the National Institutes of Health (NIH).

The free full text is available at JACI: Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel

The PDF summary is embedded below. A summary for patients is also available.



Related reading:

New Rules for Food Allergies - WSJ - Check the illustration showing what not to do vs. what to do: http://goo.gl/QNXZT
UK National Guidelines for Food Allergy, 2011 (PDF).

Japanese guideline for food allergy. Allergol Int. 2011 Mar;60(2):221-36.
Food allergy in children and young people - UK NICE guideline (PDF), 2012.

Question of the month: How to administer the flu vaccine to a patient allergic to eggs?

Option 1: For the patient who is six months of age or older and has known egg allergy of any severity, except severe anaphylaxis, administer under observation by an allergist a vaccine that contains ≤1 mcg ovalbumin per 0.5 mL as a single dose without prior vaccine skin testing.

Option 2: If a vaccine that contains ≤1 mcg ovalbumin per 0.5 mL dose is not available, or if the history of anaphylaxis was severe, administer the vaccine under observation by an allergist by a two-step protocol without prior vaccine skin testing (10% of the dose, observe for 30 minutes, then administer the remaining 90% of the dose, then observe for 30 minutes). Click here for references and more info.