51
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Garvey LH, Ebo DG, Krøigaard M, Savic S, Clarke R, Cooke P, Dewachter P, Garcez T, Guttormsen AB, Hopkins PM, Hepner DL, Khan DA, Kolawole H, Kopac P, Marshall S, Mertes PM, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Scherer K, Takazawa T, Volcheck GW, Voltolini S, Laguna JJ. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth 2019; 123:e126-e134. [DOI: 10.1016/j.bja.2019.03.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023] Open
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52
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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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53
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Kvisselgaard AD, Melchiors BB, Krøigaard M, Garvey LH. Lidocaine as a Rare and Hidden Allergen in the Perioperative Setting: A Case Report. A A Pract 2019; 12:430-432. [PMID: 30633002 DOI: 10.1213/xaa.0000000000000955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Local anesthetics are used throughout the health care system. In the perioperative setting and in other settings of exposure to local anesthetics, true allergy is reported very rarely. We present an unusual case of immediate-type perioperative hypersensitivity to lidocaine with cross-reaction to mepivacaine, which was missed on initial investigation. This case illustrates that lidocaine may be a "hidden allergen" in the perioperative setting and should always be considered a potential culprit in cases of suspected perioperative hypersensitivity. The case also demonstrates that suspected perioperative hypersensitivity requires highly specialized investigation and close collaboration between allergists and anesthesiologists.
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Affiliation(s)
- Ask D Kvisselgaard
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Birgitte B Melchiors
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,Department of Neuroanaesthesia, Rigshospitalet, University of Copenhagen, Denmark
| | - Mogens Krøigaard
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark
| | - Lene H Garvey
- From the Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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54
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Misbah SA, Krishna MT. Peri-Operative Anaphylaxis-An Investigational Challenge. Front Immunol 2019; 10:1117. [PMID: 31191519 PMCID: PMC6549036 DOI: 10.3389/fimmu.2019.01117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with suspected peri-operative anaphylaxis (POP) require thorough investigation to identify underlying trigger(s) and enable safe anesthesia for subsequent surgery. The changing epidemiology of POP has been striking. Previous estimates of the incidence of POP have ranged between 1:6,000 and1:20,000 anesthetics, but more recent data from France and the United Kingdom suggest an estimated incidence of 1:10,000. Other important changes include a change in the hierarchy of well-recognized triggers, with antibiotics (beta-lactams) supplanting neuromuscular blockers (NMB) as the leading cause of POP. The emergence of chlorhexidine, patent blue dye, and teicoplanin as important triggers have also been noteworthy findings. The mainstay of investigation revolves around critical analysis of the time-line of events leading up to anaphylaxis coupled with judicious skin testing. Skin tests have limitations with respect to unknown predictive values for most drugs/agents and therefore, knowledge of background positivity in healthy controls, test characteristics of individual drugs and the use of non-irritant concentrations is essential to avoid both false-positive and false-negative results. Specific IgE assays for individual drugs are available only for a limited number of agents and are not a substitute for skin testing. Acute serum total tryptase has a high specificity and positive predictive value in IgE-mediated POP anaphylaxis but is limited by its moderate sensitivity and negative predictive value. Planning for safe anesthesia in this group of patients is particularly challenging and consequently anesthetists need to be alert to the possibility of repeat episodes of anaphylaxis. Because of the limitations of current investigations for POP, collecting systematic data on the outcome of repeat anesthesia is valuable in validating current investigatory approaches. This paper reviews the changing epidemiology of POP with reference to the main triggers, and the investigation and outcome of subsequent anesthesia.
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Affiliation(s)
- Siraj A Misbah
- Department of Clinical Immunology, Oxford University Foundation Hospitals NHS Trust, Oxford, United Kingdom
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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55
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Chlorhexidine allergy in the perioperative setting: a narrative review. Br J Anaesth 2019; 123:e95-e103. [PMID: 30955832 DOI: 10.1016/j.bja.2019.01.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/04/2019] [Accepted: 01/26/2019] [Indexed: 02/03/2023] Open
Abstract
Chlorhexidine is an antiseptic with a broad spectrum of activity and a persistent effect on skin. Consequently, it has become an ubiquitous antiseptic in healthcare and the community. As use has become widespread, increasing numbers of cases of allergy have been reported in the literature, including cases of anaphylaxis to chlorhexidine gels used on mucous membranes, chlorhexidine-impregnated devices such as central venous catheters, chlorhexidine preparations used on wounds and broken skin, and cases after dental procedures. Numerous governmental warnings have been issued over recent decades to warn of the risk of allergy to chlorhexidine on mucosal surfaces or in medical devices. Whilst the number of published cases likely underestimates the true prevalence of reactions, we retrospectively surveyed clinics with experience in investigating perioperative chlorhexidine allergy. Despite differences in investigation practice before the survey took place, 13 clinics responded which together had diagnosed 252 cases of anaphylaxis to chlorhexidine, and cases of delayed allergy. In eight of 13 clinics, chlorhexidine was within the top four most commonly diagnosed causes of perioperative anaphylaxis. Despite this, the incidence of anaphylaxis to chlorhexidine is low given that patients are very commonly exposed. Sensitisation of healthcare workers can occur, but is uncommon. Before exposing patients to this antiseptic, consideration of the potential risk vs benefit should be undertaken, particularly for higher risk exposures, such as mucosal exposure or i.v. exposure via impregnated lines. Difficulties exist in protecting patients with known allergies from re-exposure to chlorhexidine, which would be improved with uniform labelling and chlorhexidine product registers.
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56
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Opstrup MS, Jemec GBE, Garvey LH. Chlorhexidine Allergy: On the Rise and Often Overlooked. Curr Allergy Asthma Rep 2019; 19:23. [PMID: 30874959 DOI: 10.1007/s11882-019-0858-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW In recent years, the risk of allergy to chlorhexidine is increasingly recognised. In this review, we discuss why the allergy is so easily overlooked and point out several preventative initiatives that can minimise the risk of both chlorhexidine sensitisation and allergy development and accidental re-exposure in patients with chlorhexidine allergy. Testing for chlorhexidine allergy is also discussed. RECENT FINDINGS Numerous reports have been published from many different specialties. Symptoms range from mild skin symptoms to life-threatening anaphylaxis. Testing for chlorhexidine allergy is based on skin testing and in vitro testing. Recently, it was found that both skin prick testing and specific IgE have high sensitivities and specificities. This review gives an overview of chlorhexidine allergy with a special focus on preventative initiatives and testing.
