Allergic reaction to patent blue dye in breast surgery - case report / Reação alérgica ao corante azul patente em cirurgia de mama - relato de caso

Abstract We present a case of allergic reaction to patent blue in a patient who underwent excision of sentinel lymph node associated with segmental breast resection. About 20 min after the dye injection, the patient developed hypotension (BP = 70 × 30 mmHg) associated with increased heart frequency. The patient was treated successfully with decreased inspired fraction of inhaled anesthetic and fluid replacement. At the end of the procedure, she presented with bluish urticarial-like plaques on the head, neck, upper limbs, and trunk; hydrocortisone was then used. The patient recovered uneventfully and was discharged from the PACU 2 h after the end of surgery without skin changes, and was discharged from hospital on the morning after surgery. The incidence of allergic reactions with the use of patent blue is far superior to the hypersensitivity reactions seen with anesthetic and adjuvant drugs. Therefore, the anesthesiologist must be aware of cardiovascular instability associated with skin changes during the use of patent blue, for early diagnosis and appropriate treatment of this hypersensitivity reaction to this dye.

Resumo Os autores apresentam um caso de reação alérgica ao azul patente em uma paciente submetida à exérese de linfonodo em sentinela associada a uma ressecção segmentar de mama. Paciente apresentou aproximadamente pós 20 minutos da injeção do corante hipotensão (PA = 70 × 30 mmHg) associada a aumento da frequência cardíaca. Foi tratada satisfatoriamente com diminuição da fração inspirada do anestésico inalatório e reposição volêmica. No fim do procedimento apresentava placas urticariformes azuladas em cabeça, pescoço, membros superiores e tronco e foi usada hidrocortisona. Evoluiu, sem intercorrências, na sala de recuperação pós-anestésica e teve alta duas horas após o término do procedimento cirúrgico sem a presença das alterações cutâneas. Alta hospitalar na manhã seguinte à cirurgia. A incidência de reações alérgicas com o emprego do azul patente é muito superior às reações de hipersensibilidade observadas com drogas anestésicas e adjuvantes. Portanto, o anestesiologista deve ficar atento à instabilidade cardiovascular associada a alterações cutâneas quando do uso do azul patente para o diagnóstico precoce e tratamento adequado dessa reação de hipersensibilidade com o emprego do corante.

Liver dysfunction induced by systemic hypersensitivity reaction to lamotrigine: case report

Lamotrigine is an anticonvulsant drug used to treat partial and generalized seizure disorders. Hypersensitivity to lamotrigine usually causes mild symptoms such as fever, rash, and slight invasion of internal organs. However, a 33-year-old male patient who was admitted with Stevens-Johnson syndrome after taking lamotrigine for 15 days experienced hepatic failure and died 5 days after admission. This case demonstrates the importance of realizing that lamotrigine can lead to fatal hepatic failure, and that tests for the normal liver function should be performed when administering lamotrigine.

unusual cause of post-operative orbital edema in a child after general anesthesia

We present an unusual ocular complication during the perioperative period, bilateral orbital edema in an otherwise healthy child after an outpatient surgical procedure. Ocular complications under general anesthesia remain a rare event. When periorbital edema is present, the appropriate work-up includes ruling out the potential for an allergic event by reviewing the medications administered and serum tryptase testing. Ophthalmology consultation should be considered to exclude pathology native to the eye itself. An allergist may assist in confirming a diagnosis and for allergic testing, if indicated. In our patient, the eventual diagnosis of exclusion was that of a localized reaction to the cellophane-based eye tape

Anaphylaxis in an emergency department: a 2-year study in a tertiary-care hospital.

The aim of this study was to estimate the incidence of anaphylaxis in the emergency department of a tertiary-care hospital, describe the clinical features and the management of the patients and determine those with mild manifestations. A retrospective study was conducted from 2005 to 2006 using anaphylaxis-related ICD-10 terms. Two different sets of criteria for the diagnosis of anaphylaxis were applied, first the criteria previously accepted by emergency practice, followed by the recent criteria set forth at the 2005 international meeting. Sixty-four patients fulfilled the previous criteria with an average incidence of 52.5 per 100,000 patients per year with a shift towards females in 2006. The most common presentations were cutaneous, followed by respiratory symptoms. Food allergy was the most common cause, especially prawn. After applying the recent criteria, 13 patients (20.4%) were excluded, which reduced the incidence to 42.2 per 100,000 patients per year. Long term follow up is suggested for the possible or mild cases that were re-categorized.

