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Chow TG, Brunner ES, Khan DA. Cephalosporin Allergy: Updates on Diagnostic Testing. Curr Allergy Asthma Rep 2024:10.1007/s11882-024-01171-9. [PMID: 39141068 DOI: 10.1007/s11882-024-01171-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE OF REVIEW Cephalosporins are one of the most prescribed antibiotics worldwide and are implicated in a wide range of hypersensitivity reactions (HSR). This review summarizes recent updates in cephalosporin hypersensitivity with a focus on diagnostic testing. RECENT FINDINGS Reported testing strategies to evaluate different immediate and delayed cephalosporin HSR have included skin testing, in vitro testing, and diagnostic drug challenges. However, the diagnostic performance of in vivo and in vitro tests remains unclear across different hypersensitivity endotypes; adequately powered studies investigating the true positive and negative predictive value of these diagnostic modalities are needed using the reference standard of drug challenges to define cephalosporin hypersensitivity. Refinement of diagnostic testing should be guided by growth in our understanding of cephalosporin antigenic determinants. This growth will be crucial in driving further clarification of cross-reactivity between cephalosporins, and potentially delineating streamlined evaluation processes resulting in reduced unnecessary antibiotic avoidance.
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Affiliation(s)
- Timothy G Chow
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA.
| | - Elizabeth S Brunner
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA
| | - David A Khan
- University of Texas Southwestern Medical Center Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, 5323 Harry Hines Boulevard F04.206, Dallas, TX, 75390-9063, USA
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2
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Laguna JJ. Cefazolin dilemma in perioperative setting. Balancing surgical prophylaxis and allergic reactions. Anaesth Crit Care Pain Med 2024; 43:101375. [PMID: 38484932 DOI: 10.1016/j.accpm.2024.101375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2024]
Affiliation(s)
- Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Universitario de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University, ARADyAL, REI, Madrid, Spain.
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Antécédent d’allergie periopératoire : le thiopental était-il le coupable ? ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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4
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Changes in Sensitization Patterns in the Last 25 Years in 619 Patients with Confirmed Diagnoses of Immediate Hypersensitivity Reactions to Beta-Lactams. Biomedicines 2022; 10:biomedicines10071535. [PMID: 35884838 PMCID: PMC9312895 DOI: 10.3390/biomedicines10071535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 11/22/2022] Open
Abstract
Beta-lactam (BL) drugs are the antibiotics most prescribed worldwide due to their broad spectrum of action. They are also the most frequently implied in hypersensitivity reactions with a known specific immunological mechanism. Since the commercialization of benzylpenicillin, allergic reactions have been described; over the years, other new BL drugs provided alternative treatments to penicillin, and amoxicillin is now the most prescribed BL in Europe. Diagnosis of BL allergy is mainly based on skin tests and drug provocation tests, defining different sensitization patterns or phenotypes. In this study, we evaluated 619 patients with a confirmed diagnosis of BL-immediate allergy during the last 25 years, using the same diagnostic procedures with minor adaptations to the successive guidelines. The initial eliciting drug was benzylpenicillin, which changed to amoxicillin with or without clavulanic acid and cephalosporins in recent years. In skin tests, we found a decrease in sensitivity to major and minor penicillin determinants and an increase in sensitivity to amoxicillin and others; this might reflect that the changes in prescription could have influenced the sensitization patterns, thus increasing the incidence of specific reactions to side-chain selective reactions.
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Incidence of intraoperative anaphylaxis caused by blood products: a 12-year single-center, retrospective study. J Anesth 2022; 36:390-398. [PMID: 35416534 DOI: 10.1007/s00540-022-03059-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Intraoperative anaphylaxis caused by blood products is uncommon, but it is unclear whether the rarity of this reaction is attributable to the difficulty of diagnosis, underreporting, or both. We investigated the incidence of intraoperative transfusion anaphylaxis and its reporting to the hemovigilance system. METHODS We retrospectively reviewed cases wherein general anesthesia was used at a single hospital during a 12-year period. Cases of intraoperative anaphylaxis were extracted using an electronic search strategy and determined using the recently developed grading and clinical scoring system. The causative blood products were determined by the onset duration based on literature regarding intraoperative transfusion anaphylaxis cases. RESULTS Among the 62,146 general anesthesia cases, 22 cases of intraoperative anaphylaxis were identified, and 11 of the 22 cases received transfusions before the onset of anaphylaxis. Intraoperative transfusion anaphylaxis was defined as occurring within 30 min of transfusion. Finally, nine cases of intraoperative transfusion anaphylaxis were analyzed. The overall incidence of intraoperative transfusion anaphylaxis was 1/3,994, with the highest incidence noted for fresh frozen plasma (1/2146; 95% confidence interval [CI] 1/6610-1/920), platelet concentrate (1/2348; 95% CI 1/92,742-1/422), and red blood cells (1/22,867; 95% CI 1/903,199-1/4,105). No evidence indicated that these cases were reported to the Japanese hemovigilance system, although all intraoperative transfusion anaphylaxis cases were diagnosed by anesthesiologists. CONCLUSION The incidence of intraoperative anaphylaxis caused by blood products was higher than that reported and may be underreported to the Japanese hemovigilance system. Further research, particularly multicenter studies, is needed to confirm our results.
