Letters / Ann Allergy Asthma Immunol 114 (2015) 522e536 [9] Maarof G, Krzysiek R, Decline J, Cohen J, Habes D, Jacquemin E. Management of post-liver transplant-associated IgE mediated food allergy in children. J Allergy Clin Immunol. 2011;127:1296e1298.
533
[10] Sakaguchi M, Nakayama T, Inouye S. Food allergy to gelatin in children with systemic immediate-type reactions, including anaphylaxis, to vaccines. J Allergy Clin Immunol. 1996;98:1058e1061.
Black and Hispanic perceptions of asthma medication in the School Inner-City Asthma Study Racial and ethnic minorities suffer a disproportionate rate of asthma morbidity.1 We aimed to determine racial and ethnic differences in the perception of asthma medications of caregivers of black vs Hispanic school children enrolled in the School Inner-City Asthma Study. Furthermore, we investigated whether these beliefs were associated with asthma morbidity. The School Inner-City Asthma Study is a prospective, observational study of home and school environments related to asthma morbidity in inner-city school children.2 Questionnaires completed by caregivers of enrolled students with asthma elicited selfidentified race and ethnicity, perception of asthma control, attitudes toward asthma medications, and asthma symptoms. Analysis was limited to black and Hispanic subjects because fewer than 5% of participants were white. The study was approved by the Boston Children’s Hospital investigational review board. Subject assent and parental consent were obtained for all subjects before enrollment. Univariate analysis examined the associations of race and ethnicity on reported asthma control (4-week recall), belief that asthma medications can be effective, belief the child receives too much medication, worry about side effects, reports that medications “do not really work,” use of alternative remedies, and modification of drug therapy owing to these concerns. Multivariate models evaluated the perception of asthma control and medication attitudes with race if the univariate P value was less than or equal to .05 and adjusting for age, sex, and potential sociodemographic characteristics if associated with the outcome (P < .2) and confounding to the main effect. Quantitative assessment of asthma morbidity was measured as the maximum number of asthma symptom days,2 defined as the largest of the following variables in the 2 weeks before the baseline survey: (1) daytime wheezing, chest tightness, or cough; (2) days on which child had to slow down or discontinue play activities owing to wheezing, chest tightness, or cough; and (3) nights with wheezing, chest tightness, or cough leading to disturbed sleep. Associations between attitudes toward medication and asthma morbidity were tested by the Wilcoxon rank-sum test. Race was reported by 268 subjects: 15 (4%) white, 120 (34%) black, 133 (38%) Hispanic, and 83 (31%) mixed or other. The average age was 7.8 years, and 46% were girls. There was no Dr Gaffin and Mr Landrum contributed equally to this study. Disclosure: Authors have nothing to disclose. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, the National Center for Research Resources, or the National Institutes of Health Clinical Trial Service Unit Principal Investigator (Lee Nagler). Funding Sources: This study was supported by grants K23AI106945, R01 AI 073964, R01 AI 073964-02S1, K24 AI 106822, K23 AI104780, L40 AI107923, U01AI110397, and U10HL098102 from the National Institutes of Health. This work was conducted with support from Harvard Catalyst and The Harvard Clinical and Translational Science Center (National Institutes of Health award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers. This work also was supported in part by the American College of Allergy, Asthma, and Immunology Young Faculty Award and Respiratory Diseases Faculty Award; Boston Children’s Hospital Division of Immunology Clinical Research Advisory Group Research Grant; the American Lung Association; and the Deborah Munroe Noonan Memorial Award.
