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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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Making a Diagnosis in Allergic Reactions Occurring in the Operating Room. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gelincik A, Demir S. Hypersensitivity Reactions to Non-Beta Lactam Antibiotics. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ghrelin Expression in Mast Cells of Infant Lung with Respiratory Distress Syndrome. ACTA MEDICA BULGARICA 2021. [DOI: 10.2478/amb-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
This article sheds light on some features of ghrelin (GHR)- and tryptase (Try)-positive mast cells (MCs) distribution in human lung of preterm newborns with respiratory distress syndrome (RDS). GHR possessed anti-inflammatory activity and reliable therapeutic properties in some lung diseases. So far, GHR expression has been defined predominantly in neuroendocrine cells of bronchial mucosa in fetal and infant lungs. Lung tissue from 8 dead newborns with RDS were investigated immunohistochemically with anti-GHR and anti-Try antibodies. The number of GHR+ and Try+ MCs was determined in three locations –bronchi, bronchiole and in alveolar septa. MCs were more numerous around main bronchi with diminishing numbers around bronchiole and in alveolar septa. The number of MCs in the latter was increased in newborns with pneumonia. The number of GHR+ MCs in alveolar septa was lower in newborns with RDS as compared to newborns with RDS combined with pneumonia (2.83 ± 1.13 vs 4.81 ± 2.6, p < 0.001). The amount of Try+ MCs along bronchial wall was significantly more than GHR+ MCs in RDS newborns (6.97 ± 4.53 vs 3.85 ± 4.30, p = 0.001). It could be supposed that pulmonary MCs increased in newborn lungs in inflammatory process. MCs in human lung contained GHR peptide that had immunomodulatory function and participated in hormone regulation of inflammation.
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Recommendations for Diagnosing and Management of Patients with Perioperative Drug Reactions. CURRENT TREATMENT OPTIONS IN ALLERGY 2020. [DOI: 10.1007/s40521-020-00253-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Serum Tryptase Cannot Differentiate Vancomycin-Induced Anaphylaxis From Red Man Syndrome. J Clin Immunol 2019; 39:855-856. [DOI: 10.1007/s10875-019-00707-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
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Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: potential, limitations, and perspectives. Br J Anaesth 2019; 123:e117-e125. [DOI: 10.1016/j.bja.2019.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/25/2018] [Accepted: 01/03/2019] [Indexed: 12/28/2022] Open
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Pedersen AF, Green S, Rose MA. Failure to Investigate Anaesthetic Anaphylaxis Resulting in a Preventable Second Anaphylactic Reaction. Anaesth Intensive Care 2019. [DOI: 10.1177/0310057x1204000619] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A. F. Pedersen
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - S. Green
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - M. A. Rose
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales, Australia
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De Souza RL, Short T, Warman GR, Maclennan N, Young Y. Anaphylaxis with Associated Fibrinolysis, Reversed with Tranexamic Acid and Demonstrated by Thrombelastography. Anaesth Intensive Care 2019; 32:580-7. [PMID: 15675222 DOI: 10.1177/0310057x0403200419] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the surgical setting, fibrinolysis can be a serious complication of anaphylaxis. We present four cases of anaphylaxis that were associated with fibrinolysis during anaesthesia, and the use of the thrombelastograph to demonstrate this haemostatic defect and its correction using tranexamic acid.
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Affiliation(s)
- R L De Souza
- Anaesthetic Department, Auckland Hospital, Auckland, New Zealand
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11
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Abstract
Profound hypotension and cardiac arrest after commencement of combined spinal and general anaesthesia in a patient for knee replacement surgery raised the suspicion of anaphylaxis. This seemed to be confirmed when a mast cell tryptase test taken about 90 minutes after the onset of the hypotension was elevated. However, subsequent intradermal skin testing twelve weeks later did not identify a causal drug. Repeat mast cell tryptase at the time showed the same elevation, which led to the correct diagnosis of mastocytosis and a secondary diagnosis that the patient's hypotension and cardiac arrest were the result of her spinal anaesthesia. If the serum tryptase is elevated during the event but no allergic agent can be identified, a further serum tryptase should be taken several weeks later to exclude a persistent elevation due to mastocytosis.
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Affiliation(s)
- W J Russell
- Department of Anaesthesia, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
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Savic L, Savic S, Hopkins P. Sugammadex: the sting in the tail? Br J Anaesth 2018; 121:694-697. [DOI: 10.1016/j.bja.2018.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 12/20/2022] Open
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Sugammadex hypersensitivity and underlying mechanisms: a randomised study of healthy non-anaesthetised volunteers. Br J Anaesth 2018; 121:758-767. [PMID: 30236238 DOI: 10.1016/j.bja.2018.05.057] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 05/01/2018] [Accepted: 05/24/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We investigated potential for hypersensitivity reactions after repeated sugammadex administration and explored the mechanism of hypersensitivity. METHODS In this double-blind, placebo-controlled study (NCT00988065), 448 healthy volunteers were randomised to one of three arms to receive three repeat i.v. administrations of either sugammadex 4 mg kg-1, 16 mg kg-1, or placebo. Primary endpoint was percentage of subjects with hypersensitivity (assessed by an independent adjudication committee). Secondary endpoint of anaphylaxis was classified per Sampson and Brighton criteria. Exploratory endpoints included skin testing, serum tryptase, anti-sugammadex antibodies [immunoglobulin (Ig) E/IgG], and other immunologic parameters. RESULTS Hypersensitivity was adjudicated for 1/148 (0.7%), 7/150 (4.7%), and 0/150 (0.0%) subjects after sugammadex 4 mg kg-1, 16 mg kg-1, and placebo, respectively. After sugammadex 16 mg kg-1, one subject met Sampson criterion 1 and Brighton level 1 (highest certainty) anaphylaxis criteria; two met Brighton level 2 criteria. After database lock it was determined that certain protocol deviations could have introduced bias in the reporting of hypersensitivity signs/symptoms in a subject subset. Objective laboratory investigations indicated that potential underlying hypersensitivity mechanisms were unlikely to have been activated; the results suggest that most of the observed hypersensitivity reactions were unlikely IgE/IgG-mediated. CONCLUSION Dose-dependent hypersensitivity or anaphylaxis reactions to sugammadex were observed when administered without prior neuromuscular blocking agent. Laboratory investigations do not suggest prevalent allergen-specific IgE/IgG-mediated immunologic hypersensitivity. Because it could not be fully excluded that estimates of hypersensitivity/anaphylaxis incidence were unbiased, an additional study was conducted to characterise the potential for hypersensitivity reactions and is described in a companion report. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov NCT00988065; Protocol number P06042.