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Affiliation(s)
- Morten Schjørring Opstrup
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark. .,Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Kildegårdsvej 28, 2900, Hellerup, Denmark.
| | - Gregor Borut Ernst Jemec
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Kildegårdsvej 28, 2900, Hellerup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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57
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Opstrup MS, Garvey LH. Chlorhexidine Allergy: Mild Allergic Reactions Can Precede Anaphylaxis in the Healthcare Setting. Turk J Anaesthesiol Reanim 2019; 47:342-344. [PMID: 31380516 DOI: 10.5152/tjar.2019.22058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/26/2018] [Indexed: 11/22/2022] Open
Abstract
Chlorhexidine can cause severe immediate-type allergic reactions such as urticaria, anaphylactic shock or, even, cardiac arrest. We report the case of a patient who developed perioperative anaphylactic shock caused by chlorhexidine 1 year after a postoperative urticarial reaction, which was assumed not to be significant at the time. This case highlights the importance of identifying mild allergy symptoms after exposure to chlorhexidine at the pre-anaesthetic assessment to prevent more severe allergic reactions in future.
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Affiliation(s)
- Morten Schjørring Opstrup
- Department of Dermatology, Zealand University Hospital, Roskilde, Denmark.,Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | - Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital Gentofte, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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58
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Abstract
Summary We report three precautionary cases of perioperative anaphylaxis to chlorhexidine isopropyl alcohol antiseptic wipes (CAW). In two cases, the patients were inadvertently re-exposed to CAW despite known chlorhexidine hypersensitivity. Chlorhexidine has been described as ‘the hidden allergen’. As a result, patients may suffer multiple reactions before chlorhexidine is confirmed as the cause. Healthcare workers may not recognize that products they use for common clinical steps contain chlorhexidine. These cases highlight the need for constant vigilance to facilitate the safe management of patients with a history of chlorhexidine anaphylaxis.
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59
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Mayorga C, Ebo DG, Lang DM, Pichler WJ, Sabato V, Park MA, Makowska J, Atanaskovic-Markovic M, Bonadonna P, Jares E. Controversies in drug allergy: In vitro testing. J Allergy Clin Immunol 2019; 143:56-65. [DOI: 10.1016/j.jaci.2018.09.022] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/18/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
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60
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Maciag MC, Foley JP, Broyles AD. Reply. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:2176-2177. [PMID: 30390913 PMCID: PMC6604832 DOI: 10.1016/j.jaip.2018.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Michelle C Maciag
- Department of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Joseph P Foley
- Harvard Medical School, Boston, Mass; Department of Anesthesia, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Ana D Broyles
- Department of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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61
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Opstrup MS, Garvey LH. Intraoperative anaphylaxis: remember the hidden allergens. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:2175-2176. [DOI: 10.1016/j.jaip.2018.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/27/2018] [Indexed: 11/28/2022]
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62
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Garvey L, Hunter J. Changing culprits in perioperative anaphylaxis. Br J Anaesth 2018; 121:114-117. [DOI: 10.1016/j.bja.2018.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
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63
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Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth 2018; 121:159-171. [DOI: 10.1016/j.bja.2018.04.014] [Citation(s) in RCA: 290] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/30/2018] [Accepted: 04/13/2018] [Indexed: 12/25/2022] Open
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64
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In Vitro Diagnosis of Immediate Drug Hypersensitivity During Anesthesia: A Review of the Literature. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1176-1184. [DOI: 10.1016/j.jaip.2018.01.004] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/05/2018] [Accepted: 01/16/2018] [Indexed: 02/07/2023]
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65
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Bouadma L, Klompas M. Oral care with chlorhexidine: beware! Intensive Care Med 2018; 44:1153-1155. [DOI: 10.1007/s00134-018-5221-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
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66
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Zhou E, Parikh PS, Kanchuger MS, Balsam LB. Intraoperative Anaphylaxis to Chlorhexidine During LVAD and Transplant Surgery. J Cardiothorac Vasc Anesth 2018; 33:169-172. [PMID: 29859756 DOI: 10.1053/j.jvca.2018.04.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Eric Zhou
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, NY.
| | - Purvi S Parikh
- Department of Medicine, Division of Rheumatology, NYU Langone Medical Center, New York, NY; Department of Medicine, Division of Infectious Diseases and Immunology, NYU Langone Medical Center, New York, NY
| | - Marc S Kanchuger
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Medical Center, New York, NY
| | - Leora B Balsam
- Division of Cardiac Surgery, UMass Memorial Medical Center, Worcester, MA
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67
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Abstract
Background For most physicians, quantification of drug-specific immunoglobulin E (drug-sIgE) antibodies constitutes the primary in vitro measure to document immediate drug hypersensitivity reactions (IDHR). Unfortunately, this is often insufficient to correctly identify patients with IgE-mediated IDHR and impossible for non-IgE-mediated IDHR that result from alternative routes of basophil and mast cell activation. In these difficult cases, diagnosis might benefit from cellular tests such as basophil activation tests (BAT). Aim The aim was to review the potential and limitations of quantification of sIgE and BAT in diagnosing IDHR. The utility of quantification of serum tryptase is discussed. Methods A literature search was conducted using the key words allergy, basophil activation, CD63, CD203c, diagnosis, drugs, hypersensitivity, flow cytometry, specific IgE antibodies; this was complemented by the authors’ own experience. Results The drugs that have been most studied with both techniques are β-lactam antibiotics and curarizing neuromuscular blocking agents (NMBA). For sIgE morphine, data are available on the value of this test as a biomarker for sensitization to substituted ammonium structures that constitute the major epitope of NMBA, especially rocuronium and suxamethonium. For the BAT, there are also data on non-steroidal anti-inflammatory drugs (NSAIDs) and iodinated radiocontrast media. For β-lactam antibiotics, sensitivity and specificity of sIgE varies between 0 and 85% and 52 and 100%, respectively. For NMBA, sensitivity and specificity varies between 38.5 and 92% and 85.7 and 100%, respectively. Specific IgE to morphine should not be used in isolation to diagnose IDHR to NMBA nor opiates. For the BAT, sensitivity generally varies between 50 and 60%, whereas specificity attains 80%, except for quinolones and NSAIDs. Conclusions Although drug-sIgE assays and BAT can provide useful information in the diagnosis of IDHR, their predictive value is not absolute. Large-scale collaborative studies are mandatory to harmonize and optimize test protocols and to establish drug-specific decision thresholds.