difference in perception of asthma control between blacks and Hispanics. However, caregivers of Hispanic children were 4.9 times as likely to report the child was on too much medication compared with caregivers of black children. Furthermore, Hispanic caregivers tended to be less confident medications could control the child’s asthma and were more likely to worry about side effects, report medications did not work, use alternative remedies, and cut back on asthma medications for these concerns (Table 1). After adjusting for age, sex, and caregiver education, Hispanics remained significantly more likely to believe the child was taking too much medication (odds ratio 4.9, 95% confidence interval 1.7e14.0, P ¼ .003). Negative perceptions of asthma medications were significantly associated with more asthma symptoms days. Report of “child gets too much medication” was associated with more asthma symptom days (median 4 days, interquartile range [IQR] 2,7, vs 1 day, IQR 0,3, P < .001), as were worry about side effects (median 3 days, IQR 0,5, vs 1 day, IQR 0,3, P ¼ .005) and believing the drugs were not effective (median 3 days, IQR 0,5, vs 1 day, IQR 0,3, P ¼ .007). There was no difference in asthma symptoms by alternative remedy use (median 2, IQR 0,4, vs 1, IQR 0,4, P ¼ .4). We found that caregivers of Hispanic children were almost 5 times as likely to be concerned their child took too much medicine and that medication concerns were strongly and consistently associated with poor asthma control. Although race, medication perception, and asthma control have been described separately, this study found the associations of Hispanic ethnicity, negative medication beliefs, and increased asthma symptoms within the same carefully studied cohort of inner-city school children with asthma. Our findings are consistent with prior studies reporting lower expectations and greater worry about minority children’s asthma,3 particularly Hispanic caregivers’ heightened concern over medication use.3 Hispanic ethnicity was associated with the belief that the child receives too much medication independent of caregiver education, income, or Medicaid status, suggesting racial and ethnic identification is the key influence on attitudes. These findings support that underuse of controller medication by minority populations is independent of sociodemographic factors.4,5 Medication concerns could be a key modifiable risk factor for suboptimal controller medication use6 because they directly influence adherence7 and could be the target of counseling interventions to improve outcomes. In addition, we found that negative beliefs linked to medication were associated with poor asthma control. Parental concern over medications can lead to poor adherence8 and thereby control,9 although similar findings have been found independent of adherence.10 In this context, the causal relation might be bidirectionaldparents of symptomatic children might have less confidence in the benefit-to-risk ratio of prescribed medications. This bears further investigation. Despite standardization of asthma care and efforts to improve minority access to health care, racial, ethnic, and cultural disparities in asthma persist.1 The present findings highlight the racial and ethnic differences in the perception of asthma medication and the effect of negative medication perceptions on asthma control.
534
Letters / Ann Allergy Asthma Immunol 114 (2015) 522e536
Table 1 Racial and ethnic differences in caregiver perception of asthma and asthma medications Caregiver-reported perception of asthma medications
Hispanic, % (n)
Black, % (n)
OR
95% CI
P valuea
Rates asthma as well controlled Believes asthma drugs can be effective Believes child receives too much medicine Worries about side effects Of those, cut back on the medicine because of concern of side effects Believes the medicine does not work Of those, stopped giving the medicine because they believed the medicine was not working Used alternative therapies during past 3 mo Of those, used alternative therapies instead of prescribed medicine
73 89 17 26 53 22 25
76 95 5 18 43 16 18
0.9 0.5 4.1 1.6 1.5 1.5 1.5
0.5e1.6 0.1e1.3 1.4e14.7 0.8e3.2 0.4e5.1 0.7e3.2 0.3e11.2
.7 .2 .005 .1 .6 .3 .7
1.7 1.5
0.8e3.6 0.3e8.2
.1 .7
(94) (106) (20) (34) (19) (25) (6)
21 (28) 33 (9)
(91) (108) (5) (21) (9) (17) (3)
13 (16) 25 (4)
Abbreviations: CI, confidence interval; OR, odds ratio. a By Fisher exact test.
Jonathan M. Gaffin, MD, MMSc*,y Aaron Landrum, BAz Carter R. Petty, MAx Sachin Baxi, MD*,z William J. Sheehan, MD*,z Wanda Phipatanakul, MD*,z *Harvard Medical School y Division of Respiratory Diseases z Division of Allergy and Immunology x Clinical Research Center Boston Children’s Hospital Boston, Massachusetts [email protected]
References [1] Moorman JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States, 2001e2010. Vital Health Stat 3. 2012;35:1e67.