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Clement O, Dewachter P, Mouton-Faivre C, Nevoret C, Guilloux L, Bloch Morot E, Katsahian S, Laroche D, Audebert M, Benabes-Jezraoui B, Benoit Y, Beot S, Berard F, Berthezene Y, Bertrand P, Bouffard J, Bourrain JL, Boyer B, Carette MF, Caron-Poitreau C, Cavestri B, Cercueil JP, Charpin DA, Collet E, Crombe-Ternamian A, Dalmas J, Decoux E, Defrance MF, Delaval Y, Demoly P, Depriester C, Depriester P, Didier A, Drouet M, Dupas B, Dupre-Goetchebeur D, Dzviga C, Fabre C, Ferretti G, Fourre-Jullian C, Girardin P, Giron J, Gouitaa M, Grenier N, Guenard Bilbault L, Guez S, Gunera-Saad N, Heautot JF, Herbin D, Hoarau C, Jacquot C, Julien C, Laborie L, Lambert C, Larroche P, Leclerc X, Lemaitre L, Leynadier F, Lillo-Le-Louet A, Louvel JP, Louvier N, Lucas MM, Meites G, Mennesson N, Metge L, Meunier Y, Monnier-Cholley L, Musacchio M, Nicolie B, Occelli G, Oesterle H, Paisant-Thouveny F, Panuel M, Railhac N, Rety-Jacob F, Rochefort-Morel C, Roy C, Sarlieve P, Sesay M, Sgro C, Taourel P, Terrier P, Theissen O, Topenot I, Valfrey J, Veillon F, Vergnaud MC, Veyret C, Vincent D, Wallaert B, Wessel F, Zins M. Immediate Hypersensitivity to Contrast Agents: The French 5-year CIRTACI Study. EClinicalMedicine 2018; 1:51-61. [PMID: 31193689 PMCID: PMC6537532 DOI: 10.1016/j.eclinm.2018.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/28/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Iodinated and gadolinium-based contrast media (ICM; GBCM) induce immediate hypersensitivity (IH) reactions. Differentiating allergic from non-allergic IH is crucial; allergy contraindicates the culprit agent for life. We studied frequency of allergic IH among ICM or GBCM reactors. METHODS Patients were recruited in 31 hospitals between 2005 and 2009. Clinical symptoms, plasma histamine and tryptase concentrations and skin tests were recorded. Allergic IH was diagnosed by intradermal tests (IDT) with the culprit CM diluted 1:10, "potentially allergic" IH by positive IDT with pure CM, and non-allergic IH by negative IDT. FINDINGS Among 245 skin-tested patients (ICM = 209; GBCM = 36), allergic IH to ICM was identified in 41 (19.6%) and to GBCM in 10 (27.8%). Skin cross-reactivity was observed in 11 patients with ICM (26.8%) and 5 with GBCM (50%). Allergy frequency increased with clinical severity and histamine and tryptase concentrations (p < 0.0001). Cardiovascular signs were strongly associated with allergy. Non-allergic IH was observed in 152 patients (62%) (ICM:134; GBCM:18). Severity grade was lower (p < 0.0001) and reaction delay longer (11.6 vs 5.6 min; p < 0.001). Potentially allergic IH was diagnosed in 42 patients (17.1%) (ICM:34; GBCM:8). The delay, severity grade, and mediator release were intermediate between the two other groups. INTERPRETATION Allergic IH accounted for < 10% of cutaneous reactions, and > 50% of life-threatening ones. GBCM and ICM triggered comparable IH reactions in frequency and severity. Cross-reactivity was frequent, especially for GBCM. We propose considering skin testing with pure contrast agent, as it is more sensitive than the usual 1:10 dilution criteria.
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Affiliation(s)
- Olivier Clement
- Assistance Publique Hôpital Européen Georges Pompidou, Service de Radiologie 20 rue Leblanc Paris, FR 75015, France
- Inserm U970 Université Paris Descartes Sorbonne Paris Cité, Laboratoire Imagerie 56 rue Leblanc Paris, FR 75015, France
- Corresponding author at: Assistance Publique Hôpital Européen Georges Pompidou, Service de Radiologie 20 rue Leblanc Paris, FR 75015, France
| | - Pascale Dewachter
- Assistance Publique Groupe Hospitalier de Paris-Seine Saint Denis, Université Paris Descartes Sorbonne Paris Cité, Anesthésie-Réanimation Chirurgicale, Bondy, FR 93140, France
| | - Claudie Mouton-Faivre
- CHU Nancy-Brabois, Bâtiment Philippe Canton Rue du Morvan, Vandoeuvre-lès-Nancy, FR 54511, France
| | - Camille Nevoret
- Hôpital Européen Georges Pompidou, Unité d'épidémiologie et de recherche clinique Paris, FR 75015, France
| | - Laurence Guilloux
- Laboratoire Biomnis, Immuno Allergologie, 17/19 avenue Tony Garnier Lyon, FR 69357, France
| | - Evelyne Bloch Morot
- Assistance Publique Hôpital Européen Georges Pompidou, Médecine Interne Allergologie Paris, FR 75015, France
| | - Sandrine Katsahian
- Assistance Publique Hôpital Européen Georges Pompidou, Unité d'épidémiologie et de recherche clinique Paris, FR 75015, France
| | - Dominique Laroche
- Centre Hospitalier Universitaire de Caen, Laboratoire d'Hormonologie Caen cedex 9, FR 14033, France
- Université de Caen Basse-Normandie, UFR de Médecine Caen, FR 14000, France
| | | | | | | | - Yves Benoit
- Unité d'Allergologie-Anesthésie, Hôpital Edouard Herriot, Place d'Arsonval, 69437 Lyon Cedex 03, France
| | - Sylvie Beot
- Service de Radiologie, CHU Brabois, Rue du Morvan, 54511 Vandoeuvre-lès-Nancy, France
| | - Frédéric Berard
- Service d'Immunologie clinique et Allergologie, Pavillon 5 F, Centre Hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Benite Cedex, France
| | - Yves Berthezene
- Service d'Imagerie Médicale, Hôpital de la Croix Rousse, 103 Grande Rue de la Croix Rousse, 69317 Lyon Cedex 04, France
| | - Philippe Bertrand
- Service de Radiologie, CHU de Tours, Hôpital Bretonneau, 2 Boulevard Tonnelé, 37044 Tours Cedex, France
| | - Juliette Bouffard
- Service de Radiologie et Imagerie Médicale, Pavillon 3 B, Centre Hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre Benite Cedex, France
| | - Jean-Luc Bourrain
- Département pluridisciplinaire de médecine, Service de Dermatologie, CHU de Grenoble, BP 217, 38043 Grenoble Cedex 09, France
| | - Bruno Boyer
- Service de Radiologie, Centre Alexis Vautrin, 6 avenue de Bourgogne, 54 511 Vandoeuvre cedex, France
| | - Marie-France Carette
- Centre d’Allergologie, Hôpital TENON, 4 rue de la Chine, 75970 Paris Cedex 20, France
| | - Christine Caron-Poitreau
- CHRU Angers, Hôpital Hôtel Dieu, Service de Radiologie, 4 rue Larrey, 49933 Angers Cedex 09, France
| | - Béatrice Cavestri
- Service de Pneumologie du Pr André-Bernard Tonnel, Hôpital Calmette, Boulevard du Professeur Leclerc, 59037 Lille cedex, France
| | - Jean Pierre Cercueil
- Service de Radiologie, CHU de Dijon, Hôpital du Bocage, 2 Bd Mal de Lattre de Tassigny, BP 77908, 21034 Dijon Cedex, France
| | - Denis-André Charpin
- Service de Pneumologie- Allergologie, Hôpital Nord, Chemin des Bourrelys, 13915 Marseille Cedex 20, France
| | - Evelyne Collet
- Service de Dermatologie, CHU de Dijon, Hôpital du Bocage, 2 Bd Mal de Lattre de Tassigny, 21034 Dijon Cedex, France
| | - Arielle Crombe-Ternamian
- Service de Radiologie digestive, Pavillon H, Hôpital Edouard Herriot, Place d'Arsonval, 69437 Lyon Cedex 03, France
| | - Jacques Dalmas
- Service d'Imagerie Médicale, Centre Hospitalier de Martigues, 3 bd des Rayettes, BP 50248, 13698 Martigues Cedex, France
| | - Eric Decoux
- Service de Radiologie, Hôpital Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Marie-France Defrance
- Service de Médecine Interne, Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75674 Paris Cedex 14, France
| | - Yvonne Delaval
- Service de Pneumologie, Consultation d'Allergolo-Anesthésie, CHU Pontchaillou, Rue H. Le Guilloux, 35033 Rennes Cedex 09, France
| | - Pascal Demoly