¿Cómo debe tratarse a las mujeres embarazadas con diagnóstico de sífilis y alergia a la penicilina? / How do pregnant women with syphilis and penicillin allergy should be treated?

Se presenta un caso clínico de una paciente embarazada con diagnóstico presuntivo de sífilis en el rastreo y alergia confirmada a la peniciclina. Se construye la pregunta que generó el caso, se diseña una estrategia de búsqueda, y se analizan las dos citas más pertinentes para responderla. Se repasa brevemente el tema de sífilis y embarazo.

Predisposing factors for nevirapine toxicity among AIDS patients with low baseline CD4 count.

The objective of the study was to determine the predisposing factors and incidence of toxicity among AIDS patients treated with a nevirapine (NVP)-based regimen in clinical practice. A retrospective cohort study of representative samples of AIDS patients treated with a NVP-based regimen was performed. A total of 206 adult HIV/AIDS cases with median age (IQR) 33 years (range, 29-38 years), 51% male, treated between January 2004-December 2005, were included. Most (92.2%) of the patients were naïve to antiretroviral drug. The incidence of NVP toxicity was 1.09/100 person-months. The median onset time was 4 weeks post NVP initiation (2.57 weeks for skin toxicity and 12.43 weeks for hepatic toxicity). History of drug allergy and NVP toxicity were significantly associated (p = 0.006), as were sulfamethoxazole allergy and toxicity (p = 0.015). Regarding concomitant medication, concurrent anti-tuberculosis drugs significantly increased the risk of NVP associated liver toxicity (p = 0.001). Therefore, it is important to monitor adverse events from NVP, including liver function tests among HIV/AIDS patients with history of drug allergy, especially against sulfamethoxazole, and those concurrently treated with antituberculosis drugs.

Adverse reactions of fluorescein angiography: a prospective study

PURPOSES: To determine both the incidence of adverse reactions in patients who underwent fluorescein angiography for the first time and to determine whether systemic arterial hypertension, diabetes or allergy history increases the chance of reaction to intravenous fluorescein. METHODS:Data collection was carried out between January 2001 and October 2002 in Recife, Brazil. Patients with prior fluorescein angiography history, pregnant patients or patients in use of corticosteroids, immunosuppressive or antihistamine drugs were excluded. RESULTS: Out of 1,500 enrolled patients, 1,039 (69.3 percent) underwent the test for the first time. The mean age was 58 ± 16 years and the median age was 60 years. Of these, 628 (60.4 percent) were women. Nausea occurred in 71 (6.83 percent) patients, vomiting in 14 (1.35 percent), urticaria in 11 (1.06 percent), bronchospasm in 4 (0.38 percent) and laryngeal edema in 1 (0.01 percent). Five patients presented more than one adverse reaction. Higher incidences of adverse reactions were observed in diabetic patients [p<0.002, RR=1.80 (CI=1.24-2.60)], patients with systemic arterial hypertension [p<0.002, RR=1.84 (CI=1.26-2.71)] and patients with allergy history [p<0.001, RR=3.90 (CI=2.70-5.63)]. CONCLUSIONS: A cumulative incidence of 9.72 percent adverse reactions was observed in patients who had undergone this test for the first time. The presence of the allergy history, diabetes or systemic arterial hypertension increased the incidence of adverse reactions to the dye.

OBJETIVO: Determinar a incidência de reações adversas em pacientes submetidos à angiofluoresceinografia pela primeira vez e determinar se hipertensão arterial sistêmica, diabetes ou história de alergia aumentam a chance de reações à fluoresceína intravenosa. MÉTODOS: Os dados foram coletados entre janeiro de 2001 e outubro de 2002 em Recife, Brasil. Pacientes com angiofluoresceinografia prévia, gestantes ou pacientes em uso de medicamentos corticosteróides, imunossupressores ou anti-histamínicos foram excluídos. RESULTADOS: Dos 1.500 pacientes iniciais, 1.039 (69,3 por cento) realizavam o exame pela primeira vez. A idade média foi de 58 ± 16 anos e a mediana de 60 anos. Dentre esses, 628 (60,4 por cento) pessoas eram do sexo feminino. Náusea ocorreu em 71 (6,83 por cento) pacientes, vômito em 14 (1,35 por cento), urticária em 11 (1,06 por cento), broncoespasmo em 4 (0,38 por cento) e edema de laringe em 1 (0,01 por cento). Cinco pacientes apresentaram mais de uma reação adversa. Maiores incidências de reações adversas foram observadas em diabéticos [p<0,002, RR=1,80 (IC=1,24-2,60)], hipertensos [p<0,002, RR=1,84 (IC=1,26-2,71)] e pacientes com história de alergia [p<0,001, RR=3,90 (IC=2,70-5,63)]. CONCLUSÕES: Uma incidência cumulativa de 9,72 por cento de reações adversas foi observada em pacientes submetidos à angiofluoresceinografia pela primeira vez. Presença de história de alergia, diabetes ou hipertensão arterial aumentou a incidência de reações adversas ao contraste.