[2] Phipatanakul W, Bailey A, Hoffman EB, et al. The school inner-city asthma study: design, methods, and lessons learned. J Asthma. 2011;48: 1007e1014. [3] Wu AC, Smith L, Bokhour B, Hohman KH, Lieu TA. Racial/ethnic variation in parent perceptions of asthma. Ambul Pediatr. 2008;8:89e97. [4] Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics. 2002;109:857e865. [5] Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156:562e567. [6] Smith LA, Bokhour B, Hohman KH, et al. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics. 2008;122:760e769. [7] McQuaid EL, Everhart RS, Seifer R, et al. Medication adherence among Latino and non-Latino white children with asthma. Pediatrics. 2012;129:e1404ee1410. [8] Conn KM, Halterman JS, Fisher SG, Yoos HL, Chin NP, Szilagyi PG. Parental beliefs about medications and medication adherence among urban children with asthma. Ambul Pediatr. 2005;5:306e310. [9] Warman KL, Silver EJ, Stein RE. Asthma symptoms, morbidity, and antiinflammatory use in inner-city children. Pediatrics. 2001;108:277e282. [10] Koster ES, Wijga AH, Koppelman GH, et al. Uncontrolled asthma at age 8: the importance of parental perception towards medication. Pediatr Allergy Immunol. 2011;22:462e468.
Utility of delayed reading of intradermal test in carboplatin-induced drug hypersensitivity Delayed-onset reactions (>1e2 hours) to platinum drugs have been described1,2 when a noneIgE-mediated hypersensitivity is suspected.3 Delayed reading of skin prick tests (SPTs) has been well validated for non-immediate drug allergy.4 Nevertheless, the use of delayed SPT reading for platinum is controversial.5 We describe a case of a delayed hypersensitivity reaction in which a delayed SPT reading was used to diagnose the culprit drug and predict tolerance to an alternative drug. The patient was a 63-year-old woman diagnosed with stage IIIC papillary serous ovarian carcinoma with peritoneal involvement that was treated with neoadjuvant chemotherapy consisting of weekly doses of carboplatin and paclitaxel and a biweekly dose of bevacizumab. A totally implantable device (Port-A-Cath, Smiths Medical, London, United Kingdom) was placed without complications in the right subclavian vein immediately before the second day of chemotherapy. Four hours after completion of the third dose of chemotherapy with paclitaxel, carboplatin, and bevacizumab through the Port-A-Cath, she presented with fever (38.5 C), facial rash, and selflimited diarrhea without pathologic products. Blood cultures were performed through a peripheral vein, and empiric treatment with oral ciprofloxacin and amoxicillin plus clavulanic acid was started and maintained for a week for suspected infection. The patient was asymptomatic 24 hours later and blood culture findings were negative. One hour after the administration of paclitaxel followed by carboplatin in the fourth dose of treatment, the patient presented with Disclosure: Authors have nothing to disclose.
chills, vomiting, a maculopapular rash on the face and extremities, high fever (39.2 C), tachycardia, and hypotension. Normal leukocytes (4,650 cells/mL) without eosinophilia (10 cells/mL), elevation of C-reactive protein (9.06 mg/dL, normal value [NV] 0e0.5 mg/dL), and mild hyper-transaminasemia (aspartate aminotransferase 35 IU/L, NV 1e31 IU/L; alanine transaminase 55 IU/L, NV 0e33 IU/L) without cholestasis (alkaline phosphatase 24 IU/L, NV 35e105 IU/L; g-glutamyl transpeptidase 69 IU/L, NV 0e40 IU/L; total and direct bilirubin 0.37 and 0.16 mg/dL) were observed. A catheter-related bloodstream infection was suspected and paired blood samples were drawn from the catheter and a peripheral vein and cultured before initiation of antimicrobial therapy with vancomycin systemic and lock therapies. All blood culture results were negative. The patient completed 3 days of vancomycin systemic therapy and 10 days of vancomycin lock therapy. Blood cultures taken through the Port-A-Cath 72 hours after the end of treatment also showed negative findings. Three hours after the fifth dose administered through a peripheral vein, the patient presented with nausea, facial rash, and fever (38.8 C). Blood test results showed mild leukopenia (3,330 cells/mL) without eosinophilia (10 cells/mL), mild elevation of C-reactive protein (1.52 mg/dL), hyper-transaminasemia (aspartate aminotransferase 645 IU/L, alanine transaminase 616 IU/L), and cholestasis (alkaline phosphatase 247 IU/L, g-glutamyl transpeptidase 669 IU/L, total and direct bilirubin 1.26 and 1.03 mg/dL). Endocarditis and liver involvement owing to oncologic disease were ruled out by ultrasound scans. An enzyme-linked immunosorbent assay result for
533
[10] Sakaguchi M, Nakayama T, Inouye S. Food allergy to gelatin in children with systemic immediate-type reactions, including anaphylaxis, to vaccines. J Allergy Clin Immunol. 1996;98:1058e1061.