- Service d'Allergologie, CHU de Montpellier, Hôpital Arnaud de Villeneuve, 371 Av Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Claude Depriester
- Service d'Imagerie Médicale, Polyclinique du Bois, 44 avenue Marx Dormoy, 59000 Lille, France
| | | | - Alain Didier
- Service de Pneumologie, CHU de Toulouse, Hôpital Larrey, 24 chemin de Pouvourville, 31059 Toulouse Cedex 9, France
| | - Martine Drouet
- CHRU Angers, Hôpital Hôtel Dieu, Laboratoire d'Allergologie, 4 rue Larrey, 49933 Angers Cedex 09, France
| | - Benoît Dupas
- Service de Radiologie, CHU de Nantes, Hôpital Hôtel Dieu, Place Alexis Ricordeau, 44093 Nantes Cedex 01, France
| | | | - Charles Dzviga
- Service de Radiologie, CHU de Saint-Etienne, Hôpital Nord, Avenue Albert Raymond, 42055 Saint Etienne Cedex 2, France
| | - Christine Fabre
- Service de Pneumologie, Groupe Hospitalo-Universitaire Caremeau, Place du Pr Robert Debré, 30029 Nîmes Cedex 9, France
| | - Gilbert Ferretti
- Service Central de Radiologie et d' Imagerie Médicale, CHU Grenoble, BP 217, 38043 Grenoble Cedex 09, France
| | - Corinne Fourre-Jullian
- Service de Pneumo-allergologie, Centre Hospitalier de Martigues, 3 bd des Rayettes, BP 248, 13698 Martigues Cedex, France
| | - Pascal Girardin
- Service de Dermatologie II, Hôpital Saint-Jacques, 2 Place Saint-Jacques, 25030 Besancon Cedex, France
| | - Jacques Giron
- Service Centrale d'Imagerie médicale, CHU de Toulouse, Hôpital Purpan, Place du Dr Baylac, 31059 Toulouse Cedex 9, France
| | - Marion Gouitaa
- Service de Pneumologie- Allergologie, Hôpital Nord, Chemin des Bourrelys, 13915 Marseille Cedex 20, France
| | - Nicolas Grenier
- Service de Radiologie B, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
| | - Lydie Guenard Bilbault
- Service Immuno-Allergologie, Hôpital Central, 29, avenue Maréchal de Lattre de Tassigny, 54035 Nancy Cedex, France
| | - Stéphane Guez
- Unité des Maladies Allergiques, Groupe Hospitalier Pellegrin, Bâtiment PQR, Place Amélie Raba-Léon, 33076 Bordeaux Cedex, France
| | | | - Jean-François Heautot
- Service de Radiologie, CHU Pontchaillou, 2 rue Henri Le Guilloux, 35033 Rennes Cedex, France
| | - Dominique Herbin
- Service de Pneumologie, Centre hospitalier Louis Pasteur, 46, rue du val de saire, 50102 Cherbourg Cedex, France
| | - Cyrille Hoarau
- Service d'Immunologie Clinique et Néphrologie, CHRU de Tours, Hôpital Bretonneau, 2 Boulevard Tonnelé, 37 044 Tours Cedex, France
| | - Claude Jacquot
- Département d'Anesthésie Réanimation 1, CHU de Grenoble, Hôpital A.Michallon, BP 127, 38043 Grenoble Cedex 09, France
| | - Christian Julien
- Service d'imagerie médicale, Centre hospitalier Louis Pasteur, 46, rue du val de saire, 50 102 Cherbourg Cedex, France
| | - Laurent Laborie
- Service de Radiologie A, CHRU Jean Minjoz, 22, Bd A. Flemming, 25030 Besancon Cedex, France
| | - Claude Lambert
- Laboratoire Immunologie, Pavillon 5 bis, CHU de Saint-Etienne, Hôpital Bellevue, 42055 Saint Etienne Cedex 2, France
| | - Pascal Larroche
- Service de Radiologie, Hôpital de la Cavale blanche, Boulevard Tanguy Prigent, 29200 BREST Cedex, France
| | - Xavier Leclerc
- Service de Neuroradiologie, CHRU, Hôpital Roger Salengro, Boulevard du Professeur Leclercq, 59037 Lille Cedex, France
| | - Laurent Lemaitre
- Plateau Commun d'Imagerie Médicale, Hôpital Claude Huriez, Rue Michel Polonovski, 59037 Lille Cedex, France
| | - Francisque Leynadier
- Centre d’Allergologie, Hôpital TENON, 4 rue de la Chine, 75970 Paris Cedex 20, France
| | - Agnès Lillo-Le-Louet
- Centre de Pharmacovigilance, Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75908 Paris Cedex 15, France
| | - Jean-Pierre Louvel
- Service de Radiologie, CHU de Rouen, Hôpital de Boisguillaume-147, avenue du Maréchal Juin, 76230, Boisguillaume, France
| | - Nathalie Louvier
- Service Anesthésie Réanimation, Centre Georges Francois Leclerc, 1 rue Professeur Marion, BP 77980, 21079 Dijon Cedex, France
| | - Marie-Madeleine Lucas
- Service de Pneumologie, Consultation d'Allergolo-Anesthésie, CHU Pontchaillou, Rue H. Le Guilloux, 35033 Rennes Cedex 09, France
| | - Geneviève Meites
- Service de Radiologie, Hôpital Rangueil, 1, avenue Professeur Jean Poulhès, 31059 Toulouse Cedex 9, France
| | - Nicolas Mennesson
- Service de Radiologie digestive, Pavillon H, Hôpital Edouard Herriot, Place d'Arsonval, 69437 Lyon Cedex 03, France
| | - Liliane Metge
- Département d'Imagerie Médicale, Groupe Hospitalo-Universitaire Caremeau, Place du Pr Robert Debré, 30 029 Nimes Cedex 9, France
| | - Yannick Meunier
- Département d'Anesthésie Réanimation, CHU de Rouen, Hôpital Charles Nicolle, 1, rue de Germont, 76031 Rouen Cedex, France
| | - Laurence Monnier-Cholley
- Service de Radiologie, Hôpital Saint Antoine, 184, rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - Mariano Musacchio
- Service de Radiologie, Hôpitaux civils, Hôpital Pasteur, Neuro Radiologie Pôle 3, 39 avenue de la liberté, 68024 Colmar Cedex, France
| | - Brigitte Nicolie
- CHRU Angers, Hôpital Hôtel Dieu, Unité fonctionnelle d'allergologie, 4 rue Larrey, 49933 Angers Cedex 09, France
| | - Gisèle Occelli
- Service de Pneumologie, CHU de Nice, Hôpital Pasteur, H.O, 30, avenue de la Voie Romaine, 06100 Nice, France
| | - Hélène Oesterle
- Service de Radiologie, Hôpitaux civils, Hôpital Pasteur, Neuro Radiologie Pôle 3, 39 avenue de la liberté, 68024 Colmar Cedex, France
| | - Francine Paisant-Thouveny
- CHRU Angers, Hôpital Hôtel Dieu, Service de Radiologie C, 4 rue Larrey, 49933 Angers Cedex 09, France
| | - Michel Panuel
- Service de Radiologie, Hôpital Nord, Chemin des Bourrelys, 13915 Marseille Cedex 20, France
| | - Nadine Railhac
- Service de Radiologie, Hl Purpan, Place du Dr Baylac, 31059 Toulouse Cedex 9, France
| | - Frédérique Rety-Jacob
- Service de Radiologie et Imagerie Médicale, Pavillon 3 B, Centre Hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69495 Pierre Benite Cedex, France
| | - Cécile Rochefort-Morel
- Service de Pneumologie, Consultation d'Allergolo-Anesthésie, CHU Pontchaillou, Rue H. Le Guilloux, 35033 Rennes Cedex 09, France
| | - Catherine Roy
- Service de Radiologie B, Pavillon Chirurgical A, Hôpital Civil, 1 place de l'Hôpital, BP 426, 67091 Strasbourg Cedex, France
| | - Philippe Sarlieve
- Service de Radiologie A et C, CHRU Jean Minjoz, 22, Bd A.Flemming, 25030 Besancon Cedex, France
| | - Musa Sesay
- Service de Radiologie, Groupe Hospitalier Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux Cedex, France
| | - Catherine Sgro
- Service de Pharmacologie, CHU de Dijon, Hôpital du Bocage, 2 Bd Mal de Lattre de Tassigny, 21034 Dijon Cedex, France
| | - Patrice Taourel
- Service de Radiologie A, CHU de Montpellier, Hôpital Lapeyronie, 371 Avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France
| | - Patrick Terrier
- Service de Pneumologie, CHU de Rouen, Hôpital Charles Nicolle, 1, rue Germont, 76031 Rouen Cedex, France
| | - Odile Theissen
- Service d'Anesthésie Réanimation Chirurgicale, Hôpitaux civils, Hôpital Pasteur, Pôle 2, 39 avenue de la liberté, 68024 Colmar Cedex, France
| | - Ingrid Topenot
- Service de Dermatologie, Hôpital Edouard Herriot, Place d'Arsonval, 69437 Lyon Cedex 03, France
| | - Jocelyne Valfrey
- Département d'Anesthésie, Hôpital Lyautey, 1 rue des Canonniers, 67100 Strasbourg, France
| | - Francis Veillon
- Service de Radiologie 1, Hôpital de Hautepierre, Avenue Molière, 67098 Strasbourg Cedex, France
| | - Marie-Claude Vergnaud