Evaluation of a new premedication protocol for administration of equine rabies immunoglobulin in patients with hypersensitivity.

OBJECTIVES: The present study was undertaken to standardize skin testing and to develop a safe and effective premedication protocol for administration of ERIG in those with skin test positivity/hypersensitivity. METHODS: A method of grading of skin testing was developed using injection histamine as a positive control. This was evaluated by using it on 517 subjects who had severe (WHO category III) exposure to rabies. A premedication protocol consisting of injections pheniramine, ranitidine, hydrocortisone and adrenaline was evaluated by using it on fifty one subjects who were skin test positive/hypersensitive to ERIG. RESULTS: The premedication protocol was safe and effective as all the S1 subjects could be administered the full dose of ERIG despite being skin test positive/hypersensitive to ERIG. Besides the premedication drugs/protocol did not affect the immune response to vaccine and ERIG therapy.

Management of the patient reporting an allergy to penicillin

Recent emphasis on the prevention of surgical wound infection has highlighted the role of the anesthesiologist as the physician responsible for administering appropriate antibiotic prophylaxis. Patients often report a distant or unclear history of penicillin allergy. Administering an antibiotic to which the patient has a true allergy can provoke a life threatening reaction. The anesthesiologist should be aware of the prevalence, severity, and manifestations of allergies to antibiotics, as well as the available alternatives. Unnecessary administration of more powerful broad-spectrum antibiotics leads to the development of antimicrobial resistance and should be avoided. It is the anesthesiologists' duty to balance these issues when selecting appropriate antibiosis

The Thai Anesthesia Incidents Study (THAI Study) of perioperative allergic reactions.

OBJECTIVES: To determine the incidence, risk factors, signs, symptoms and management of perioperative allergic reactions in the Thai Anesthesia Incidents Study (THAI Study). MATERIAL AND METHOD: Between February 1, 2003, and January 31, 2004, a descriptive, prospective, multicenter study was conducted in 20 hospitals across Thailand. All patients receiving anesthetic and medical agents were monitored for allergic reactions for the first 24 postoperative-hours. Signs and symptoms of suspected allergic reactions included skin reactions, wheezing and unexpected hypotension. The details of allergic reactions were reviewed and recorded. RESULTS: Allergic reactions occurred in 30 of the 163,403 patients included in this study. The reaction-incidence was approximately 1 in 5,500 cases of anesthesia. Forty-eight percent of the affected patients had a history of allergic reactions. The manifestations were skin reactions, hypotension and wheezing in 38, 22 and 19 percent of the overall symptoms, respectively. Reactions were mild, moderate and severe in 40, 23 and 37 percent of the patients, respectively. The three drugs most suspected of causing the reaction(s) were antibiotics (19%), muscle relaxants (17%) and propofol (15%). All of the affected patients recovered after treatment including the one who suffered cardiac arrest because of the allergic reaction. CONCLUSION: The incidence of perioperative allergic reactions was 1 in 5,500 cases of anesthesia. History of allergies was obtained from half of the patients and the most common sign was a skin reaction. The drugs most suspected of causing an allergic reaction were antibiotics. All of the patients responded well to rescue treatment.

Dapsone syndrome with acute renal failure during leprosy treatment: case report

Dapsone syndrome is a rare hypersensitivity reaction to dapsone and is characterized by high fever, papular or exfoliative dermatitis, progressing to liver toxicity and generalized lymphadenopathy, resembling a mononucleosis infection. We report a patient who developed acute renal failure, as well as other complications characteristic of dapsone syndrome, during leprosy treatment. Renal involvement had not been previously described as a dapsone syndrome feature.