Black and Hispanic perceptions of asthma medication in the School Inner-City Asthma Study Racial and ethnic minorities suffer a disproportionate rate of asthma morbidity.1 We aimed to determine racial and ethnic differences in the perception of asthma medications of caregivers of black vs Hispanic school children enrolled in the School Inner-City Asthma Study. Furthermore, we investigated whether these beliefs were associated with asthma morbidity. The School Inner-City Asthma Study is a prospective, observational study of home and school environments related to asthma morbidity in inner-city school children.2 Questionnaires completed by caregivers of enrolled students with asthma elicited selfidentified race and ethnicity, perception of asthma control, attitudes toward asthma medications, and asthma symptoms. Analysis was limited to black and Hispanic subjects because fewer than 5% of participants were white. The study was approved by the Boston Children’s Hospital investigational review board. Subject assent and parental consent were obtained for all subjects before enrollment. Univariate analysis examined the associations of race and ethnicity on reported asthma control (4-week recall), belief that asthma medications can be effective, belief the child receives too much medication, worry about side effects, reports that medications “do not really work,” use of alternative remedies, and modification of drug therapy owing to these concerns. Multivariate models evaluated the perception of asthma control and medication attitudes with race if the univariate P value was less than or equal to .05 and adjusting for age, sex, and potential sociodemographic characteristics if associated with the outcome (P < .2) and confounding to the main effect. Quantitative assessment of asthma morbidity was measured as the maximum number of asthma symptom days,2 defined as the largest of the following variables in the 2 weeks before the baseline survey: (1) daytime wheezing, chest tightness, or cough; (2) days on which child had to slow down or discontinue play activities owing to wheezing, chest tightness, or cough; and (3) nights with wheezing, chest tightness, or cough leading to disturbed sleep. Associations between attitudes toward medication and asthma morbidity were tested by the Wilcoxon rank-sum test. Race was reported by 268 subjects: 15 (4%) white, 120 (34%) black, 133 (38%) Hispanic, and 83 (31%) mixed or other. The average age was 7.8 years, and 46% were girls. There was no Dr Gaffin and Mr Landrum contributed equally to this study. Disclosure: Authors have nothing to disclose. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University and its affiliated academic health care centers, the National Center for Research Resources, or the National Institutes of Health Clinical Trial Service Unit Principal Investigator (Lee Nagler). Funding Sources: This study was supported by grants K23AI106945, R01 AI 073964, R01 AI 073964-02S1, K24 AI 106822, K23 AI104780, L40 AI107923, U01AI110397, and U10HL098102 from the National Institutes of Health. This work was conducted with support from Harvard Catalyst and The Harvard Clinical and Translational Science Center (National Institutes of Health award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers. This work also was supported in part by the American College of Allergy, Asthma, and Immunology Young Faculty Award and Respiratory Diseases Faculty Award; Boston Children’s Hospital Division of Immunology Clinical Research Advisory Group Research Grant; the American Lung Association; and the Deborah Munroe Noonan Memorial Award.