- Service de médecine polyvalente, CHU de Caen, Avenue de la Côte de Nacre, 14033 Caen Cedex, France
| | - Charles Veyret
- Service de Radiologie, CHU de Saint-Etienne, Hôpital Nord, Avenue Albert Raymond, 42055 Saint Etienne Cedex 2, France
| | - Denis Vincent
- Service de Pneumologie – Médecine Interne, Groupe Hospitalo-Universitaire Caremeau, Place du Pr Robert Debré, 30029 Nimes Cedex 9, France
| | - Benoit Wallaert
- Service de Pneumologie, CHR de Lille, Clinique des Maladies Respiratoires, RCO - Hôpital Calmette, Boulevard du Professeur Leclercq, 59037 Lille Cedex, France
| | - François Wessel
- Service de Pneumologie, Hôpital G et R Laënnec, Bd Jacques Monod, 44093 Nantes Cedex 1, France
| | - Marc Zins
- Service de Médecine Interne, Hôpital Saint Joseph, 185 Rue Raymond Losserand, 75674 Paris Cedex 14, France
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Landsem LM, Ross FJ, Eisses MJ. A case of midazolam anaphylaxis during a pediatric patient's first anesthetic. J Clin Anesth 2017; 43:75-76. [PMID: 29049905 DOI: 10.1016/j.jclinane.2017.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Leah M Landsem
- Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States.
| | - Faith J Ross
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Michael J Eisses
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
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In Vivo Cysteinyl Leukotriene Release in Allergic and Nonallergic Immediate Hypersensitivity Reactions during Anesthesia. Anesthesiology 2017; 126:834-841. [PMID: 28301407 DOI: 10.1097/aln.0000000000001600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Immediate hypersensitivity reactions occurring during anesthesia are classified as allergic when skin tests and mast cell tryptase are positive and as nonallergic when negative results are obtained. Cysteinyl leukotrienes (cysLTs) are potent mediators synthesized by mast cell and eosinophil that induce bronchial constriction. They could play a role in hypersensitivity reactions. METHODS cysLT C4, D4, and E4 concentrations were measured by a competition immunoassay in serial plasma samples obtained prospectively from 21 anesthetized controls and retrospectively from 34 patients who reacted at induction of anesthesia (24 with allergic and 10 with nonallergic reactions). RESULTS In controls, the median (interquartile range) cysLT concentration was 0.83 (0.69 to 1.02) μg/l before anesthesia and was unchanged 30 min, 6 h, and 24 h afterward. In the patients with allergic reactions, the values were highly increased 30 to 60 min after the reaction (17.9 [7.8 to 36.0] μg/l), while the patients with nonallergic reactions had less increased values (7.3 [3.0 to 11.5] μg/l). The difference between the three groups was significant (P < 0.0001). Increased values persisted during the 24 h of observation. Concentrations were significantly higher in patients with bronchospasm (P = 0.016). CONCLUSIONS cysLTs appear to be an important mediator of allergic and nonallergic immediate hypersensitivity reactions. These findings might open a new field for management of patients with hypersensitivity reactions, especially nonallergic ones.
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Haldar R, Bajwa SS, Kaur J. Xylometazoline nasal drops induced anaphylaxis: An atypical perioperative complication. J Anaesthesiol Clin Pharmacol 2017; 33:399-401. [PMID: 29109644 PMCID: PMC5672530 DOI: 10.4103/0970-9185.173331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Xylometazoline nasal drops used for nasal decongestion can have side-effect in the form of palpitation, hypertension, headache, and tremors. Anaphylaxis to xylometazoline nasal drops is a relatively unrecognized complication. We encountered a patient posted for tonsillectomy who developed serious anaphylaxis upon administration of a commercially available preparation of xylometazoline nasal drops and required aggressive management for stabilization. Further evaluation and literature search indicated toward the preservative (benzylalkonium chloride) as the cause of this adverse event.
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Affiliation(s)
| | | | - Jasleen Kaur
- Department of Anaesthesia, Gian Sagar Medical College, Banur, Patiala, Punjab, India
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Egner W, Sargur R, Shrimpton A, York M, Green K. A 17-year experience in perioperative anaphylaxis 1998-2015: harmonizing optimal detection of mast cell mediator release. Clin Exp Allergy 2016; 46:1465-1473. [DOI: 10.1111/cea.12785] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 05/24/2016] [Accepted: 07/20/2016] [Indexed: 12/20/2022]
Affiliation(s)
- W. Egner
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - R. Sargur
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - A. Shrimpton
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - M. York
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - K. Green
- Clinical Immunology and Allergy Unit and Department of Immunology and Protein Reference Unit; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
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Mechanisms of anaphylaxis in human low-affinity IgG receptor locus knock-in mice. J Allergy Clin Immunol 2016; 139:1253-1265.e14. [PMID: 27568081 DOI: 10.1016/j.jaci.2016.06.058] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 05/13/2016] [Accepted: 06/13/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anaphylaxis can proceed through distinct IgE- or IgG-dependent pathways, which have been investigated in various mouse models. We developed a novel mouse strain in which the human low-affinity IgG receptor locus, comprising both activating (hFcγRIIA, hFcγRIIIA, and hFcγRIIIB) and inhibitory (hFcγRIIB) hFcγR genes, has been inserted into the equivalent murine locus, corresponding to a locus swap. OBJECTIVE We sought to determine the capabilities of hFcγRs to induce systemic anaphylaxis and identify the cell types and mediators involved. METHODS hFcγR expression on mouse and human cells was compared to validate the model. Passive systemic anaphylaxis was induced by injection of heat-aggregated human intravenous immunoglobulin and active systemic anaphylaxis after immunization and challenge. Anaphylaxis severity was evaluated based on hypothermia and mortality. The contribution of receptors, mediators, or cell types was assessed based on receptor blockade or depletion. RESULTS The human-to-mouse low-affinity FcγR locus swap engendered hFcγRIIA/IIB/IIIA/IIIB expression in mice comparable with that seen in human subjects. Knock-in mice were susceptible to passive and active anaphylaxis, accompanied by downregulation of both activating and inhibitory hFcγR expression on specific myeloid cells. The contribution of hFcγRIIA was predominant. Depletion of neutrophils protected against hypothermia and mortality. Basophils contributed to a lesser extent. Anaphylaxis was inhibited by platelet-activating factor receptor or histamine receptor 1 blockade. CONCLUSION Low-affinity FcγR locus-switched mice represent an unprecedented model of cognate hFcγR expression. Importantly, IgG-related anaphylaxis proceeds within a native context of activating and inhibitory hFcγRs, indicating that, despite robust hFcγRIIB expression, activating signals can dominate to initiate a severe anaphylactic reaction.