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68
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Khan DA. Precision Medicine in the Management of Drug Allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0159-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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69
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Toletone A, Dini G, Massa E, Bragazzi NL, Pignatti P, Voltolini S, Durando P. Chlorhexidine-induced anaphylaxis occurring in the workplace in a health-care worker: case report and review of the literature. LA MEDICINA DEL LAVORO 2018; 109:68-76. [PMID: 29411737 PMCID: PMC7682154 DOI: 10.23749/mdl.v109i1.6618] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 12/18/2017] [Accepted: 12/22/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chlorhexidine has been widely used in the occupational field as an effective antiseptic and disinfectant, especially in the health-care services. Several cases of allergic reactions to chlorhexidine have been reported, both in the general population and in workers. OBJECTIVES To describe a case of occupational chlorhexidine-induced severe anaphylaxis that occurred in the workplace in a health-care worker (HCW) and to update the literature on chlorhexidine as a possible occupational allergen. METHODS We report a case of a severe anaphylactic reaction that occurred in the workplace in a 63-year-old man, who had worked as a dentist for over 20 years. We also carried out a systematic review of the literature according to the PRISMA guidelines. No time or language filters were applied. Only occupational case-reports and case-series were included. RESULTS The causative role of chlorhexidine was suspected owing to the presence of chlorhexidine-containing products in the workplace. Positive results on the Basophil Activation Test confirmed the diagnosis of immediate chlorhexidine-induced hypersensitivity reaction and excluded a role of other disinfectants. No other causes of anaphylaxis were suspected. Our systematic literature review identified 14 cases of occupational chlorhexidine-induced allergy among HCWs; in these cases, the clinical presentation was mild and the symptoms resolved. No cases of systemic reactions in the workplace were reported. CONCLUSIONS This is the first report of chlorhexidine-induced severe anaphylaxis occurring in the workplace. This case report underlines the importance of investigating and being aware of individual and environmental risk factors in the occupational field, which can cause, albeit infrequently, severe reactions with serious consequences.
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Affiliation(s)
- Alessandra Toletone
- Department of Health Sciences (DISSAL), Postgraduate School in Occupational Medicine, University of Genoa, Italy.
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70
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Lasa EM, González C, García-Lirio E, Martínez S, Arroabarren E, Gamboa PM. Anaphylaxis caused by immediate hypersensitivity to topical chlorhexidine in children. Ann Allergy Asthma Immunol 2017; 118:118-119. [PMID: 28007083 DOI: 10.1016/j.anai.2016.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 09/28/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Eva María Lasa
- Servicio de Alergología, Hospital Universitario Donostia, San Sebastián, España.
| | - Carlos González
- Servicio de Alergología, Hospital Universitario de Basurto, Bilbao, España
| | | | - Sara Martínez
- Servicio de Alergología, Hospital Universitario Donostia, San Sebastián, España
| | - Esozia Arroabarren
- Servicio de Alergología, Complejo Hospitalario de Navarra, Pamplona, España
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71
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Anaphylaxis to invasive chlorhexidine administration despite tolerance of topical chlorhexidine use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1067-1069.e1. [PMID: 29226805 DOI: 10.1016/j.jaip.2017.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 11/24/2022]
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72
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Kvisselgaard AD, Mosbech HF, Fransson S, Garvey LH. Risk of Immediate-Type Allergy to Local Anesthetics Is Overestimated-Results from 5 Years of Provocation Testing in a Danish Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1217-1223. [PMID: 28988784 DOI: 10.1016/j.jaip.2017.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/14/2017] [Accepted: 08/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Local anesthetics (LAs) are used in many health care settings and exposure during a lifetime is almost inevitable. Immediate-type allergy to LAs is considered rare among allergy experts but is commonly suspected by health care workers from other specialties, and by patients. OBJECTIVE The main aim of this study was to investigate the incidence of immediate-type allergy to LAs in our regional allergy clinic over the 5-year period 2010 to 2014. METHODS This was a retrospective single-center study of patients referred to a regional allergy clinic (excluding patients with perioperative reactions) with suspected immediate allergy to LAs, who had undergone subcutaneous provocation with 1 or more LAs. Patients were identified in the hospital clinical coding system and clinical information about the reaction and investigation results was obtained from their medical records. RESULTS A total of 164 patients (123 women/41 men; median age, 56 years; range, 7-89 years) who had 189 provocations with LAs were included over the 5-year period 2010 to 2014. All 164 patients had negative subcutaneous provocations to all 189 tests with LAs (95% CI, 0%-1.83%). Another allergen was identified in 10% (n = 17) of the patients. CONCLUSIONS None of the 164 patients with suspected immediate-type allergy to LAs reacted on provocation. Thus, no patients have been diagnosed with an immediate allergy to LAs in our regional allergy clinic in the 5-year period studied, and allergy to LAs must be considered very rare. Alternative mechanisms should be considered, but if symptoms are consistent with allergy, other potential allergens should be investigated.
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Affiliation(s)
- Ask D Kvisselgaard
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Holger F Mosbech
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Sara Fransson
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergology, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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73
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Egner W, Cook T, Harper N, Garcez T, Marinho S, Kong KL, Nasser S, Thomas M, Warner A, Hitchman J, Floss K. Specialist perioperative allergy clinic services in the UK 2016: Results from the Royal College of Anaesthetists Sixth National Audit Project. Clin Exp Allergy 2017; 47:1318-1330. [DOI: 10.1111/cea.12993] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 06/19/2017] [Accepted: 07/14/2017] [Indexed: 11/27/2022]
Affiliation(s)
- W. Egner
- Clinical Immunology and Allergy Unit; Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield UK
| | - T. Cook
- Anaesthesia and Intensive Care Medicine; Royal United Hospital Bath NHS Trust; Bath UK
| | - N. Harper
- Department of Anaesthesia; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - T. Garcez
- Immunology and Allergy; Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - S. Marinho
- Manchester Academic Health Science Centre; NIHR Translational Research Facility in Respiratory Medicine; The University of Manchester; University Hospital of South Manchester NHS Foundation Trust; Manchester UK
| | - K. L. Kong
- Department of Anaesthesia; Sandwell and West Birmingham Hospitals NHS Trust; City Hospital; Birmingham UK
| | - S. Nasser
- Department of Allergy & Clinical Immunology; Addenbrooke's NHS Trust; Cambridge UK
| | - M. Thomas
- Department of Aneasthetics; Great Ormond Street Hospital For Children NHS Trust; London UK
| | - A. Warner
- Clinical Services; Allergy UK; Sidcup UK
| | - J. Hitchman
- The Royal College of Anaesthetists Lay Committee; Royal College of Anaesthetists; London UK
| | - K. Floss
- Pharmacy Department; Oxford University Hospitals NHS Foundation Trust; Oxford UK
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74
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The Importance of Prolonged Provocation in Drug Allergy — Results From a Danish Allergy Clinic. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1394-1401. [DOI: 10.1016/j.jaip.2017.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/19/2017] [Accepted: 02/17/2017] [Indexed: 11/24/2022]
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75
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Schunter JA, Stöcker B, Brehler R. A Case of Severe Anaphylaxis to Polyhexanide: Cross-Reactivity between Biguanide Antiseptics. Int Arch Allergy Immunol 2017; 173:233-236. [PMID: 28848174 DOI: 10.1159/000478700] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/13/2017] [Indexed: 11/19/2022] Open
Abstract
We present the case of a 77-year-old female patient who suffered from severe anaphylaxis during wound care. Allergologic evaluation yielded specific IgE antibodies to chlorhexidine, but anaphylaxis to chlorhexidine was not congruent with the patient history and dermal provocation tests. However, skin prick tests provided evidence for a sensitization to polyhexanide that was further supported by the detection of specific IgE antibodies to polyhexanide, the results of basophil activation tests and IgE inhibition analysis. We presume cross-reactive IgE antibodies binding to both biguanide antiseptics and identified polyhexanide as the likely cause of the anaphylactic reaction. We recognize polyhexanide as an emerging allergen that has to be considered as a cause of anaphylaxis.