difference in perception of asthma control between blacks and Hispanics. However, caregivers of Hispanic children were 4.9 times as likely to report the child was on too much medication compared with caregivers of black children. Furthermore, Hispanic caregivers tended to be less confident medications could control the child’s asthma and were more likely to worry about side effects, report medications did not work, use alternative remedies, and cut back on asthma medications for these concerns (Table 1). After adjusting for age, sex, and caregiver education, Hispanics remained significantly more likely to believe the child was taking too much medication (odds ratio 4.9, 95% confidence interval 1.7e14.0, P ¼ .003). Negative perceptions of asthma medications were significantly associated with more asthma symptoms days. Report of “child gets too much medication” was associated with more asthma symptom days (median 4 days, interquartile range [IQR] 2,7, vs 1 day, IQR 0,3, P < .001), as were worry about side effects (median 3 days, IQR 0,5, vs 1 day, IQR 0,3, P ¼ .005) and believing the drugs were not effective (median 3 days, IQR 0,5, vs 1 day, IQR 0,3, P ¼ .007). There was no difference in asthma symptoms by alternative remedy use (median 2, IQR 0,4, vs 1, IQR 0,4, P ¼ .4). We found that caregivers of Hispanic children were almost 5 times as likely to be concerned their child took too much medicine and that medication concerns were strongly and consistently associated with poor asthma control. Although race, medication perception, and asthma control have been described separately, this study found the associations of Hispanic ethnicity, negative medication beliefs, and increased asthma symptoms within the same carefully studied cohort of inner-city school children with asthma. Our findings are consistent with prior studies reporting lower expectations and greater worry about minority children’s asthma,3 particularly Hispanic caregivers’ heightened concern over medication use.3 Hispanic ethnicity was associated with the belief that the child receives too much medication independent of caregiver education, income, or Medicaid status, suggesting racial and ethnic identification is the key influence on attitudes. These findings support that underuse of controller medication by minority populations is independent of sociodemographic factors.4,5 Medication concerns could be a key modifiable risk factor for suboptimal controller medication use6 because they directly influence adherence7 and could be the target of counseling interventions to improve outcomes. In addition, we found that negative beliefs linked to medication were associated with poor asthma control. Parental concern over medications can lead to poor adherence8 and thereby control,9 although similar findings have been found independent of adherence.10 In this context, the causal relation might be bidirectionaldparents of symptomatic children might have less confidence in the benefit-to-risk ratio of prescribed medications. This bears further investigation. Despite standardization of asthma care and efforts to improve minority access to health care, racial, ethnic, and cultural disparities in asthma persist.1 The present findings highlight the racial and ethnic differences in the perception of asthma medication and the effect of negative medication perceptions on asthma control.
534
Letters / Ann Allergy Asthma Immunol 114 (2015) 522e536
Table 1 Racial and ethnic differences in caregiver perception of asthma and asthma medications Caregiver-reported perception of asthma medications
Hispanic, % (n)
Black, % (n)
OR
95% CI
P valuea
Rates asthma as well controlled Believes asthma drugs can be effective Believes child receives too much medicine Worries about side effects Of those, cut back on the medicine because of concern of side effects Believes the medicine does not work Of those, stopped giving the medicine because they believed the medicine was not working Used alternative therapies during past 3 mo Of those, used alternative therapies instead of prescribed medicine
73 89 17 26 53 22 25
76 95 5 18 43 16 18
0.9 0.5 4.1 1.6 1.5 1.5 1.5
0.5e1.6 0.1e1.3 1.4e14.7 0.8e3.2 0.4e5.1 0.7e3.2 0.3e11.2
.7 .2 .005 .1 .6 .3 .7
1.7 1.5
0.8e3.6 0.3e8.2
.1 .7
(94) (106) (20) (34) (19) (25) (6)
21 (28) 33 (9)
(91) (108) (5) (21) (9) (17) (3)
13 (16) 25 (4)
Abbreviations: CI, confidence interval; OR, odds ratio. a By Fisher exact test.
Jonathan M. Gaffin, MD, MMSc*,y Aaron Landrum, BAz Carter R. Petty, MAx Sachin Baxi, MD*,z William J. Sheehan, MD*,z Wanda Phipatanakul, MD*,z *Harvard Medical School y Division of Respiratory Diseases z Division of Allergy and Immunology x Clinical Research Center Boston Children’s Hospital Boston, Massachusetts [email protected]
References [1] Moorman JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States, 2001e2010. Vital Health Stat 3. 2012;35:1e67.