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20
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Ozcan J, Nicholls K, Jones K. Immunoglobulin E-Mediated Hypersensitivity Reaction to Ketamine. Pain Pract 2016; 16:E94-8. [DOI: 10.1111/papr.12466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Revised: 03/10/2016] [Accepted: 03/21/2016] [Indexed: 11/30/2022]
Affiliation(s)
- John Ozcan
- Department of Anaesthesia; The Royal Women's Hospital; Parkville Victoria Australia
| | - Katherine Nicholls
- Department of Immunology and Allergy; The Royal Melbourne Hospital; Parkville Victoria Australia
| | - Karin Jones
- Department of Anaesthesia; The Royal Women's Hospital; Parkville Victoria Australia
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21
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Diagnostic value of histamine and tryptase concentrations in severe anaphylaxis with shock or cardiac arrest during anesthesia. Anesthesiology 2014; 121:272-9. [PMID: 24787350 DOI: 10.1097/aln.0000000000000276] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The diagnosis of acute life-threatening allergic reactions during anesthesia relies on clinical signs, histamine and/or tryptase measurements, and allergic testing. In patients who die after the reaction, skin tests cannot be performed, and the effect of resuscitation manoeuvres on mediator concentrations is unknown. The authors compared plasma histamine and tryptase concentrations in patients with severe allergic reactions during anesthesia with those measured in patients with shock due to other causes. METHODS Patients with life-threatening allergic reactions were retrieved from a previous database (Group ALLERGY). All had positive allergy tests to administered agents. Patients with severe septic/cardiogenic shock or cardiac arrest (Group CONTROL) had histamine and tryptase measurements during resuscitation manoeuvres. Receiver operating characteristics curves were built to calculate the optimal mediator thresholds differentiating allergic reactions from others. RESULTS One hundred patients were included, 75 in Group ALLERGY (cardiovascular collapse, 67; cardiac arrest, 8) and 25 in Group CONTROL (shock, 11; cardiac arrest, 14). Mean histamine and tryptase concentrations remained unchanged throughout resuscitation in Group CONTROL and were significantly higher in Group ALLERGY. The optimal thresholds indicating an allergic mechanism were determined as 6.35 nmol/l for histamine (sensitivity: 90.7% [95% CI, 81.7 to 96.1]; specificity: 91.7% [73.0 to 98.9]) and 7.35 μg/l for tryptase (sensitivity: 92% [83.4 to 97.0]; specificity: 92% [73.9 to 99.0]). CONCLUSIONS Resuscitation manoeuvres by themselves did not modify mediator concentrations. Virtually all life-threatening reactions during anesthesia associated with mediator concentrations exceeding the thresholds were allergic events. These findings have potential forensic interest when a patient dies during anesthesia.
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Abstract
Perioperative anaphylaxis is a life-threatening condition with an estimated prevalence of 1:3,500 to 1:20,000 procedures and a mortality rate of up to 9 %. Clinical presentation involves signs such as skin rash, urticaria, angioedema, bronchospasm, tachycardia, bradycardia, and hypotension. Prompt recognition and treatment is of utmost importance to the patient's prognosis, since clinical deterioration can develop rapidly. Epinephrine is the main treatment drug, and its use should not be postponed, since delayed administration is associated with increased mortality. Elevated levels of serum tryptase help to confirm the diagnosis. The main agents involved in IgE-mediated perioperative anaphylaxis are neuromuscular blocking agents, latex, antibiotics, hypnotics, opioids, and colloids. Specific investigation should be conducted 4 to 6 weeks after the reaction and relies on skin tests, serum-specific IgE, and challenge procedures. This review aims to discuss the main aspects of perioperative anaphylaxis: risk factors, diagnosis, treatment, culprit agents, specific investigation, and preventive measures.
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23
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Stefanutto TB, Wright PMC. Anaphylaxis precipitated by intravenous morphine sulphate. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2005.10872392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Barnes M, Van L, DeLong L, Lawley LP. Severity of cutaneous findings predict the presence of systemic symptoms in pediatric maculopapular cutaneous mastocytosis. Pediatr Dermatol 2014; 31:271-5. [PMID: 24612340 DOI: 10.1111/pde.12291] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although the prognosis of maculopapular cutaneous mastocytosis (MPCM), also referred to as urticaria pigmentosa, is often benign, clinicians lack evidence to reliably predict those at risk of associated systemic manifestations. We sought to elucidate clinical markers of disease severity to provide better treatment and prognostic information for individuals with MPCM. A retrospective chart review querying characteristics of children diagnosed with MPCM in the Emory Dermatology Clinic was performed. Follow-up was obtained through a clinical encounter or telephone interview. Linear regression was used to determine predictors of the number of MPCM-related systemic symptoms. Of 67 subjects, 57% were male, and the mean age of onset was 4.5 months. The maximum number of MPCM lesions was 1 to 10 in 16%, 11 to 30 in 33%, 31 to 50 in 25%, 51 to 100 in 6%, and more than 100 in 20% of subjects. For their MPCM lesions, 46% of subjects reported itching, 34% flushing, and 25% blistering. Reported systemic symptoms included diarrhea (22%), abdominal pain (15%), wheezing or dyspnea (13%), vomiting (10%), bone pain (10%), headaches (8%), cough (10%), rhinorrhea (8%), irritability (6%), and anaphylaxis (1.5%). In a multivariate linear regression analysis, the maximum number of MPCM lesions (p = 0.02) and the number of skin symptoms (p < 0.01) were statistically significant predictors of the number of systemic symptoms, controlling for age of onset, body sites involved, and sex. The correlation between cutaneous findings and symptomatology could aid clinicians in identifying individuals with MPCM who might warrant systemic evaluation and therapy.
