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Kulthanan K, Tuchinda P, Eimpunth S, Chuthapisith S, Rushatamukayanunt P, Limphoka P, Panjapakkul W, Pochanapan O, Maurer M. Blue Wheals and Blue Angioedema Induced by Blue Dyes: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3223-3234.e7. [PMID: 37451616 DOI: 10.1016/j.jaip.2023.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 05/29/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Blue wheals and blue angioedema, the adverse reactions to blue dye injections with or without anaphylaxis, are poorly defined. OBJECTIVE The objective is to review the characteristics (ie, sex and age at onset, interval between blue dye injection and symptom onset, clinical manifestations, duration of blue wheals or angioedema), natural courses, and treatments of blue dye adverse reactions. METHODS A review of the articles published through July 2021 was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS Across 523 patients (175 studies) with any adverse reactions to blue dye injections, wheals, angioedema, or both occurred in 193 patients (36.9%). Of these 193 patients, 68 patients (35.2%) developed blue wheals or angioedema, 118 (61.1%) had ordinary wheals or angioedema (nonbluish), and 7 had both (3.6%). We reviewed 169 patients with available data (99 with ordinary lesions and 70 with blue lesions). Patent blue violet had the highest rate of inducing blue wheals or angioedema (odds ratio 4.9). Almost half of the patients with blue wheals or angioedema developed systemic symptoms; and of those with systemic symptoms, all except 1 progressed to anaphylaxis. On-demand treatments with antihistamines, corticosteroids, and epinephrine were commonly used and effective. CONCLUSIONS Using blue dyes can lead to blue wheals or angioedema and systemic reactions. In patients with a history of a severe allergic reaction to a blue dye, repeat administration of a blue dye should be used only after carefully weighing all the risks and benefits.
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Affiliation(s)
- Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Papapit Tuchinda
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sasima Eimpunth
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suebwong Chuthapisith
- Division of Head-Neck and Breast Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pranee Rushatamukayanunt
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pichaya Limphoka
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Waratchaya Panjapakkul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Oraya Pochanapan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Schönmann C, Brockow K. Adverse reactions during procedures: Hypersensitivity to contrast agents and dyes. Ann Allergy Asthma Immunol 2019; 124:156-164. [PMID: 31765812 DOI: 10.1016/j.anai.2019.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/06/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This review provides an overview of the literature on hypersensitivity reactions during procedures to commonly used contrast agents and dyes. A synthesis of current knowledge on clinical symptoms, epidemiology and risk factors, pathomechanism, and management of hypersensitivity reactions to these substances is presented. DATA SOURCES A literature search was conducted through Medline. Included were peer-reviewed articles written in English between 2000 and 2019. STUDY SELECTIONS Relevant clinical studies, experimental studies, and review articles have been selected. Additionally, case reports have been included if they carried significant information about rare clinical forms of hypersensitivity reactions, disease mechanisms, or therapy. RESULTS An allergological workup is only indicated for patients with a history of immediate (IHR) and nonimmediate hypersensitivity reactions (NIHR) but not for toxic or unrelated adverse events. Skin tests with or without experimental cellular laboratory tests in patients with previous reactions can provide evidence for an allergic mechanism. Positive skin tests indicating allergy are more common in severe reactions. If the adverse event was allergic, skin testing of alternatives is helpful for the selection of other contrast agents for future procedures. Premedication alone may be insufficient in these cases, and breakthrough reactions occur. For nonallergic reactions, change of contrast agent and premedication is often but not always sufficient to suppress reactions. CONCLUSION Patients with previous NIHR or IHR, especially moderate and severe IHR, needing potential re-administration of contrast agents should be skin tested to identify an allergic mechanism as well as alternative agents to be used for future procedures.
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Affiliation(s)
- Christine Schönmann
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany.
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Jeand'heur A, Pelletier F, Girardin P, Moumane L, Aubin F, Castelain F. A case of immediate hypersensitivity reaction after an oral administration of patent blue dye. Contact Dermatitis 2019; 82:116-118. [PMID: 31566746 DOI: 10.1111/cod.13402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 09/17/2019] [Accepted: 09/22/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Anne Jeand'heur
- Department of Dermatology and EA3181, University Hospital and University of Franche Comté, Besançon, France
| | - Fabien Pelletier
- Department of Dermatology and EA3181, University Hospital and University of Franche Comté, Besançon, France
| | - Pascal Girardin
- Department of Dermatology and EA3181, University Hospital and University of Franche Comté, Besançon, France
| | | | - François Aubin
- Department of Dermatology and EA3181, University Hospital and University of Franche Comté, Besançon, France
| | - Florence Castelain
- Department of Dermatology and EA3181, University Hospital and University of Franche Comté, Besançon, France
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Azevedo JP, Alves M, Ribeiro C, Todo Bom A. Anaphylactic shock perioperative to patent blue dye. BMJ Case Rep 2018; 2018:bcr-2018-224330. [PMID: 29735500 DOI: 10.1136/bcr-2018-224330] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Patent blue is one of the most used dyes for the identification of sentinel lymph nodes in breast cancer. This report describes a case of an anaphylactic shock reaction to patent blue dye in a patient with cross-reactivity to methylene blue. Therefore, after allergy confirmation, the operation was repeated avoiding blue dye and an alternative labelling technique with 99mTc albumin nanocolloids was used.
