title: Patch-testing for the management of hypersensitivity reactions to second-line anti-tuberculosis drugs: a case report.
abstract: BACKGROUND
  The second-line anti-tuberculosis drugs used in the treatment of multidrug-resistant tuberculosis often cause adverse events, especially in patients co-infected with the human immunodeficiency virus. Severe hypersensitivity reactions due to these drugs are rare and there is little published experience to guide their management.
  
  
  METHODS
  A 17-year old Indian female multidrug-resistant tuberculosis patient co-infected with human immunodeficiency virus developed a hypersensitivity reaction after starting second-line anti-tuberculosis treatment in Mumbai, India. The patient was being treated with kanamycin, moxifloxacin, para-aminosalicylic acid, cycloserine, clofazimine, and amoxicillin-clavulanic acid. Twenty-four hours later, the patient developed generalized urticaria, morbilliform rash and fever. All drugs were suspended and the patient was hospitalised for acute management. Skin patch-testing was used to identify drugs that potentially caused the hypersensitivity reaction; results showed a strong reaction to clofazimine, moderate reaction to kanamycin and mild reaction to cycloserine. An interim second-line anti-tuberculosis regimen was prescribed; cycloserine and kanamycin were then re-challenged one-by-one using incremental dosing, an approach that allowed clinicians to re-introduce these drugs promptly and safely. The patient is currently doing well.
  
  
  CONCLUSIONS
  This is the first case-report of a multidrug-resistant tuberculosis patient co-infected with the human immunodeficiency virus with hypersensitivity reaction to multiple second-line anti-tuberculosis drugs. Skin patch-testing and controlled re-challenge can be a useful management strategy in such patients. There is an urgent need for second-line anti-tuberculosis regimens that are more effective, safe and better tolerated.
authors.forename: Samsuddin
authors.initials: S
authors.lastname: Khan
authors.forename: Aristomo
authors.initials: A
authors.lastname: Andries
authors.forename: Asha
authors.initials: A
authors.lastname: Pherwani
authors.forename: Peter
authors.initials: P
authors.lastname: Saranchuk
authors.affiliation: Médecins Sans Frontières, Chandni Bungalow, Union Park, Off Carter Road, Khar (W), Mumbai 400 052, India. msfocb-asia-epidemio@brussels.msf.org.
authors.forename: Petros
authors.initials: P
authors.lastname: Isaakidis
mesh_terms: D000293:Adolescent; D023241:Antiretroviral Therapy, Highly Active; D000995:Antitubercular Agents / Q000009:adverse effects* / Q000627:therapeutic use*; D003523:Cycloserine / Q000627:therapeutic use; D004305:Dose-Response Relationship, Drug; D004342:Drug Hypersensitivity / Q000209:etiology*; D005260:Female; D006801:Humans; D007612:Kanamycin / Q000627:therapeutic use; D009894:Opportunistic Infections / Q000188:drug therapy / Q000517:prevention & control; D010328:Patch Tests; D014376:Tuberculosis / Q000188:drug therapy* / Q000517:prevention & control
chemical_list: D000995:Antitubercular Agents; D007612:Kanamycin; D003523:Cycloserine