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Amano Y, Matsuura A, Tamura T, Kato Y, Kameyama N, Takazawa T, Nishiwaki K. Life-threatening chlorhexidine anaphylaxis caused by skin preparation before chlorhexidine-free central venous catheter insertion: a case report and literature review. J Anesth 2023; 37:474-481. [PMID: 37120585 DOI: 10.1007/s00540-023-03189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/29/2023] [Indexed: 05/01/2023]
Abstract
Chlorhexidine is a common cause of perioperative anaphylaxis, and global regulatory authorities have issued warnings about anaphylaxis due to chlorhexidine-containing central venous catheters (CVC) and its mucosal absorption. We present a case of life-threatening anaphylaxis after CVC insertion caused by chlorhexidine used for skin preparation. The onset of anaphylaxis was rapid and very severe, resulting in pulseless electrical activity. The patient was successfully resuscitated by emergency veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Our case suggests that even skin preparation before chlorhexidine-free CVC insertion can cause life-threatening anaphylaxis. We reviewed the literature on chlorhexidine anaphylaxis cases and categorized all potential routes of chlorhexidine exposure to assess the risk following skin preparation. Our results showed that skin preparation before CVC insertion was the third most common cause of chlorhexidine anaphylaxis after transurethral exposure and chlorhexidine-containing CVCs. However, skin preparation with chlorhexidine before CVC insertion was sometimes overlooked as a cause of chlorhexidine anaphylaxis, and its risk might be underestimated. Further, no previous reports have described life-threatening anaphylaxis solely due to chlorhexidine skin preparation before CVC insertion. CVC insertion might cause the chlorhexidine used for skin preparation to reach the vascular system and should be recognized as a potential cause of life-threatening chlorhexidine anaphylaxis.
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Affiliation(s)
- Yasuhiro Amano
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Akari Matsuura
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Tamura
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Yuki Kato
- Department of Anesthesiology, Nagoya University Hospital, Nagoya, Japan
| | - Natsumi Kameyama
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Tomonori Takazawa
- Intensive Care Unit, Gunma University Hospital, 3-39-15 Showa-machiachi, Maebashi, 371-8511, Japan.
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Devinck A, Bauters T, Lapeere H, Willems L. Anaphylaxis related to disinfection with chlorhexidine in a teenager treated for cancer. J Oncol Pharm Pract 2020; 27:227-231. [PMID: 32476588 DOI: 10.1177/1078155220925531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Literature shows upcoming allergy to chlorhexidine due to the widespread use of the disinfectant within and outside surgical settings. Only a few case reports have been published regarding the use of topical chlorhexidine disinfectant outside surgery and only a minority of these within the pediatric population. CASE REPORT We present a case-report of a teenager, treated for acute lymphoblastic leukemia who developed an anaphylactic shock after repeated chlorhexidine use for skin disinfection at the insertion of a central venous catheter during his chemotherapy treatment. Preceding minor symptoms such as local swelling and pruritus were not recognized as possible allergy to chlorhexidine.Management and outcome: He was treated with two doses of intramuscular adrenaline and transferred to the pediatric intensive care unit where he fully recovered. Specific IgE testing was positive for chlorhexidine. A total avoidance of chlorhexidine was instructed. DISCUSSION A similar case was published regarding an anaphylaxis after use of chlorhexidine disinfectant for a dialysis catheter. Almost all other case reports of anaphylactic shock were found within surgical settings or after insertion of an impregnated central venous catheter/urine catheter. We suggest that some of the disinfectant might have been flushed in the catheter and then caused an anaphylactic reaction. The link between symptoms and chlorhexidine was not made until an anaphylactic reaction occurred. Literature data show that chlorhexidine often causes mild preceding symptoms before an anaphylaxis occurs. So let awareness arise around this 'hidden allergen' of which warning reactions often are being missed.