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Affiliation(s)
- Meredith Barnes
- Department of Dermatology, School of Medicine, Emory University, Atlanta, Georgia
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25
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Berroa F, Lafuente A, Javaloyes G, Ferrer M, Moncada R, Goikoetxea MJ, Urbain CM, Sanz ML, Gastaminza G. The usefulness of plasma histamine and different tryptase cut-off points in the diagnosis of peranaesthetic hypersensitivity reactions. Clin Exp Allergy 2014; 44:270-7. [DOI: 10.1111/cea.12237] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 11/11/2013] [Accepted: 11/11/2013] [Indexed: 11/30/2022]
Affiliation(s)
- F. Berroa
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - A. Lafuente
- Departamento de Anestesiología; Clínica Universidad de Navarra; Pamplona Spain
| | - G. Javaloyes
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - M. Ferrer
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - R. Moncada
- Departamento de Anestesiología; Clínica Universidad de Navarra; Pamplona Spain
| | - M. J. Goikoetxea
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - C. M. Urbain
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - M. L. Sanz
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
| | - G. Gastaminza
- Departamento de Alergología e Inmunología Clínica; Clínica Universidad de Navarra; Pamplona Spain
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Sánchez-Borges M, Thong B, Blanca M, Ensina LFC, González-Díaz S, Greenberger PA, Jares E, Jee YK, Kase-Tanno L, Khan D, Park JW, Pichler W, Romano A, Jaén MJT. Hypersensitivity reactions to non beta-lactam antimicrobial agents, a statement of the WAO special committee on drug allergy. World Allergy Organ J 2013; 6:18. [PMID: 24175948 PMCID: PMC4446643 DOI: 10.1186/1939-4551-6-18] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 09/18/2013] [Indexed: 01/12/2023] Open
Abstract
Antibiotics are used extensively in the treatment of various infections. Consequently, they can be considered among the most important agents involved in adverse reactions to drugs, including both allergic and non-allergic drug hypersensitivity [J Allergy Clin Immunol 113:832–836, 2004]. Most studies published to date deal mainly with reactions to the beta-lactam group, and information on hypersensitivity to each of the other antimicrobial agents is scarce. The present document has been produced by the Special Committee on Drug Allergy of the World Allergy Organization to present the most relevant information on the incidence, clinical manifestations, diagnosis, possible mechanisms, and management of hypersensitivity reactions to non beta-lactam antimicrobials for use by practitioners worldwide.
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Affiliation(s)
- Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico-Docente La Trinidad, Caracas, Venezuela.
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Mariappan R, Manninen P, Massicotte EM, Bhatia A. Circulatory collapse after topical application of vancomycin powder during spine surgery. J Neurosurg Spine 2013; 19:381-3. [PMID: 23829290 DOI: 10.3171/2013.6.spine1311] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A hypersensitivity reaction, either anaphylactic or anaphylactoid, is a well-known adverse effect following intravenous and oral administration of vancomycin. The authors report a case of circulatory collapse and its management after the topical application of vancomycin powder during spinal instrumentation surgery. A 52-year-old woman with breast cancer and metastasis to her spine underwent a vertebrectomy of the T-10 vertebra with instrumented reconstruction from T-8 to T-12. The patient was hemodynamically stable during most of the procedure despite a 2-L blood loss requiring administration of crystalloids, colloids, packed red blood cells, and fresh-frozen plasma. During closure of the subcutaneous layer, there was a sudden drop in blood pressure from 120/60 to 30/15 mm Hg and an increase in heart rate from 95 to 105 bpm. No skin erythema or rash was visible, and there was no bronchospasm or increase in airway pressure. The patient was treated with fluids, boluses of ephedrine, phenylephrine, and adrenaline. The operation was completed and the patient woke up neurologically intact but did require blood pressure support with a norepinephrine infusion for the next 4 hours. She was discharged from hospital in a good clinical state on the 4th postoperative day. It was speculated that the rapid absorption of vancomycin powder applied on the surgical wound caused an anaphylactoid reaction and the circulatory collapse. With an increase in the use of topical vancomycin in surgical wounds, communication and awareness among all intraoperative team members is important for rapid diagnosis of an adverse reaction and for appropriate management.
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Affiliation(s)
- Ramamani Mariappan
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
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Bridgman DE, Clarke R, Sadleir PHM, Stedmon JJ, Platt P. Systemic mastocytosis presenting as intraoperative anaphylaxis with atypical features: a report of two cases. Anaesth Intensive Care 2013; 41:116-21. [PMID: 23362901 DOI: 10.1177/0310057x1304100120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Two cases of perioperative cardiovascular collapse are presented that were associated with markedly elevated mast cell tryptase levels shortly after the event, leading to the assumption that an immunoglobin E-mediated, drug-induced anaphylaxis had occurred. However, the clinical picture in both cases was atypical and subsequent skin testing failed to identify a triggering drug. Further blood tests, some weeks later, revealed persistently elevated baseline levels of mast cell tryptase. In both cases bone marrow biopsy and genetic testing confirmed the diagnosis of mastocytosis. We present evidence and speculate that mast cell degranulation was triggered by tourniquet release in the first case and by exposure to peanuts in the second. An atypical presentation of anaphylaxis should alert the anaesthetist to the possibility of previously undiagnosed mastocytosis.
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Affiliation(s)
- D E Bridgman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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29
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Klein NJ, Misseldine S. Anesthetic considerations in pediatric mastocytosis: a review. J Anesth 2013; 27:588-98. [DOI: 10.1007/s00540-013-1563-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022]
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Mariotte D, Bazin A, Da Silva Costa-Aze V, Pottier V, Samba D, Vergnaud MC, Comby E, Le Mauff B, Laroche D. Immediate hypersensitivity to platelet concentrate: allergic or not? Transfus Med 2013; 23:136-7. [PMID: 23356776 DOI: 10.1111/tme.12007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 11/19/2012] [Accepted: 12/20/2012] [Indexed: 12/01/2022]
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Anaphylaxis associated with general anaesthesia: Challenges and recent advances. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sebeo J, Ezziddin O, Eisenkraft JB. Severe anaphylactoid reaction to thymoglobulin in a pediatric renal transplant recipient. J Clin Anesth 2012; 24:659-63. [PMID: 23164644 DOI: 10.1016/j.jclinane.2012.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 04/18/2012] [Accepted: 04/29/2012] [Indexed: 11/29/2022]
Abstract
Intraoperative administration of thymoglobulin is an integral part of the anti-rejection regimen during organ transplantation. However, its administration may be associated with complications. An anaphylactoid reaction that occurred in a pediatric recipient of a living-related renal transplant, on initiating an intravenous infusion of thymoglobulin, is presented.
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Affiliation(s)
- Joseph Sebeo
- Department of Anesthesiology, The Mount Sinai Medical Center, New York, NY 10029, USA.
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Tomar GS, Tiwari AK, Chawla S, Mukherjee A, Ganguly S. Anaphylaxis related to fentanyl citrate. J Emerg Trauma Shock 2012; 5:257-61. [PMID: 22988407 PMCID: PMC3440895 DOI: 10.4103/0974-2700.99703] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 11/05/2011] [Indexed: 12/03/2022] Open
Abstract
Anaphylaxis is a fulminant, unexpected, immunoglobulin E-mediated allergic reaction that can be triggered by multiple agents. Common causative agents include neuromuscular blocking drugs, latex, antibiotics, colloids, hypnotics, and opioids. Fentanyl citrate, however, is an extremely unusual cause of anaphylaxis. Pulmonary edema, although uncommon in anaphylaxis, can be a prominent feature, as was in one of the patient. An adverse drug reaction is a noxious or unintended reaction to a drug that is administered in standard doses by the proper route for the purpose of prophylaxis, diagnosis, or treatment. Reactions are classified into two major subtypes: type A, which are dose dependent and predictable; and type B, which are not dose dependent and unpredictable. Unpredictable reactions include immune (allergic) or no immune drug hypersensitivity reactions and are related to genetic susceptibilities or undefined mechanisms (formally called idiosyncratic and intolerance reactions). A drug allergy is always associated with an immune mechanism for which evidence of drug-specific antibodies or activated T lymphocytes can be shown. In the last few years, many novel drugs have entered clinical practice (i.e., biologic agents) generating novel patterns of drug hypersensitivity reactions. As old drugs continue to be used, new clinical and biologic techniques enable improvement in the diagnosis of these reactions.