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Affiliation(s)
- Jo Ana Schunter
- Department of Dermatology, University Hospital Münster, Münster, Germany
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76
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Bahal S, Sharma S, Garvey LH, Nagendran V. Anaphylaxis after disinfection with 2% chlorhexidine wand applicator. BMJ Case Rep 2017; 2017:bcr-2017-219794. [PMID: 28790050 DOI: 10.1136/bcr-2017-219794] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A 54-year-old man with end-stage renal failure attended for dialysis. Within seconds of applying 2% w/v chlorhexidine (ChloraPrep 3 mL Wand Applicator) to the skin surrounding the insertion point of his dialysis catheter (Tesio catheter), he developed pruritus, urticaria, shortness of breath, hypotension and reduced responsiveness. Treatment for anaphylaxis was initiated with rapid improvement of his symptoms, and he made a full recovery. Allergy to chlorhexidine was confirmed with skin testing, and the patient was warned against all future exposure to chlorhexidine. Subsequent dialysis without chlorhexidine was uneventful.
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Affiliation(s)
- Sameer Bahal
- Department of Immunology, Barts Health NHS Trust, London, UK
| | - Samriti Sharma
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lene Heise Garvey
- Department of Dermatology and Allergy, Danish Anaesthesia Allergy Centre, Gentofte Hospital, Hellerup, Denmark
| | - Vasantha Nagendran
- Department of Immunology, Epsom and Saint Helier University Hospitals NHS Trust, Carshalton, UK
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77
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Vu M, Rajgopal Bala H, Cahill J, Toholka R, Nixon R. Immediate hypersensitivity to chlorhexidine. Australas J Dermatol 2017; 59:55-56. [PMID: 28589697 DOI: 10.1111/ajd.12674] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/09/2017] [Indexed: 11/26/2022]
Abstract
Chlorhexidine is a widely used and effective antiseptic agent. Although skin contact is usually well tolerated, it may cause both immediate and delayed hypersensitivity reactions. We report a case of immediate hypersensitivity to chlorhexidine causing both skin and respiratory symptoms following occupational exposure to chlorhexidine in a health-care worker.
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Affiliation(s)
- Mi Vu
- Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia
| | - Harini Rajgopal Bala
- Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia
| | - Jennifer Cahill
- Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia
| | - Ryan Toholka
- Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia
| | - Rosemary Nixon
- Occupational Dermatology Research and Education Centre, Skin and Cancer Foundation Inc., Melbourne, Victoria, Australia
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78
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Hsu Blatman KS, Hepner DL. Current Knowledge and Management of Hypersensitivity to Perioperative Drugs and Radiocontrast Media. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:587-592. [DOI: 10.1016/j.jaip.2017.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/16/2017] [Accepted: 03/21/2017] [Indexed: 12/25/2022]
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79
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Egner W, Helbert M, Sargur R, Swallow K, Harper N, Garcez T, Savic S, Savic L, Eren E. Chlorhexidine allergy in four specialist allergy centres in the United Kingdom, 2009-13: clinical features and diagnostic tests. Clin Exp Immunol 2017; 188:380-386. [PMID: 28194756 DOI: 10.1111/cei.12944] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2017] [Indexed: 12/01/2022] Open
Abstract
We describe an observational survey of diagnostic pathways in 104 patients attending four specialist allergy clinics in the United Kingdom following perioperative hypersensitivity reactions to chlorhexidine reactions. The majority were life-threatening. Men undergoing urological or cardiothoracic surgery predominated. Skin prick testing and specific immunoglobulin (sIg)E testing were the most common tests used for diagnosis. Fifty-three per cent of diagnoses were made on the basis of a single positive test. Where multiple tests were performed the sensitivity of intradermal, basophil activation and skin prick testing was 68% (50-86%), 50% (10-90%) and 35% (17-55%), respectively. Seven per cent were negative on screening tests initially, and 12 cases were only positive for a single test despite multiple testing. Intradermal tests appeared most sensitive in this context. Additional sensitization to other substances used perioperatively, particularly neuromuscular blocking agents (NMBA), was found in 28 patients, emphasizing the need to test for possible allergy to all drugs to which the patient was exposed even where chlorhexidine is positive.
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Affiliation(s)
- W Egner
- Clinical Immunology and Allergy Unit, Northern General Hospital, Sheffield, UK
| | - M Helbert
- Department of Allergy and Immunology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - R Sargur
- Clinical Immunology and Allergy Unit, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - K Swallow
- Clinical Immunology and Allergy Unit, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - N Harper
- Department of Anaesthesia, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - T Garcez
- Department of Immunology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - S Savic
- Department of Immunology, Leeds Teaching Hospitals, Leeds, UK
| | - L Savic
- Department of Anaesthetics, Leeds Teaching Hospitals, Leeds, UK
| | - E Eren
- Department of Immunology, Southampton General Hospital, Southampton, UK
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80
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Torres MJ, Romano A, Celik G, Demoly P, Khan DA, Macy E, Park M, Blumenthal K, Aberer W, Castells M, Barbaud A, Mayorga C, Bonadonna P. Approach to the diagnosis of drug hypersensitivity reactions: similarities and differences between Europe and North America. Clin Transl Allergy 2017; 7:7. [PMID: 28293415 PMCID: PMC5347172 DOI: 10.1186/s13601-017-0144-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/22/2017] [Indexed: 12/18/2022] Open
Abstract
Drug hypersensitivity reactions (DHRs) affect an unknown proportion of the general population, and are an important public health problem due to their potential to cause life-threatening anaphylaxis and rare severe cutaneous allergic reactions. DHR evaluations are frequently needed in both ambulatory and hospital settings and have a complex diagnosis that requires a detailed clinical history and other tests that may include in vitro tests and in vivo procedures such as skin tests and drug provocation tests. Although over the years both European and U.S. experts have published statements on general procedures for evaluating DHRs, a substantial discordance in their daily management exists. In this review, we highlight both the differences and the similarities between the European and U.S. perspectives. While a general consensus exists on the importance of skin tests for evaluating DHRs, concordance between Americans and Europeans exists solely regarding their use in immediate reactions and the fact that a confirmation of a presumptive diagnosis by drug provocation tests is often the only reliable way to establish a diagnosis. Finally, great heterogeneity exists in the application of in vitro tests, which require further study to be well validated.
