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RATIONALE: Immediate hypersensitivity reactions (HSR) are commonly encountered during infusion of chemotherapy, especially with platinum agents suchas oxaliplatin. The literature contains reports of4 patients who developed reactions during, or up to 24 hours after oxaliplatin infusion, with fever being a predominant symptom. Since fever is not an expected feature of an immediate HSR, the term idiosyncratic has been used to describe these reactions. While rapid drug desensitization has been shown effective in allowing infusion of drugs despite a history of immediate HSR, there are no reports indicating whether rapid drug desensitization is helpful is the management of febrile idiosyncratic reactions to oxaliplatin. METHODS: We report two patients with a history of immediate HSR to oxaliplatin, referred for rapid drug desensitization. During or within 1 hour after rapid drug desensitization with oxaliplatin, both patients developed signs and symptoms similar to previously reported cases of febrile idiosyncratic reactions to oxaliplatin, with maximum temperatures of 101.8 and 103.0 respectively. Both patients were hospitalized for several days, during which infection was ruled out. RESULTS: Rapid drug desensitization did not prevent febrile idiosyncratic reactions to oxaliplatin. CONCLUSION: The optimal management of patients with febrile idiosyncratic reactions to oxaliplatin remains unclear

Case Presentation: A 39-year-old African American woman presented with nausea, postprandial emesis, early satiety, abdominal distension/pain for 1 week, and 2 days of hematemesis. Physical exam revealed a diffusely distended, tender abdomen and a firm, immobile 8 x 12 cm abdominal mass in the left upper quadrant. A complete blood count was significant for a hemoglobin and hematocrit of 6.5 and 21.5, respectively. She was transfused 2 units of packed red blood cells. CT revealed gastric trichobezoars. On further questioning, she revealed a 28-year history of trichotillomania and trichophagia and reported consuming a quart-sized bag of hair daily that she obtained from barber shops. Esophagogastroduodenoscopy demonstrated 3 large trichobezoars within the stomach and a 1-cm nonbleeding ulcer on the greater curvature, without evidence of complete gastric outlet obstruction or Rapunzel syndrome (tracking beyond the pylorus). The trichobezoars were deemed too large to be removed endoscopically. She was started on Prozac 20 mg by mouth daily to decrease the compulsion to consume hair, Coca-Cola 300 mL 3 times a day to decrease the size of the trichobezoars in anticipation of surgical removal, and metoclopramide 10 mg by mouth twice a day. Psychiatric management was initiated. Discussion: Trichobezoars are accumulations of hair typically located in the stomach that may track beyond the pylorus into the small bowel. This finding is associated with the psychiatric disorders trichotillomania and trichophagia, which usually occur in young females. When not recognized early, trichobezoars may continue growing because of persistent hair consumption and cause gastric erosion, ulceration, or gastric outlet obstruction (Gorter RR, Kneepkens CMF, Mattens ECJL, Aronson DC, Heij HA. Management of trichobezoar: case report and literature review. Ped Surg Int. 2010;26:457-463). In this case, the significant size of this patient's trichobezoars resulted in partial pyloric obstruction, leading to gastrointestinal (GI) symptoms. We propose that the trichobezoars eroded the gastric mucosa causing ulceration. During 1 week of vomiting, the marked increase in intra-abdominal pressure was transmitted to the esophagus, which likely caused Mallory-Weiss syndrome, manifesting as hematemesis. The patient's malnutrition resulted in severe iron -deficiency anemia, which was exacerbated by hematemesis and gastric ulceration. Conclusions: Although a rare occurrence, trichobezoars must be considered in a differential diagnosis of a patient, especially in young females presenting with either an abdominal mass or nonspecific GI symptoms in the context of an upper GI bleed. We also highlight the importance of managing trichobezoars medically and with psychiatric counseling prior to surgical removal in order to alleviate GI symptoms and prevent reoccurrence. 1