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Affiliation(s)
- Gaurav Singh Tomar
- Department of Anesthesiology and Intensive Care, St. Stephen's Hospital, Delhi, India
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Tomak Y, Yılmaz A, Bostan H, Tümkaya L, Altuner D, Kalkan Y, Erdivanlı B. Effects of sugammadex and rocuronium mast cell number and degranulation in rat liver. Anaesthesia 2012; 67:1101-4. [PMID: 22827538 DOI: 10.1111/j.1365-2044.2012.07264.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We investigated the effect of rocuronium- and sugammadex-induced mast cell increase and degranulation in rat portal triads. Forty-two rats, in six groups, received either rocuronium 1 mg.kg(-1); sugammadex 15 mg.kg(-1); sugammadex 100 mg.kg(-1); rocuronium 1 mg.kg(-1) and 5 min later, sugammadex 15 mg.kg(-1); rocuronium 1 mg.kg(-1) and 5 min later, sugammadex 100 mg.kg(-1); or isotonic saline. Total mast cell numbers were significantly higher with rocuronium only, than in all other groups (p<0.003), although in all active groups, the number was greater than the control. Total mast cell number was significantly higher with rocuronium and low-dose sugammadex compared with low-dose sugammadex only. The number of tryptase-positive mast cells with rocuronium only was significantly higher than in all other groups (p<0.003). Tryptase-positive mast cell numbers in both groups receiving both rocuronium and sugammadex were significantly higher compared with both groups receiving sugammadex only. Rocuronium increased mast cell numbers, and degranulation was mitigated by sugammadex. These results suggest that sugammadex may be beneficial in treatment of rocuronium-induced anaphylaxis.
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Affiliation(s)
- Y Tomak
- Department of Anaesthesiology and Reanimation, Rize University, Medical Faculty, and Rize Education and Research Hospital, Rize, Turkey.
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Baldo BA, Pham NH. Histamine-releasing and allergenic properties of opioid analgesic drugs: resolving the two. Anaesth Intensive Care 2012; 40:216-35. [PMID: 22417016 DOI: 10.1177/0310057x1204000204] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioid analgesics are amongst the most commonly administered drugs in hospitals. Whether natural or synthetic, they show some common structural features, morphine-like pharmacological action and binding specificity for complementary opioid receptors. Tramadol differs from the other opioid analgesics in possessing monoaminergic activity in addition to its affinity for the µ opioid receptor. Many opioids are potent histamine releasers producing a variety of haemodynamic changes and anaphylactoid reactions, but the relationship of the appearance of these effects to the histamine plasma concentration is complex and there is no direct and invariable relationship between the two. Studies of the histamine-releasing effects, chiefly centred on morphine, reveal variable findings and conclusions often due to a range of factors including differences in technical measurements, dose, mode of administration, site of injection, the anatomical distribution of histamine receptors and heterogeneity of patient responses. Morphine itself has multiple direct effects on the vasculature and other haemodynamically-active mediators released along with histamine contribute to the variable responses to opioid drug administration. Despite their heavy use and occasional apparent anaphylactic-like side-effects, immunoglobulin E antibody-mediated immediate hypersensitivity reactions to the drugs are not often encountered. Uncertainties associated with skin testing with these known histamine-releasers, and the general unavailability of opioid drug-specific immunoglobulin E antibody tests contribute to the frequent failure to adequately investigate and establish underlying mechanisms of reactions by distinguishing anaphylactoid from true anaphylactic reactions. Clinical implications for diagnosis of reactions and some speculations on the rarity of true Type 1 allergies to these drugs are presented.
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36
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Gurrieri C, Weingarten TN, Martin DP, Babovic N, Narr BJ, Sprung J, Volcheck GW. Allergic Reactions During Anesthesia at a Large United States Referral Center. Anesth Analg 2011; 113:1202-12. [DOI: 10.1213/ane.0b013e31822d45ac] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Castells M, Metcalfe DD, Escribano L. Diagnosis and treatment of cutaneous mastocytosis in children: practical recommendations. Am J Clin Dermatol 2011; 12:259-70. [PMID: 21668033 DOI: 10.2165/11588890-000000000-00000] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cutaneous mastocytosis in children is a generally benign disease that can present at birth and is often associated with mast cell mediator-related symptoms including pruritus, flushing, and abdominal pain with diarrhea. The most common form of presentation is urticaria pigmentosa, also referred to as maculopapular mastocytosis. Flares of lesions are induced by triggers such as physical stimuli, changes in temperature, anxiety, medications, and exercise. The skin lesions are typically present on the extremities. Symptoms respond to topical and systemic anti-mediator therapy including antihistamines and cromolyn sodium. Remission at puberty is seen in a majority of cases. Progression to systemic mastocytosis with involvement of extracutaneous organs is not common. The cause of cutaneous mastocytosis is unknown and familial cases are rare. Mutations of c-kit have been observed in the skin of those affected. The diagnosis is established on clinical grounds and the findings on skin biopsy. Bone marrow studies are recommended if there is suspicion of progression of disease to an adult form, if cytoreductive therapy is contemplated, or if skin lesions remain present and/or tryptase levels remain elevated after puberty. The use of chemotherapy, including kinase inhibitors, is strongly discouraged unless severe hematologic disease is present, since malignant evolution is extremely rare.
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Affiliation(s)
- Mariana Castells
- Department of Medicine, Division of Rheumatology, Immunology, and Allergy, Brigham Womens Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Baldo BA, McDonnell NJ, Pham NH. Drug-specific cyclodextrins with emphasis on sugammadex, the neuromuscular blocker rocuronium and perioperative anaphylaxis: implications for drug allergy. Clin Exp Allergy 2011; 41:1663-78. [PMID: 21732999 DOI: 10.1111/j.1365-2222.2011.03805.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cyclodextrins, oligosaccharides linked in a circular arrangement around a central cavity, are used extensively in the pharmaceutical industry to improve drug delivery. Their usefulness depends on their capacity to form a drug inclusion, or host-guest, complex within the cavity. In an attempt to improve the delivery of the widely used neuromuscular blocking drug (NMBD) rocuronium, a rocuronium inclusion complex was formed with a chemically modified γ-cyclodextrin. The high binding affinity and specificity of the modified carrier (named sugammadex) for rocuronium (and other aminosteroid NMBDs) led to its use in anaesthesia as an innovative and useful agent for rapid reversal of rocuronium-induced neuromuscular block by sequestering the drug as an inclusion complex. This, in turn, led to the suggestion that sugammadex might be useful to remove the NMBD from the circulation of patients experiencing rocuronium-induced anaphylaxis, a suggestion subsequently supported in case reports where traditional treatment had failed. Successful resuscitations suggested that sugammadex might be a valuable new treatment for such intractable cases but, given the inappropriateness of clinical trials, confirmation or refutation will have to await the slow accumulation of results of individual case reports. Important questions related to antibody accessibility of drug allergenic structures on the rocuronium-sugammadex inclusion complex, and the competition between sugammadex and IgE antibodies (both free and cell bound) for rocuronium, also remain and can be investigated in vitro. The sugammadex findings indicate that the use of carrier molecules such as the cyclodextrins to improve drug delivery will sometimes give rise to changed immunologic and allergenic behaviour of some drugs and this will have to be taken into account in preclinical drug safety assessments of drug-carrier complexes. The possibility of encapsulating and removing other allergenic drugs, e.g., penicillins and cephalosporins, in cases of difficult-to-reverse anaphylaxis to these drugs is discussed.