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Affiliation(s)
- M J Torres
- Allergy Unit, National Network ARADyAL, IBIMA-Regional University Hospital of Malaga-UMA (Pavilion C), Plaza del Hospital Civil, 29009 Malaga, Spain.,BIONAND-Andalusian Centre for Nanomedicine and Biotechnology, Malaga, Spain
| | - A Romano
- Allergy Unit, Presidio Columbus, Rome, Italy.,IRCCS Oasi Maria S.S., Troina, Italy
| | - G Celik
- Department of Chest Diseases, Division of Immunology and Allergy, Ankara University School of Medicine, Ankara, Turkey
| | - P Demoly
- Hôpital Arnaud de Villeneuve, University Hospital of Montpellier and Sorbonne Universités, UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, 75013 Paris, France
| | - D A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - E Macy
- Kaiser Permanente Health Care Program, San Diego, CA USA
| | - M Park
- Mayo Clinic College of Medicine, Division of Allergic Diseases, Mayo Clinic, Rochester, MN 55905 USA
| | - K Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
| | - W Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - M Castells
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MSA USA
| | - A Barbaud
- Sorbonne Universities, UPMC Univ Paris 06, Dermatology and Allergology Department, Tenon Hospital (AP-HP), 4 rue de la chine, 75020 Paris, France
| | - C Mayorga
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMA (Pavilion C), Plaza del Hospital Civil, 29009 Malaga, Spain
| | - P Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Intergrata of Verona, Verona, Italy
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81
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Tacquard C, Collange O, Gomis P, Malinovsky JM, Petitpain N, Demoly P, Nicoll S, Mertes PM. Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey. Acta Anaesthesiol Scand 2017; 61:290-299. [PMID: 28164269 DOI: 10.1111/aas.12855] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 09/25/2016] [Accepted: 12/27/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immediate hypersensitivity reactions during anaesthesia are rare but potentially life-threatening. The epidemiology changes with time and evolving professional practice, and hence needs to be monitored. Our objective was to follow this epidemiology. METHODS This was a retrospective, observational study in French hospital clinics, conducted by GERAP members (Groupe d'Étude des Réactions Anaphylactoïdes Périopératoires). Consecutive patients seen in allergo-anaesthesia outpatient clinics, who had experienced a hypersensitivity reaction during anaesthesia between 1 January 2011 and 31 December 2012, were included. Demographic data, allergy history, drugs received before the reaction, symptoms of the reaction, results of blood samples (histamine, tryptase, IgE-specific assays), and results of the allergy assessment were recorded. RESULTS The most common causes of allergic reactions were (Neuromuscular Blocking Agents) NMBAs (N = 302; 60.6%), antibiotics (N = 91, 18.2%, Cephalosporin N = 49, 10%) and dyes (N = 27; 5.4%). Latex as an allergic agent was involved in 26 cases (5.2%), hypnotics in 11 cases (2.2%) and opioids in seven cases (1.4%). Of the NMBAs, Rocuronium had the highest proportion of reactions (13.8 reactions/100,000 vials sold) followed by Suxamethonium (13.3/100,000 vials sold). Cisatracurium had the lowest proportion of reactions (0.4/100,000 vials sold). Patients were sensitized to two or more NMBAs in 48.9% of cases and without testing, cross-sensitivity cannot be predicted. CONCLUSIONS When compared with the previous GERAP studies, NMBAs are still the most frequently triggering allergens, with marked differences between individual NMBAs, but they are now followed by antibiotics (of which greater than 50% were cephalosporins) and dyes. Anaesthetists must be aware of the differences between drugs and of the pattern of emerging allergens. For the future of safe anaesthesia, allergy assessment is essential.
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Affiliation(s)
- C. Tacquard
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - O. Collange
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
| | - P. Gomis
- Department of Anaesthesiology and Intensive Care; Hôpital Maison Blanche; CHU de Reims; Reims France
| | - J.-M. Malinovsky
- Department of Anaesthesiology and Intensive Care; Hôpital Maison Blanche; CHU de Reims; Reims France
| | - N. Petitpain
- Centre Regional de Pharmacovigilance de Lorraine; CHU de Nancy; Nancy France
| | - P. Demoly
- Department of Pulmonology - Division of Allergy; Hôpital Arnaud de Villeneuve; University Hospital of Montpellier; Montpellier France
- UPMC Paris 06; UMR-S 1136; IPLESP; Equipe EPAR; Sorbonne Universités; Paris France
| | - S. Nicoll
- Department of anaesthesia; Christchurch Hospital; Christchurch New Zealand
| | - P. M. Mertes
- Department of Anaesthesiology and Intensive Care; Hôpitaux Universitaires de Strasbourg; Strasbourg France
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Kvisselgaard AD, Krøigaard M, Mosbech HF, Garvey LH. No cases of perioperative allergy to local anaesthetics in the Danish Anaesthesia Allergy Centre. Acta Anaesthesiol Scand 2017; 61:149-155. [PMID: 27878813 DOI: 10.1111/aas.12833] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/30/2016] [Accepted: 10/30/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Local anaesthetics (LA) are often suspected as possible causes of allergic reactions. The Danish Anaesthesia Allergy Centre (DAAC) is the national reference centre for investigation of perioperative allergic reactions. The purpose of this study was to investigate the incidence of IgE-mediated immediate type perioperative allergic reactions to LA. METHODS In the period 2004-2013, a total of 409 patients (244 women/165 men; median age 49 years, range 1-86 years) were investigated in DAAC on suspicion of allergy associated with anaesthesia and surgery. A total of 162 (40%) patients were exposed to one or more LA. Suspected allergy to LA was investigated by prick test, intradermal test and subcutaneous provocation with the suspected drug. Patients with positive skin tests still underwent subcutaneous provocation, as false positive skin tests can occur. RESULTS A total of 203 test series with LA were carried out on 162 patients (89 women/73 men; mean age 49 years, range 2-85 years) with the following drugs: Lidocaine n = 80 (49%), bupivacaine n = 82 (51%), ropivacaine n = 31 (19%) and mepivacaine n = 10 (6%). All 162 patients had negative subcutaneous provocation for all tested LA (95% CI: 0-1.8%). Investigations revealed another allergen in 52 of 162 patients. CONCLUSION None of the 162 patients with suspected perioperative allergic reactions and exposure to LA reacted on subcutaneous provocation with the relevant LA. Thus, no patients have been diagnosed with allergy to LA in DAAC in the period 2004-2013 and allergy to LA must be considered very rare in this population.
