Urticaria and Angioedema Secondary to Methylphenidate Exposure in a Young Child

[Author Affiliation]Rakesh Goyal. Institute of Living/Hartford Hospital, Hartford, Connecticut.Alejandra Arroyave. Institute of Living/Hartford Hospital, Hartford, Connecticut.Salma Malik. Institute of Living/Hartford Hospital, Hartford, Connecticut.Address correspondence to: Rakesh Goyal, MD, Institute of Living/Hartford Hospital, Braceland Building, 200 Retreat Ave. Hartford, CT 06106, E-mail: rakeshpsy@gmail.comTo the Editor:Allergic adverse reactions to methylphenidate are exceedingly rare, and even rarer with the oral formulation of methylphenidate. Few cases of contact dermatitis secondary to transdermal formulations of methylphenidate have been reported (Warshaw et al. 2010; Vashi et al. 2011). A PubMed search produced only a handful of reports (case reports) of allergic adverse reaction to oral methylphenidate (Weil 1968; Rothschild and Nicol 1972; Sverd et al. 1977; Cohen et al. 1992; Coskun et al. 2009; Heinzerling et al. 2011). We present a case involving hypersensitivity allergic adverse reaction to methylphenidate and dexmethylphenidate. Notably, our patient developed urticaria and angioedema secondary to methylphenidate and dexmethylphenidate, which has been reported only once before (Sverd et al. 1977).Case ReportA 6-year-old Hispanic boy came to our outpatient clinic with his mother with complaints of hyperactivity, poor attention, and disruptive behavior. His school also reported that he was having difficulty sitting at his desk when expected to, was disruptive to the whole class, and had poor attention. Past medical history was significant for severe eczema and current mild asthma. One first degree and four second degree relatives of the patient had allergic skin problems, including eczema. The patient was using an albuterol inhaler daily on an as-needed basis for asthma. His mother denied his having any known drug or food allergy. Results of laboratory tests including complete blood count, basic metabolic profile, and electrocardiogram (ECG) were within normal limits. The patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) combined type, and was prescribed methylphenidate 2.5 mg daily as a starting dose. Approximately 5 days after he started methylphenidate therapy, his mother noticed that there was swelling and redness in his left eyelid and all around his left eye (Fig. 1). He complained of discomfort over the same area and was constantly rubbing it with his hand, which led to mild erythema and watering from the eyes. There was no swelling or erythema of the conjunctiva. There was no involvement of the right eye or the rest of his face, but he itched all over his body. When examined, he also had a rash that was distributed over his trunk and both arms. His rash consisted of raised, edematous, circular-oval shaped lesions from 1 mm to 2 cm in size, which were highly pruritic (Fig. 2). Per the patient's mother, his body rash developed at approximately the same time as the swelling around the left eye. Swelling around the eye was nonpitting and nontender. He did not have any fever, difficulty in breathing, or dizziness. He was not taking any medications other than methylphenidate and the as-needed albuterol inhaler (which he had been taking for many months). There was no history of application of any medication to the eyes. Methylphenidate was immediately discontinued. The child was evaluated and was diagnosed to be having an allergic hypersensitivity reaction in the form of urticaria and angioedema, possibly caused by methylphenidate. He was treated with antihistaminic medications, and his symptoms fully subsided in next few days. One week later, after discussion with his mother, dexmethylphenidate was introduced at a dose of 2.5 mg daily. This time the patient again developed a similar adverse reaction, but it was in the other (right) eye and developed relatively quickly. Within 24 hours of taking the first dose of dexmethylphenidate, he developed swelling and redness of the right eyelid and around the right eye (Fig. …