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Affiliation(s)
- B A Baldo
- School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
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40
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Latex-Induced Anaphylactic Reaction in a Patient Undergoing Open Appendectomy. Case Report. Braz J Anesthesiol 2011; 61:360-6. [PMID: 21596197 DOI: 10.1016/s0034-7094(11)70043-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Accepted: 12/13/2010] [Indexed: 11/18/2022] Open
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41
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Howard JD, Moo V, Sivalingam P. Anaphylaxis and other Adverse Reactions to Blue Dyes: A Case Series. Anaesth Intensive Care 2011; 39:287-92. [DOI: 10.1177/0310057x1103900221] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet – Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.
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Affiliation(s)
- J. D. Howard
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - V. Moo
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - P. Sivalingam
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Abstract
UNLABELLED background: the anaesthetic allergy clinic has been established at our institution for 30 years. Our practice has been to give patients a letter detailing the results of their investigations to pass on to subsequent anaesthetists. Our aims were to assess the adequacy of this letter in ensuring this vital communication, and to quantify the effectiveness of our recommendations on the safety of future anaesthesia. METHODS a project was undertaken to contact 606 previous clinic patients living in New South Wales by using last known addresses on our database, public telephone listing and local doctors. The review also involved collecting information, where available, about subsequent anaesthesia and the adequacy of information transfer about medications given safely or otherwise at this time. RESULTS of 606 patients, 246 were contactable. Of these, 183 had been anaesthetised subsequently, all safely. It was found that in only 11 cases had the patient's clinic letter been updated with the information from subsequent anaesthesia. We updated the letters of 82 patients with new information to improve the safety of drug selection for future anaesthesia. CONCLUSIONS although clinic testing allowed a high degree of safety in subsequent anaesthesia, it is evident that there is a need for systems to be implemented to improve the flow of patient anaesthetic allergy information after subsequent anaesthesia.
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Affiliation(s)
- M M Fisher
- Intensive Care Unit, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
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44
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Barthelmes L, Goyal A, Sudheer P, Mansel R. Investigation of anaphylactic reaction after patent blue V dye injection. Breast 2010; 19:516-20. [DOI: 10.1016/j.breast.2010.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 04/19/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022] Open
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Mertes PM, Tajima K, Regnier-Kimmoun MA, Lambert M, Iohom G, Guéant-Rodriguez RM, Malinovsky JM. Perioperative anaphylaxis. Med Clin North Am 2010; 94:761-89, xi. [PMID: 20609862 DOI: 10.1016/j.mcna.2010.04.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The incidence of immune-mediated anaphylaxis during anesthesia ranges from 1 in 10,000 to 1 in 20,000. Neuromuscular blocking agents are most frequently incriminated, followed by latex and antibiotics, although any drug or substance used may be a culprit. Diagnosis relies on tryptase measurements at the time of the reaction and skin tests, specific immunoglobulin E, or basophil activation assays. Treatment consists of rapid volume expansion and epinephrine administration titrated to symptom severity.
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Affiliation(s)
- P M Mertes
- Service d'Anesthésie-Réanimation Chirurgicale, CHU de Nancy, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035 Nancy Cedex, France.
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46
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Guttormsen AB, Harboe T, Pater GD, Florvaag E. [Anaphylaxis during anaesthesia]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:503-6. [PMID: 20224620 DOI: 10.4045/tidsskr.08.0654] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Anaphylaxis is a serious life-threatening generalized or systemic hypersensitivity reaction. The aim of this paper is to provide knowledge on how to diagnose, treat and follow up patients with suspected anaphylaxis during general and local anaesthesia. MATERIAL AND METHODS The article is based on literature identified through a non-systematic search in PubMed, the Scandinavian Guidelines on anaphylaxis during anaesthesia and on own research. RESULTS Anaphylactic symptoms during anaesthesia vary with respect to severity. Manifestations from skin and the cardiovascular and respiratory systems are present simultaneously in approximately 70 % of patients. Early treatment with adrenaline, fluid and extra oxygen may be vital for survival without sequelae. The following patients should be assessed before anaesthesia: those with moderate or serious reactions or with reactions that raise suspicion of allergy which may cause problems in connection with future treatment. Neuromuscular blocking agents are the main cause of IgE-mediated anaphylaxis during anaesthesia in Norway. New research has shown that allergy towards neuromuscular blocking agents can develop after ingestion of cough syrup containing pholcodine (stimulates asymptomatic production of antibodies). These antibodies cause cross-sensibilisation with neuromuscular blocking agents. The cough syrup Tuxi was withdrawn from the Norwegian market during spring 2007. INTERPRETATION Allergic reactions during anaesthesia are rare and potentially life-threatening; patients should be followed up and treated in a standardized way.
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Affiliation(s)
- Anne Berit Guttormsen
- Kirurgisk serviceklinikk, Haukeland universitetssykehus, 5021 Bergen, og, Institutt for kirurgiske fag, Universitetet i Bergen.
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47
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Risque allergique en anesthésie pédiatrique. ACTA ACUST UNITED AC 2010; 29:215-26. [DOI: 10.1016/j.annfar.2009.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2009] [Accepted: 11/13/2009] [Indexed: 11/19/2022]
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48
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Suspected recurrent anaphylaxis in different forms during general anesthesia. J Anesth 2010; 24:143-5. [PMID: 20052499 DOI: 10.1007/s00540-009-0839-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 09/03/2009] [Indexed: 10/20/2022]
Abstract
We report on a patient who presented with recurrent severe shock during general anesthesia. The patient was a man scheduled for lung surgery whose first attack was a coronary spasm, which was followed by a second shock with severe bronchospasm and hypotension 4 weeks later. An elevated serum tryptase concentration was observed, and subsequent skin testing revealed negative reactions to some drugs administered in this case. This case serves to alert anesthetists to the possibility of some different forms of allergy and highlights the importance of rigorous investigation of all the reagents and phenomena.
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Fisher MM, Ramakrishnan N, Doig G, Rose M, Baldo B. The investigation of bronchospasm during induction of anaesthesia. Acta Anaesthesiol Scand 2009; 53:1006-11. [PMID: 19572931 DOI: 10.1111/j.1399-6576.2009.02044.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of this study was to ascertain whether anaesthetic induction-related anaphylactic bronchospasm could be distinguished from other types of bronchospasm by clinical features and response to treatment. Such features could then be used to identify a group of patients in whom skin testing is indicated. METHODS We retrospectively studied data from 183 patients referred to an anaesthetic allergy clinic because of bronchospasm during induction. For the analysis, the patients were divided into two groups depending on whether there was evidence suggesting immunological anaphylaxis. RESULTS When the patients in whom intradermal tests were positive were compared with those in whom intradermal tests were negative, the skin test-positive patients had significantly more severe reactions, and they were more commonly associated with other clinical signs. Mast cell tryptase (MCT) was an excellent discriminator between reactions likely to be allergic and those unlikely to be allergic. CONCLUSIONS Anaphylactic bronchospasm related to induction of anaesthesia is more likely to be severe than bronchospasm due to non-immune causes. An allergic cause is more likely if there are associated features of anaphylaxis (skin changes, hypotension, angioedema) or elevated MCT. Patients with any of these features should undergo immuno-allergolical investigation.
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Affiliation(s)
- M M Fisher
- Intensive Care Unit, Royal North Shore Hospital of Sydney, University of Sydney, Sydney, NSW, Australia.
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Abstract
Anaphylaxis in the setting of general anesthesia is a rare but potentially lethal event. The investigation of severe reactions is important for confirming the clinical diagnosis and identifying likely causative agents and safe agents that may be used in the future. Many comprehensive reports have described the testing protocol of individual specialized units, whereas there has been no standardization of testing techniques or formal assessment of these tests' diagnostic accuracy. We review the literature with reference to the recently published standards for reporting of diagnostic accuracy (STARD) and make recommendations for future studies of diagnostic accuracy in the field.
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