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Affiliation(s)
- A. D. Kvisselgaard
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - M. Krøigaard
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - H. F. Mosbech
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
| | - L. H. Garvey
- Danish Anaesthesia Allergy Centre; Allergy Clinic; Department of Dermatology and Allergy; Herlev and Gentofte Hospital; University of Copenhagen; Hellerup Denmark
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83
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Cogné Y, Mouton-Faivre C, Cavasino T, Teychene AM, de Pontual L, Dewachter P. Chlorhexidine-induced IgE-mediated allergy in a 6-year-old child. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 5:837-838. [PMID: 28042002 DOI: 10.1016/j.jaip.2016.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/19/2016] [Accepted: 11/23/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Yann Cogné
- Service de Pédiatrie Générale, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, Bondy and Université Paris 13, France
| | - Claudie Mouton-Faivre
- Service de Dermatologie and Consultation d'Allergo-Anesthésie, Centre Hospitalier Universitaire de Nancy and Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Thomas Cavasino
- Service de Pédiatrie Générale, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, Bondy and Université Paris 13, France
| | - Anne-Marie Teychene
- Service de Pédiatrie Générale, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, Bondy and Université Paris 13, France
| | - Loïc de Pontual
- Service de Pédiatrie Générale, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Hôpital Jean Verdier, Bondy and Université Paris 13, France
| | - Pascale Dewachter
- Service d'Anesthésie-Réanimation Chirurgicale, Groupe Hospitalier de Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Bondy and INSERM UMR-S970, Université Paris 13, Sorbonne Paris Cité, France.
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84
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Trautmann A, Seidl C, Stoevesandt J, Seitz CS. General anaesthesia-induced anaphylaxis: impact of allergy testing on subsequent anaesthesia. Clin Exp Allergy 2016; 46:125-32. [PMID: 26767493 DOI: 10.1111/cea.12632] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Immunoglobulin E-mediated allergy to drugs and substances used during general anaesthesia as well as non-allergic drug hypersensitivity reactions may account for anaesthesia-induced anaphylaxis. As IgE-mediated anaphylaxis is a potentially life-threatening reaction, identification of the culprit allergen is essential to avoid anaphylaxis recurrence during subsequent general anaesthesia. OBJECTIVE To study whether preventive recommendations derived from allergy testing after intraoperative anaphylaxis were followed in subsequent general anaesthesia. METHODS Results of standardized allergy testing after anaesthesia-induced anaphylaxis and outcome of subsequent general anaesthesia were analysed retrospectively. RESULTS Fifty-three of 107 patients were diagnosed with IgE-mediated allergy to a drug or substance used during general anaesthesia, and 54 patients were test negative. Twenty-eight of 29 allergy patients tolerated subsequent general anaesthesia uneventfully. One patient with cefazolin allergy suffered from anaphylaxis recurrence due to accidental reapplication of cefazolin. Twenty-two of 24 test-negative patients tolerated subsequent general anaesthesia, whereas two patients again developed anaphylaxis despite pre-medication regimens. CONCLUSION AND CLINICAL RELEVANCE Our results confirm the practical impact of allergy testing in general anaesthesia-induced anaphylaxis. By identification of the allergen, it is possible to avoid allergic anaphylaxis during subsequent anaesthesia. In most cases, recommended pre-medication seems to prevent the recurrence of non-allergic drug hypersensitivity reactions.
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Affiliation(s)
- A Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - C Seidl
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - J Stoevesandt
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - C S Seitz
- Department of Dermatology and Allergy, University Hospital Göttingen, Göttingen, Germany
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85
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86
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Decuyper II, Ebo DG, Uyttebroek AP, Hagendorens MM, Faber MA, Bridts CH, De Clerck LS, Sabato V. Quantification of specific IgE antibodies in immediate drug hypersensitivity: More shortcomings than potentials? Clin Chim Acta 2016; 460:184-9. [PMID: 27376983 DOI: 10.1016/j.cca.2016.06.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND For many physicians, quantification of serum drug-specific IgE (sIgE) antibodies constitutes the first measure in the diagnostic approach of immediate drug hypersensitivity reactions (IDHR). AIM To review the accuracy and limitations of the main drug-sIgE tests, especially those that are commercially available. METHODS A literature search was conducted, using the key-words allergy, diagnosis, drugs, hypersensitivity, specific IgE antibodies; this was complemented by the authors' own experience. RESULTS The drugs that have mostly been studied appeared to be β-lactam antibiotics, neuromuscular blocking agents (NMBA) and morphine, the latter as a biomarker for sensitisation to substituted ammonium structures that constitute the major epitope of NMBA. For β-lactams sensitivity and specificity varied between 0-85% and 52-100%, respectively. For NMBA, sensitivity and specificity varied between 38.5-92% and 92-100%, respectively. With respect to sIgE to morphine it appears this drug to be a sensitive biomarker for sensitisation to rocuronium and suxamethonium but not for atracurium. However, sIgE morphine should not be applied in isolation to diagnose IDHR to NMBA nor opiates. CONCLUSIONS Although drug-sIgE assay can provide valuable information they should not be performed in isolation to establish correct diagnosis, as their predictive value is not per se absolute. Larger comprehensive studies are urgently required to determine the accuracy of drug-sIgE assays.
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Affiliation(s)
- I I Decuyper
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - D G Ebo
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium.