[2] Phipatanakul W, Bailey A, Hoffman EB, et al. The school inner-city asthma study: design, methods, and lessons learned. J Asthma. 2011;48: 1007e1014. [3] Wu AC, Smith L, Bokhour B, Hohman KH, Lieu TA. Racial/ethnic variation in parent perceptions of asthma. Ambul Pediatr. 2008;8:89e97. [4] Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. Pediatrics. 2002;109:857e865. [5] Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156:562e567. [6] Smith LA, Bokhour B, Hohman KH, et al. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma. Pediatrics. 2008;122:760e769. [7] McQuaid EL, Everhart RS, Seifer R, et al. Medication adherence among Latino and non-Latino white children with asthma. Pediatrics. 2012;129:e1404ee1410. [8] Conn KM, Halterman JS, Fisher SG, Yoos HL, Chin NP, Szilagyi PG. Parental beliefs about medications and medication adherence among urban children with asthma. Ambul Pediatr. 2005;5:306e310. [9] Warman KL, Silver EJ, Stein RE. Asthma symptoms, morbidity, and antiinflammatory use in inner-city children. Pediatrics. 2001;108:277e282. [10] Koster ES, Wijga AH, Koppelman GH, et al. Uncontrolled asthma at age 8: the importance of parental perception towards medication. Pediatr Allergy Immunol. 2011;22:462e468.
Utility of delayed reading of intradermal test in carboplatin-induced drug hypersensitivity Delayed-onset reactions (>1e2 hours) to platinum drugs have been described1,2 when a noneIgE-mediated hypersensitivity is suspected.3 Delayed reading of skin prick tests (SPTs) has been well validated for non-immediate drug allergy.4 Nevertheless, the use of delayed SPT reading for platinum is controversial.5 We describe a case of a delayed hypersensitivity reaction in which a delayed SPT reading was used to diagnose the culprit drug and predict tolerance to an alternative drug. The patient was a 63-year-old woman diagnosed with stage IIIC papillary serous ovarian carcinoma with peritoneal involvement that was treated with neoadjuvant chemotherapy consisting of weekly doses of carboplatin and paclitaxel and a biweekly dose of bevacizumab. A totally implantable device (Port-A-Cath, Smiths Medical, London, United Kingdom) was placed without complications in the right subclavian vein immediately before the second day of chemotherapy. Four hours after completion of the third dose of chemotherapy with paclitaxel, carboplatin, and bevacizumab through the Port-A-Cath, she presented with fever (38.5 C), facial rash, and selflimited diarrhea without pathologic products. Blood cultures were performed through a peripheral vein, and empiric treatment with oral ciprofloxacin and amoxicillin plus clavulanic acid was started and maintained for a week for suspected infection. The patient was asymptomatic 24 hours later and blood culture findings were negative. One hour after the administration of paclitaxel followed by carboplatin in the fourth dose of treatment, the patient presented with Disclosure: Authors have nothing to disclose.
chills, vomiting, a maculopapular rash on the face and extremities, high fever (39.2 C), tachycardia, and hypotension. Normal leukocytes (4,650 cells/mL) without eosinophilia (10 cells/mL), elevation of C-reactive protein (9.06 mg/dL, normal value [NV] 0e0.5 mg/dL), and mild hyper-transaminasemia (aspartate aminotransferase 35 IU/L, NV 1e31 IU/L; alanine transaminase 55 IU/L, NV 0e33 IU/L) without cholestasis (alkaline phosphatase 24 IU/L, NV 35e105 IU/L; g-glutamyl transpeptidase 69 IU/L, NV 0e40 IU/L; total and direct bilirubin 0.37 and 0.16 mg/dL) were observed. A catheter-related bloodstream infection was suspected and paired blood samples were drawn from the catheter and a peripheral vein and cultured before initiation of antimicrobial therapy with vancomycin systemic and lock therapies. All blood culture results were negative. The patient completed 3 days of vancomycin systemic therapy and 10 days of vancomycin lock therapy. Blood cultures taken through the Port-A-Cath 72 hours after the end of treatment also showed negative findings. Three hours after the fifth dose administered through a peripheral vein, the patient presented with nausea, facial rash, and fever (38.8 C). Blood test results showed mild leukopenia (3,330 cells/mL) without eosinophilia (10 cells/mL), mild elevation of C-reactive protein (1.52 mg/dL), hyper-transaminasemia (aspartate aminotransferase 645 IU/L, alanine transaminase 616 IU/L), and cholestasis (alkaline phosphatase 247 IU/L, g-glutamyl transpeptidase 669 IU/L, total and direct bilirubin 1.26 and 1.03 mg/dL). Endocarditis and liver involvement owing to oncologic disease were ruled out by ultrasound scans. An enzyme-linked immunosorbent assay result for