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Affiliation(s)
- Astrid Devinck
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Tiene Bauters
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium.,Pharmacy Department, Ghent University Hospital, Ghent, Belgium
| | - Hilde Lapeere
- Department of Dermatology, Ghent University Hospital, Ghent, Belgium
| | - Leen Willems
- Division of Pediatric Haemato-Oncology and Stem Cell Transplantation, Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
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Fernandes M, Lourenço T, Lopes A, Spínola Santos A, Pereira Santos MC, Pereira Barbosa M. Chlorhexidine: a hidden life-threatening allergen. Asia Pac Allergy 2019; 9:e29. [PMID: 31720240 PMCID: PMC6826114 DOI: 10.5415/apallergy.2019.9.e29] [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: 05/15/2019] [Accepted: 07/30/2019] [Indexed: 11/19/2022] Open
Abstract
Chlorhexidine is a commonly used antiseptic and disinfectant in the health-care setting. Anaphylaxis to chlorhexidine is a rare but potentially life-threatening complication. Epidemiologic data suggest that the cases of chlorhexidine allergy appears to be increasing. In this article we report a life-threatening anaphylactic shock with cardiorespiratory arrest, during urethral catheterization due to chlorhexidine. The authors also performed a literature review of PubMed library of anaphylactic cases reports due to this antiseptic between 2014 and 2018, demonstrating the increase in the number of cases occurring worldwide and the importance of detailed anamnesis and appropriate diagnostic workup of allergic reactions to disinfectants.
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Affiliation(s)
- Mara Fernandes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal.,Unidade de Imunoalergologia, Hospital Dr. Nélio Mendonça, SESARAM EPE, Funchal, Portugal
| | - Tatiana Lourenço
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Anabela Lopes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Amélia Spínola Santos
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal
| | - Maria Conceição Pereira Santos
- Laboratório de Imunologia Clínica, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Portugal.,Clínica Universitária de Imunoalergologia, Faculdade de Medicina da Universidade de Lisboa, Portugal
| | - Manuel Pereira Barbosa
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Portugal.,Clínica Universitária de Imunoalergologia, Faculdade de Medicina da Universidade de Lisboa, Portugal
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Sompornrattanaphan M, Kreetapirom P, Srinoulprasert Y, Kanistanon D, Klinniyom A, Wongsa C, Thongngarm T. Severe anaphylaxis after pelvic examination: a case report of dual latex and chlorhexidine allergies. Allergy Asthma Clin Immunol 2019; 15:19. [PMID: 30976286 PMCID: PMC6441184 DOI: 10.1186/s13223-019-0335-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background Natural rubber latex and chlorhexidine have previously been identified as causative substances in perioperative anaphylaxis. A pelvic examinations is generally considered noninvasive, however, this procedure is rarely associated with severe allergic reactions. We reported a rare case of dual latex and chlorhexidine allergies which caused anaphylaxis after pelvic examination in a woman with a history of latex-related fruits allergy. Case presentation A 54-year-old woman had severe anaphylaxis after a pelvic examination due to dual latex and chlorhexidine (CHX) allergies. The gynecologist used CHX for the vaginal preparation and wore latex-containing gloves with lubricating gel during the examination. In vivo and in vitro tests revealed CHX sensitization by a positive skin prick test to chlorhexidine at a very low concentration (0.002 mg/mL), and a positive basophil activation test to CHX. Latex allergy was confirmed by a positive specific IgE to latex and a positive glove-use test at 20 min. An analysis of specific IgE to latex component revealed positive results for Hev b 1, 5, 6.02, and 11. As she also had a past history of fruit allergy, prick-to-prick testing with latex-related fruits was performed. The results were positive for avocado, banana, jackfruit, kiwi, and longan. Conclusions Concomitant mucosal exposure of both natural rubber latex and CHX in highly sensitized patients during pelvic examinations can lead to severe anaphylaxis. Pre-procedural screening for an allergy to latex or CHX, or to any other allergen, should be performed in patients where there is suspicion of a specific allergy due to a previous allergic reaction. Increased awareness of these two allergens in all healthcare settings may improve patient safety.
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Affiliation(s)
- Mongkhon Sompornrattanaphan
- 1Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Yuttana Srinoulprasert
- 3Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Duangjit Kanistanon
- 3Department of Immunology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anchalika Klinniyom
- 4Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chamard Wongsa
- 1Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Torpong Thongngarm
- 1Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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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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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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Calogiuri G, Garvey LH, DiLeo E, Nettis E, Vacca A, Foti C. Injured skin as risk factor for chlorhexidine anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:2177. [DOI: 10.1016/j.jaip.2018.07.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
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Postolova A, Hernandez JD. Reply. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:2178. [PMID: 30390915 DOI: 10.1016/j.jaip.2018.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Anna Postolova
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, Calif.
| | - Joseph D Hernandez
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Stanford University, School of Medicine, Stanford, Calif
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