| | - A P Uyttebroek
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - M M Hagendorens
- Faculty of Medicine and Health Science, Department of Pediatrics, University of Antwerp, Antwerp University Hospital, Belgium
| | - M A Faber
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - C H Bridts
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - L S De Clerck
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
| | - V Sabato
- Faculty of Medicine and Health Science, Department of Immunology, Allergology, Rheumatology, University of Antwerp, Antwerp University Hospital, Belgium
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87
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Ibler KS, Jemec GBE, Garvey LH, Agner T. Prevalence of delayed-type and immediate-type hypersensitivity in healthcare workers with hand eczema. Contact Dermatitis 2016; 75:223-9. [DOI: 10.1111/cod.12587] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/06/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kristina S. Ibler
- Department of Dermatology, Roskilde Hospital; University of Copenhagen; 4000 Roskilde Denmark
- Department of Dermatology, Bispebjerg Hospital; University of Copenhagen; 2400 Copenhagen Denmark
| | - Gregor B. E. Jemec
- Department of Dermatology, Roskilde Hospital; University of Copenhagen; 4000 Roskilde Denmark
| | - Lene H. Garvey
- Allergy Clinic; Copenhagen University Hospital Gentofte; 2900 Hellerup Denmark
| | - Tove Agner
- Department of Dermatology, Bispebjerg Hospital; University of Copenhagen; 2400 Copenhagen Denmark
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88
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Opstrup MS, Poulsen LK, Malling HJ, Jensen BM, Garvey LH. Dynamics of plasma levels of specific IgE in chlorhexidine allergic patients with and without accidental re-exposure. Clin Exp Allergy 2016; 46:1090-8. [PMID: 27079633 DOI: 10.1111/cea.12743] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/25/2016] [Accepted: 04/08/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chlorhexidine is an effective disinfectant, which may cause severe allergic reactions. Plasma level of specific IgE to chlorhexidine (ImmunoCAP(®) ) has high estimated sensitivity and specificity when measured within 6 months of allergic reaction, but knowledge of the dynamics over longer time periods is lacking and it is unknown whether levels fall below <0.35 kUA/L in patients with previously elevated levels. It is also unclear whether re-exposure influences levels of specific IgE. OBJECTIVE To investigate the dynamics of specific IgE in chlorhexidine allergic patients with and without re-exposure. METHODS All patients diagnosed with chlorhexidine allergy in the Danish Anaesthesia Allergy Centre January 1999 to March 2015 were invited to participate. The study included blood samples from the time of reaction and time of investigation and blood samples drawn prospectively over several years. RESULTS Overall, 23 patients were included. Specific IgE within hours of reaction was available in eight patients and was >0.35 kUA/L in six of these. During allergy investigations, usually 2-4 months later, specific IgE was >0.35 kUA/L in 22 of 23 patients. In the following months/years specific IgE declined <0.35 kUA/L in 17 of 23 patients (most rapidly within 4 months). Nine re-exposures in the healthcare setting were reported by seven patients (35%). Most re-exposures caused symptoms and were followed by an increase in specific IgE. Two patients with specific IgE <0.35 kUA/L reacted upon re-exposure. CONCLUSIONS & CLINICAL RELEVANCE Time from reaction should be considered when interpreting specific IgE results. Specific IgE is >0.35 kUA/L in most patients at time of reaction but should be repeated after a few weeks/months if negative. The optimal sampling time seems to be >1 month and <4 months. A value <0.35 kUA/L neither excludes allergy nor implies loss of reactivity in previously sensitized patients. Re-exposures are common, often iatrogenic, and can cause a rebound in specific IgE.
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Affiliation(s)
- M S Opstrup
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark.,National Allergy Research Centre, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - L K Poulsen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - H J Malling
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - B M Jensen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - L H Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermato-Allergology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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89
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Spoerl D, Jandus P, Harr T. Pitfalls and peculiarities in chlorhexidine allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:991-2. [PMID: 27130710 DOI: 10.1016/j.jaip.2016.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/22/2016] [Accepted: 03/28/2016] [Indexed: 11/30/2022]
Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, University Hospital and Faculty of Medicine, Genève, Switzerland.
| | - Peter Jandus
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, University Hospital and Faculty of Medicine, Genève, Switzerland
| | - Thomas Harr
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, University Hospital and Faculty of Medicine, Genève, Switzerland
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90
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Perioperative Hypersensitivity Reactions: Diagnosis, Treatment and Evaluation. CURRENT TREATMENT OPTIONS IN ALLERGY 2016. [DOI: 10.1007/s40521-016-0078-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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91
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Asserhøj LL, Mosbech H, Krøigaard M, Garvey LH. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut†. Br J Anaesth 2016; 116:77-82. [PMID: 26675952 DOI: 10.1093/bja/aev360] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Propofol is thought to be a potential cause of allergic reactions in patients allergic to egg, soy or peanut, since current formulations contain an emulsion that includes egg lecithin and soybean oil. However, other than six case reports lacking in confirmatory evidence of an allergic reaction, there is no evidence linking the two types of allergies. The aim of this study was to examine the frequency of propofol allergy and to investigate if patients with specific immunoglobulin E (IgE) to egg, soy or peanut tolerated propofol. METHODS Study A examined the frequency of propofol allergy in 273 patients systematically investigated for suspected perioperative allergic reactions. Of these, 153 had been exposed to propofol and underwent skin tests and intravenous provocation. Study B retrospectively investigated propofol exposure and tolerance in 520 adult patients with a positive specific IgE to egg, soy or peanut. RESULTS Four of the 153 propofol-exposed patients (2.6%) investigated in study A were diagnosed with propofol allergy. Of these, three tested positive only on intravenous provocation. None of the four had allergic symptoms when eating egg, soy or peanut and none had detectable levels of specific IgE to egg or soy in their serum. In study B we found no signs of allergic reactions towards propofol in 171 retrieved anaesthetic charts from 99 patients with specific IgE to egg, soy or peanut. CONCLUSION No connection between allergy to propofol and allergy to egg, soy or peanut was found. The present practice of choosing alternatives to propofol in patients with this kind of food allergy is not evidence based and should be reconsidered.
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Affiliation(s)
- L L Asserhøj
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - H Mosbech
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - M Krøigaard
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
| | - L H Garvey
- Danish Anaesthesia Allergy Centre (DAAC), Allergy Clinic UA-816, Copenhagen University Hospital, Gentofte, Kildegårdsvej 28, 2900 Hellerup, Denmark
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92
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Christiansen IS, Krøigaard M, Mosbech H, Skov PS, Poulsen LK, Garvey LH. Clinical and diagnostic features of perioperative hypersensitivity to cefuroxime. Clin Exp Allergy 2015; 45:807-14. [PMID: 25395022 DOI: 10.1111/cea.12455] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 11/05/2014] [Accepted: 11/07/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Danish Anaesthesia Allergy Centre (DAAC) investigated 89 adult patients with suspected perioperative cefuroxime-associated hypersensitivity reactions between 2004 and 2013. The goals were to determine whether the time to index reaction after cefuroxime exposure could be used to implicate cefuroxime as the cause of the reactions and explore different test modalities in diagnosing cefuroxime hypersensitivity. METHOD Skin tests, in vitro tests, and titrated provocations were used to determine cefuroxime hypersensitivity. Patients were deemed cefuroxime positive on the basis of at least two positive tests and/or a positive provocation. RESULTS One or more tests were positive for cefuroxime in 24 of 89 (27.0%) patients. One was only specific IgE positive and was deemed cefuroxime negative. Twenty-three (25.8%) were deemed cefuroxime positive. There were four specific IgE-, 4 histamine release test-, 13 skin test-, and 14 provocation positive patients. There were eight (34.8%) patients who were only provocation positive. Data on time to index reaction after cefuroxime exposure were available for 80 patients (22 in the positive group and 58 in the negative group), 22 of 22 (100%) of positive patients reacted in <15 min vs. only 38 of 58 (65.5%) of negative patients. CONCLUSION All patients with confirmed hypersensitivity to cefuroxime reacted within 15 min of administration, but so did 65.5% of Cefuroxime negative patients, making timing of administration an unreliable predictor of causation in the perioperative setting. Provocations were always positive when carried out in skin test positive patients; however, eight patients had positive provocations only, highlighting the need for provocation in skin test negative patients.
