Concern for amoxicillin allergy

Patient is 8-year-old girl who states that approximately on May 5, 2016, she developed hives reaction. She did have a surgery tonsillectomy and adenoidectomy on April 27 and was resolving from that. She was taking amoxicillin and codeine at that time and developed these hives reactions. She did go to the ER for this. They gave her Benadryl and steroids at the hospital and they did slowly resolve, however, she had to continue taking Atarax daily or every three hours 7.5 mL to completely control her hives. She did this for about one week. She stopped on Saturday and has not had a recurrence of hives since then. She did also have another episode of hives in June 2014. She is at Settler Park all day swimming and when she got home she developed the hives reaction. They took her to the ER then and swabbed her for a strep culture and it was positive. Though it did take about six days to resolve as well, but then did not recur until this last experience.

She also complains of some nasal congestion, mouth breathing, sore throat, snoring, decreased smell, however, the thing that seems to be too serious or causing significant sinus trouble with any seasonal variation. She denies sinus infection, nasal polyps, TMJ, or frequent headaches. She does have frequent tonsillitis and therefore instituted tonsillectomy and adenoidectomy. She has missed 28 days of school this year due to this. It can be associated with air infections, but she has never needed to have ear tubes placed. They deny dizziness, lightheadedness, or hearing impairment.

She does have some eye redness and tearing usually when she has an infection. They deny ever having any itching, dryness, burning, light hurting her eyes, yellow discharge from eyes, eyelid swelling, or eyelid irritation.

She denies any history of wheezing or lung troubles. Mom states that she does state that she gets short of breath and lungs hurt after exercise occasionally, but they have not tried any albuterol inhalers or noticed any other wheezing events or need for albuterol nebulization.

She denies a history of allergic skin problems such as eczema. She never was evaluated for allergies before.

ASSESSMENT:
1. Acute idiopathic urticaria most likely etiology viral induced.
2. Concern for amoxicillin allergy.
3. Status post tonsillectomy and adenoidectomy.
4. Possible allergic rhinitis.
5. Possible allergic conjunctivitis.

PLAN:
1. At this time, I talked to patient that she is exhibiting any seasonal allergies today. She has very minimal symptoms currently and I do not believe that these allergies have triggered any hives reactions currently. I do feel that due to the tonsillectomy, she may have had immunosuppression at that time and that is most likely what developed hives reaction. Prior to that it was strep infection that may have caused immunosuppression and hives reaction. We do not think it is an amoxicillin allergy at this time. She has tolerated amoxicillin very well in the past without any troubles. We can always try an oral challenge in the office if they want to see if it is instituting amoxicillin.
2. We will continue with Atarax as she has any more hives outbreaks. We will see if this has runs its course and she may not need anymore. If she does have recurrence and mom has a hard time controlling it, then she will contact me and let me know.
3. I did also do a blood work for immunodeficiency to rule this out because of her frequent infections. We will do a CBC, CMP, ESR, CRP, ANA, quantitative immunoglobulins, anti-diphtheria titer, anti-tetanus titer, and anti-pneumococcal titer. This will also help me evaluate if there is any underlying internal factors to these hives including autoimmune disorder. We will follow up with her as needed. If she continues to have troubles, then I will contact her with results of lab work.

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