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Evaluating Immediate Reactions to Cephalosporins: Time Is of the Essence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1648-1657.e1. [DOI: 10.1016/j.jaip.2020.11.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/11/2020] [Accepted: 11/13/2020] [Indexed: 12/26/2022]
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7
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Banerji A, Bhattacharya G, Huebner E, Fu X, Camargo CA, Guyer A, Kuhlen JL, Blumenthal KG. Perioperative Allergic Reactions: Allergy Assessment and Subsequent Anesthesia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1980-1991. [PMID: 33248280 DOI: 10.1016/j.jaip.2020.11.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence-based guidelines are needed in the United States to improve evaluation of perioperative allergic reactions including recommendations for subsequent anesthesia. OBJECTIVE To identify causative agent(s) and evaluate patients' tolerability of subsequent anesthesia in patients evaluated by Allergy/Immunology (A/I) at Massachusetts General Hospital. METHODS We performed a retrospective review of patients referred to the outpatient A/I clinic for perioperative allergic reactions between October 2003 and May 2017. Patient demographics, atopic history, and prior adverse drug reactions were reviewed. Patients underwent a comprehensive evaluation with testing including skin testing (ST), drug challenges (when appropriate), tryptase level measurement, and specific IgE to latex measurement. Tolerance of subsequent procedures requiring anesthesia was assessed. RESULTS Of 123 patients referred, 74 (60%) were female and the mean age was 46 (±18) years. At least 1 causative agent was identified in 28 patients (24%, n = 28 of 118). Seventeen of 28 (61%) patients were ST positive to an antibiotic, including 13 (46%) positive to cefazolin; 3 patients (11%) had a positive latex specific IgE. Of 85 patients who had subsequent anesthesia with a known outcome, 78 (91%) did not have another perioperative allergic reaction. Two of 5 patients with an elevated baseline tryptase level did not tolerate subsequent anesthesia. CONCLUSION The majority of patients safely received subsequent anesthesia after comprehensive A/I evaluation for their perioperative allergic reactions; however, improved algorithmic care is needed in the United States. Among ST-positive patients (24%), antibiotics (especially cefazolin) were the most common culprits. An elevated baseline tryptase level was associated with an increased risk of recurrent perioperative allergic reactions.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass.
| | - Gita Bhattacharya
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Emily Huebner
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Autumn Guyer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California San Francisco, San Francisco, Calif
| | - James L Kuhlen
- Department of Medicine, Apex Allergy and Immunology, Greenville, SC
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Department of Medicine, Harvard Medical School, Boston, Mass; Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. Br J Anaesth 2020; 124:154-163. [DOI: 10.1016/j.bja.2019.10.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 12/20/2022] Open
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9
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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10
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Optimising diagnostics in perioperative allergy. Br J Anaesth 2019; 123:e11-e13. [DOI: 10.1016/j.bja.2019.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 11/20/2022] Open
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Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, Cooke P, Garcez T, Guttormsen AB, Ebo DG, Hopkins PM, Khan DA, Kopac P, Krøigaard M, Laguna JJ, Marshall S, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Savic S, Scherer K, Takazawa T, Volcheck GW, Kolawole H. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth 2019; 123:e50-e64. [DOI: 10.1016/j.bja.2019.04.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 04/04/2019] [Accepted: 04/14/2019] [Indexed: 12/11/2022] Open
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12
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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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13
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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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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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15
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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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To challenge or not to challenge: Literature data on the positive predictive value of skin tests to beta-lactams. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2404-2408.e11. [PMID: 30844483 DOI: 10.1016/j.jaip.2019.01.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 12/19/2022]
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Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123:e16-e28. [PMID: 30916015 DOI: 10.1016/j.bja.2019.01.027] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/24/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.