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Affiliation(s)
- I S Christiansen
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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93
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Opstrup MS, Johansen JD, Zachariae C, Garvey LH. Contact allergy to chlorhexidine in a tertiary dermatology clinic in Denmark. Contact Dermatitis 2015; 74:29-36. [DOI: 10.1111/cod.12487] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 09/11/2015] [Accepted: 09/21/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Morten S. Opstrup
- Department of Dermato-Allergology; National Allergy Research Centre and Allergy Clinic, Copenhagen University Hospital Gentofte; 2900 Hellerup Denmark
| | - Jeanne D. Johansen
- Department of Dermato-Allergology; National Allergy Research Centre and Allergy Clinic, Copenhagen University Hospital Gentofte; 2900 Hellerup Denmark
| | - Claus Zachariae
- Department of Dermato-Allergology; National Allergy Research Centre and Allergy Clinic, Copenhagen University Hospital Gentofte; 2900 Hellerup Denmark
| | - Lene H. Garvey
- Department of Dermato-Allergology; National Allergy Research Centre and Allergy Clinic, Copenhagen University Hospital Gentofte; 2900 Hellerup Denmark
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94
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Simons FER, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J 2015; 8:32. [PMID: 26525001 PMCID: PMC4625730 DOI: 10.1186/s40413-015-0080-1] [Citation(s) in RCA: 317] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/25/2015] [Indexed: 11/10/2022] Open
Abstract
The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized. Advances in epidemiology, diagnosis, and management in healthcare and community settings are highlighted. Additionally, new information about patient factors that increase the risk of severe and/or fatal anaphylaxis and patient co-factors that amplify anaphylactic episodes is presented and new information about anaphylaxis triggers and confirmation of triggers to facilitate specific trigger avoidance and immunomodulation is reviewed. The update includes tables summarizing important advances in anaphylaxis research.
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Affiliation(s)
- F Estelle R Simons
- Department of Pediatrics & Child Health and Department of Immunology, College of Medicine, Faculty of Health Sciences, The University of Manitoba, Room FE125, 820 Sherbrook Street, Winnipeg, R3A 1R9 MB Canada
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy & Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidad, Caracas, Venezuela
| | - Bernard Y Thong
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Margitta Worm
- Allergie-Centrum-Charite, Klinik fur Dermatologie, Venerologie und Allergologie, Campus Charite Mitte, Universitatsmedizin, Berlin, Germany
| | - Luciana Kase Tanno
- Department of Allergy and Clinical Immunology, Hospital Servidor Publico Estadual de Sao Paulo and Hospital Sirio-Libanes, Sao Paulo, Brazil
| | | | - Yehia M El-Gamal
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Simon Ga Brown
- Royal Hobart Hospital, Tasmania, and University of Western Australia and Royal Perth Hospital, Perth, Western Australia
| | - Hae-Sim Park
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Seoul, South Korea
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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95
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Review of Contact Urticaria Syndrome—Evaluation to Treatment. CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0068-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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96
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Sharp G, Green S, Rose M. Chlorhexidine-induced anaphylaxis in surgical patients: a review of the literature. ANZ J Surg 2015; 86:237-43. [PMID: 26361890 DOI: 10.1111/ans.13269] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chlorhexidine (CHL) has antiseptic and disinfectant properties used to prevent hospital-acquired infections. CHL-induced anaphylaxis is poorly reported in surgical literature despite government warnings and growing recognition. The aim of this review is to increase awareness of CHL-induced anaphylaxis in the surgical population. METHODS Literature review of Embase, Medline, PubMed and the Cochrane library using 'anaphylaxis (and) chlorhexidine' search terms. RESULTS Thirty-six articles were published on surgical patients suffering anaphylaxis to CHL. Within these, seven patients had two proven separate anaphylactic reactions and one had three separate proven anaphylactic reactions. The most commonly affected speciality was urology. The majority occurred during elective procedures. A history of atopy was surprisingly uncommon as was bronchospasm. Six patients required active chest compressions and 39.71% of patients had their surgical procedure abandoned. Unplanned intensive care admissions occurred in 27.94%. DISCUSSION In order to reduce abandoned procedures, unplanned intensive care unit admissions, morbidity and mortality associated with CHL-induced anaphylaxis we recommend the following: rationalization of CHL-containing products, greater vigilance regarding subtle symptoms of CHL allergy, appropriate investigation of these symptoms and a greater awareness of CHL-containing products. Lastly, we outline the appropriate investigations and highlight the need for meticulous documentation in those who are CHL allergic.
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Affiliation(s)
- Gary Sharp
- Department of General Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Sarah Green
- Anaesthetic Allergy Service, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Michael Rose
- Anaesthetic Allergy Service, Royal North Shore Hospital, Sydney, New South Wales, Australia
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98
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Krishna MT, Huissoon A. Peri-operative anaphylaxis: beyond drugs and latex. Int Arch Allergy Immunol 2015; 167:101-2. [PMID: 26278912 DOI: 10.1159/000436971] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK
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99
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Opstrup MS, Johansen JD, Garvey LH. Chlorhexidine allergy: sources of exposure in the health-care setting. Br J Anaesth 2015; 114:704-5. [PMID: 25788633 DOI: 10.1093/bja/aev050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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100
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Moka E, Argyra E, Siafaka I, Vadalouca A. Chlorhexidine: Hypersensitivity and anaphylactic reactions in the perioperative setting. J Anaesthesiol Clin Pharmacol 2015; 31:145-8. [PMID: 25948890 PMCID: PMC4411823 DOI: 10.4103/0970-9185.155138] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Eleni Moka
- Department of Anaesthesiology, Creta Interclinic Hospital, Heraklion-Crete, Greece
| | - Eriphili Argyra
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
| | - Ioanna Siafaka
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
| | - Athina Vadalouca
- A' Anaesthesiology Clinic, Pain Relief and Palliative Care Unit, Aretaieion University Hospital, University of Athens, Athens, Greece
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