Anaphylaxis to both pegfilgrastim and sargramostim in a patient with diffuse large B-cell lymphoma

A woman in her early 60s with stage 3A diffuse large B-cell lymphoma developed anaphylaxis to pegfilgrastim after her first cycle of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) chemotherapy, presenting with syncope, severe diarrhoea and persistent hypotension requiring hospitalisation. Three further cycles were given without growth factor support. After cycle four she developed neutropenic fever and received sargramostim (granulocyte-macrophage colony-stimulating factor) under intensive premedication and intensive care monitoring, which she initially tolerated; on the third administration she developed anaphylaxis requiring epinephrine. She completed all six cycles of R-CHOP without growth factor support, using prophylactic antibiotics and close monitoring, achieved complete remission and remains disease-free 41 months after treatment. To our knowledge, this is the second documented case of anaphylaxis to agents from both the granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor classes in one patient, and the first involving pegfilgrastim.