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18
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Khan DA, Banerji A, Bernstein JA, Bilgicer B, Blumenthal K, Castells M, Ein D, Lang DM, Phillips E. Cephalosporin Allergy: Current Understanding and Future Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2019; 7:2105-2114. [PMID: 31495420 PMCID: PMC6955146 DOI: 10.1016/j.jaip.2019.06.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 01/13/2023]
Abstract
Cephalosporins are commonly used antibiotics both in hospitalized patients and in outpatients. Hypersensitivity reactions to cephalosporins are becoming increasingly common with a wide range of immunopathologic mechanisms. Cephalosporins are one of the leading causes for perioperative anaphylaxis and severe cutaneous adverse reactions. Patients allergic to cephalosporins tend to tolerate cephalosporins with disparate R1 side chains but may react to other beta-lactams with common R1 side chains. Skin testing for cephalosporins has not been well validated but appears to have a good negative predictive value for cephalosporins with disparate R1 side chains. In vitro tests including basophil activation tests have lower sensitivity when compared with skin testing. Rapid drug desensitization procedures are safe and effective and have been used successfully for immediate and some nonimmediate cephalosporin reactions. Many gaps in knowledge still exist regarding cephalosporin hypersensitivity.
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Affiliation(s)
- David A. Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8859
| | - Aleena Banerji
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Jonathan A. Bernstein
- Department of Internal Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML#563, Cincinnati, OH 45267-0563
| | - Basar Bilgicer
- Department of Chemical and Biomedical Engineering, 205 McCourtney Hall, Notre Dame, IN 46556-5637
| | - Kimberly Blumenthal
- Department of Medicine, Division of Rheumatology, Allergy & Immunology, Massachusetts General Hospital, Cox 201, MGH, 55 Fruit St, Boston, MA 02114
| | - Mariana Castells
- Department of Medicine, Division of Rheumatology, Allergy and Immunology, Brigham and Women’s Hospital, 60 Fenwood Rd Hale Building, Boston, MA 02115
| | - Daniel Ein
- Department of Internal Medicine, George Washington University Medical Center, 2300 M St. NW, Washington DC 20037
| | - David M. Lang
- Department of Internal Medicine, Cleveland Clinic, Respiratory Institute, Department of Allergy and Clinical Immunology, 9500 Euclid Ave-A90, Cleveland, OH 44195
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, 1161-21 St Ave S, A-2200 MCN, Nashville, TN 3732-2582
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Positive Skin Test or Specific IgE to Penicillin Does Not Reliably Predict Penicillin Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:676-683. [PMID: 28483318 DOI: 10.1016/j.jaip.2017.03.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 03/15/2017] [Accepted: 03/20/2017] [Indexed: 02/08/2023]
Abstract
INTRODUCTION According to guidelines, patients are diagnosed with penicillin allergy if skin test (ST) result or specific IgE (s-IgE) to penicillin is positive. However, the true sensitivity and specificity of these tests are presently not known. OBJECTIVE To investigate the clinical relevance of a positive ST result and positive s-IgE and to study the reproducibility of ST and s-IgE. METHODS A sample of convenience of 25 patients with positive penicillin ST results, antipenicillin s-IgE results, or both was challenged with their culprit penicillin. Further 19 patients were not challenged, but deemed allergic on the basis of a recent anaphylactic reaction or delayed reactions to skin testing. Another sample of convenience of 18 patients, 17 overlapping with the 25 challenged, with initial skin testing and s-IgE (median, 25; range, 3-121), months earlier (T-1), was repeat skin tested and had s-IgE measured (T0), and then skin tested and had s-IgE measured 4 weeks later (T1). RESULTS Only 9 (36%) of 25 were challenge positive. There was an increased probability of being penicillin allergic if both ST result and s-IgE were positive at T0. Positive ST result or positive s-IgE alone did not predict penicillin allergy. Among the 18 patients repeatedly tested, 46.2% (12 of 25) of positive ST results at T-1 were reproducibly positive at T0. For s-IgE, 54.2% (14 of 24) positive measurements were still positive at T0 and 7 converted to positive at T1. CONCLUSIONS The best predictor for a clinically significant (IgE-mediated) penicillin allergy is a combination of a positive case history with simultaneous positive ST result and s-IgE or a positive challenge result.