A Case of Vanishing Bile Duct Syndrome Associated with Hypersensitivity to Allopurinol / 대한간학회지

Allopurinol is frequently used for the treatment of hyperuricemia and gout. Sometimes, a life-threatening reaction develops, as is illustrated by the following case report. We describe a 60-year-old male patient who was treated with allopurinol because of asymptomatic hyperuricemia, and he was presented with fever, skin rash, eosinophilia, worsening renal function and vanishing bile duct syndrome. In this report, we discussed vanishing bile duct syndrome as a serious side effect of allopurinol, and we briefly reviewed the etiology, prevention, and treatment modalities for vanishing bile duct syndrome.

Farmacodermia / Pharmacodermia

A farmacodermia é a reação adversa mais comum aos medicamentos. As reações variam desde desconfortos leves até situações graves. Essa variedade de reações sugere uma multiplicidade de mecanismos envolvidos em sua patogenia

Alergia à lidocaína: relato de caso / Lidocaine allergy: case report

JUSTIFICATIVA E OBJETIVOS: Embora pareça ser extremamente rara, a real incidência de alergia à lidocaína é desconhecida. Eventos adversos como toxicidade ou reações fóbicas são freqüentemente interpretados como reações alérgicas. As respostas alérgicas geralmente acontecem devido a conservantes ou antioxidantes presentes nos agentes anestésicos. O objetivo deste relato é apresentar um caso de reação alérgica à lidocaína injetada por via subaracnóidea, no intuito de alertar profissionais da área de saúde para esta possibilidade com diagnóstico rápido e início precoce do tratamento. RELATO DO CASO: Paciente do sexo feminino, 16 anos, submetida a ureterolitotripsia a laser para ressecção de cálculo ureteral sob sedação e bloqueio subaracnóideo com lidocaína a 5 por cento (50 mg). Minutos após, a paciente apresentou placas eritematosas e pruriginosas no pescoço e tronco e edema discreto nas pálpebras e nos lábios. Foi tratada com prometazina, com reversão completa do quadro. Posteriormente, foi encaminhada ao serviço de Imunopediatria onde foram realizados testes de desencadeamento alérgico. Apresentou teste intradérmico positivo, sendo confirmada a hipótese de alergia à lidocaína. CONCLUSÕES: A reação alérgica à lidocaína é rara, no entanto é necessário que os profissionais da área de saúde estejam sempre alertas para essa ocorrência.

Stevens-Johnson syndrome and toxic epidermal necrolysis-challenges of recognition and management.

Skin adverse drug reactions (ADRs) generally present as transient erythematous macular/papular rashes. However these can many a times be the initial presentation of serious muco-cutaneous ADRs such as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). The incidence of SJS varies from 1.2 to 6 per million patient-years and that of TEN to be 0.4 to 1.2 per million patient-years. The pathophysiological mechanism of SJS and TEN have not been fully elucidated. The aetiological factors of SJS and TEN are diverse; drugs being the cause in more than 80% cases of TEN and about 40-50% cases of SJS. Mucous membranes are affected in nearly all cases. The extent of epidermal sloughing may vary and forms a basis for the classification of an individual case as SJS or TEN. Prognosis of SJS is better than that of TEN; mortality rates being about 5% and 30%-40% respectively. Specific therapy for these conditions is yet not available. The use of systemic corticosteroids has been controversial. Early diagnoses can prevent/reduce the morbidity of such serious ADRs. This article provides a brief review of the clinical presentation and management of SJS and TEN.

Renin angiotensin aldosterone system and drug allergies complicated with hypotension.

It has been discussed in several studies that non-immunologic factors, such as renin angiotensin aldosterone system (RAAS) may play a role in the pathophysiology of anaphylaxis. This study aimed to determine whether RAAS plays a part in the fall in blood pressure during drug reactions or not. Twenty patients who experienced hypotension during drug reaction and 15 healthy volunteers were enrolled in this study. None of the patients in the study or control groups were under treatment with any drug that was capable of influencing to RAAS. Serum levels of angiotensin-I (A-I), angiotensin-II (A-II), angiotensin converting enzyme (ACE) and aldosterone were measured in both study and control groups. The Mann-Whitney U test was used to compare the results of the groups. There were no statistically significant differences between the groups with respect to A-I, A-II, ACE and aldosterone levels. It was concluded that a fall in blood pressure during drug reaction must be the result of mast cell mediator effects on the vascular wall rather than RAAS impairment.