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Romano A, Valluzzi RL, Caruso C, Maggioletti M, Quaratino D, Gaeta F. Cross-Reactivity and Tolerability of Cephalosporins in Patients with IgE-Mediated Hypersensitivity to Penicillins. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1662-1672. [PMID: 29408440 DOI: 10.1016/j.jaip.2018.01.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Studies performed since 1990 on samples of at least 30 subjects with a documented IgE-mediated hypersensitivity to penicillins have found a rate of positive responses to allergy tests with cephalosporins ranging from 0% to 27%. OBJECTIVE We sought to assess the cross-reactivity with cephalosporins and evaluate the possibility of using cephalosporins in penicillin-allergic subjects. METHODS We conducted a prospective study of 252 consecutive subjects who had suffered 319 immediate reactions (mostly anaphylaxis) to penicillins and had positive skin tests to at least 1 penicillin reagent. All patients underwent serum specific IgE assays for cefaclor, as well as skin tests with 3 aminocephalosporins (cephalexin, cefaclor, and cefadroxil), cefamandole, cefuroxime, ceftazidime, ceftriaxone, cefotaxime, and cefepime. Patients with negative results for the last 5 cephalosporins were challenged with cefuroxime axetil and ceftriaxone; those with negative results for aminocephalosporins were also challenged with cefaclor and cefadroxil. RESULTS Ninety-nine participants (39.3%) had positive allergy tests for cephalosporins. Specifically, 95 (37.7%) were positive to aminocephalosporins and/or cefamandole, which share similar or identical side chains with penicillins. All 244 subjects who underwent challenges with cefuroxime axetil and ceftriaxone tolerated them. Of the 170 patients who underwent aminocephalosporin challenges, 3 reacted to cefaclor and 4 to cefadroxil. CONCLUSIONS Cross-reactivity between penicillins and cephalosporins seems to be mainly related to side chain similarity or identity. Subjects with an IgE-mediated hypersensitivity to penicillins could be treated with cephalosporins such as cefuroxime and ceftriaxone that have side-chain determinants different from those of penicillins and are negative in pretreatment skin testing.
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Affiliation(s)
- Antonino Romano
- Allergy Unit, Presidio Columbus, Rome, Italy; IRCCS Oasi Maria S.S., Troina, Italy.
| | - Rocco Luigi Valluzzi
- Allergy Unit, Presidio Columbus, Rome, Italy; Department of Pediatrics, Division of Allergy, Pediatric Hospital Bambino Gesù, Rome, Italy
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Roberts G, Boyle R, Bryce PJ, Crane J, Hogan SP, Saglani S, Wickman M, Woodfolk JA. Developments in the field of clinical allergy in 2015 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2017; 46:1389-1397. [PMID: 27748974 DOI: 10.1111/cea.12831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In the second of two papers, we describe developments in the field of clinical allergy as documented by Clinical and Experimental Allergy in 2015. Epidemiology, clinical allergy, asthma and rhinitis are all covered.
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Affiliation(s)
- G Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK. .,NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK.
| | - R Boyle
- Paediatric Research Unit, Imperial College London, London, UK
| | - P J Bryce
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J Crane
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - S P Hogan
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - S Saglani
- National Heart & Lung Institute, Imperial College London, London, UK
| | - M Wickman
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - J A Woodfolk
- Allergy Division, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
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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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Scolaro RJ, Crilly HM, Maycock EJ, McAleer PT, Nicholls KA, Rose MA, The RIH. Australian and New Zealand Anaesthetic Allergy Group Perioperative Anaphylaxis Investigation Guidelines. Anaesth Intensive Care 2017; 45:543-555. [DOI: 10.1177/0310057x1704500504] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These guidelines are a consensus document developed by a working party of the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) to provide an approach to the investigation of perioperative anaphylaxis. They focus primarily on the use of skin testing as it is the investigation with the greatest clinical utility for the identification of the likely causative agent and potentially safer alternatives. The practicalities and process of skin testing, its limitations, and the place of other tests are discussed. These guidelines also address the roles of graded challenge and in vitro testing. The implications of anaphylaxis associated with neuromuscular blocking agents, beta-lactam antibiotics, local anaesthetic agents and chlorhexidine are discussed. Evidence for the recommendations is derived from literature searches using the words skin test, allergy, anaphylaxis, anaesthesia, and each of the individual agents listed in these guidelines. The individual articles were then reviewed for suitability for inclusion in these guidelines. Where evidence was not strong, as is the situation for many perioperative agents, expert consensus from the ANZAAG working party was used. These guidelines are intended for use by specialists involved in the investigation of perioperative allergy. They have been approved following peer review by members of ANZAAG and are available on the ANZAAG website: http://www.anzaag.com/anaphylaxis-management/testing-guidelines.pdf .
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Affiliation(s)
- R. J. Scolaro
- Department of Anaesthesia, Sunshine Coast University Hospital, Birtinya, Queensland
| | - H. M. Crilly
- Department of Anaesthesia, The Tweed Hospital, Tweed Heads, New South Wales
| | - E. J. Maycock
- Honorary Anaesthetist, Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland
| | - P. T. McAleer
- Anaesthetist, Department of Anaesthesia, Flinders Medical Centre, Adelaide, South Australia
| | - K. A. Nicholls
- Immunologist, Department of Immunology, The Royal Melbourne Hospital, Melbourne, Victoria
| | - M. A. Rose
- Staff Anaesthetist, Department of Anaesthesia, Royal North Shore Hospital, Sydney, New South Wales
| | - R. I. H. The
- Immunology Technical Laboratory Specialist, Department of Immunology, Auckland City Hospital, Auckland, New Zealand
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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: 27] [Impact Index Per Article: 3.9] [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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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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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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