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Affiliation(s)
- João Pedro Azevedo
- Immunoallergy, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Marta Alves
- Immunoallergy, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Carmelita Ribeiro
- Immunoallergy, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | - Ana Todo Bom
- Immunoallergy, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
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DE Aguiar PHW, Aquino RGFDE, Alves MM, Correia JMS, Oliveira ALDES, Viana AB, Pinheiro LGP. Identification of the sentinel lymph node using hemosiderin in locally advanced breast cancer. ACTA ACUST UNITED AC 2017; 44:612-618. [PMID: 29267558 DOI: 10.1590/0100-69912017006013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/17/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE to verify the agreement rate in the identification of sentinel lymph node using an autologous marker rich in hemosiderin and 99 Technetium (Tc99) in patients with locally advanced breast cancer. METHODS clinical trial phase 1, prospective, non-randomized, of 18 patients with breast cancer and clinically negative axilla stages T2=4cm, T3 and T4. Patients were submitted to sub-areolar injection of hemosiderin 48 hours prior to sentinel biopsy surgery, and the identification rate was compared at intraoperative period to the gold standard marker Tc99. Agreement between methods was determined by Kappa index. RESULTS identification rate of sentinel lymph node was 88.9%, with a medium of two sentinel lymph nodes per patients. The study identified sentinel lymph nodes stained by hemosiderin in 83.3% patients (n=15), and, compared to Tc99 identification, the agreement rate was 94.4%. CONCLUSION autologous marker rich in hemosiderin was effective to identify sentinel lymph nodes in locally advanced breast cancer patients.
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Affiliation(s)
| | - Ranniere Gurgel Furtado DE Aquino
- - Federal University of Ceará, Medical Surgical Sciences Post-Graduate Program, Fortaleza, CE, Brazil.,- Fortaleza University School of Medicine, Fortaleza, CE, Brazil
| | - Mayara Maia Alves
- - Federal University of Ceará, Biotechnology Post-Graduate Program (RENORBIO), Fortaleza, CE, Brazil
| | | | | | - Antônio Brazil Viana
- - Ceará Federal University, Walter Cantídio University Hospital, Fortaleza, CE, Brazil
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Du J, Li Y, Wang Q, Batchu N, Zou J, Sun C, Lv S, Song Q, Li Q. Sentinel lymph node mapping in gynecological oncology. Oncol Lett 2017; 14:7669-7675. [PMID: 29344213 PMCID: PMC5755034 DOI: 10.3892/ol.2017.7219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/18/2017] [Indexed: 01/02/2023] Open
Abstract
The intraoperative mapping of sentinel lymph nodes (SLNs) is part of the treatment strategy for a number of types of tumor. To retrospectively compare results from the mapping of pelvic SLNs for gynecological oncology, using distinct dyes, the present review was conducted to determine the clinical significance of SLN mapping for gynecological oncology. In addition, the present study aimed at identifying an improved choice for SLN mapping tracers in clinical application. Each dye exhibits demerits when applied in the clinical environment. The combination of radioisotopes and blue dyes was identified to exhibit the most accurate detection rate of SLN drainage of gynecological oncology. However, contrast agents were unable to identify whether a SLN is positive or negative for metastasis prior to pathologic examination; additional studies are required.
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Affiliation(s)
- Jiang Du
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yaling Li
- Gongzhuling Health Workers High School, Gongzhuling, Jilin 136100, P.R. China
| | - Qing Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Nasra Batchu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Junkai Zou
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Chao Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Shulan Lv
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qing Song
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, Georgia 30310, USA.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
| | - Qiling Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China.,Big Data Center, First Affiliated Hospital, Xi'an Jiatong University, Xi'an, Shaanxi 710061, P.R. China
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Peek MC, Charalampoudis P, Anninga B, Baker R, Douek M. Blue dye for identification of sentinel nodes in breast cancer and malignant melanoma: a systematic review and meta-analysis. Future Oncol 2016; 13:455-467. [PMID: 27578614 DOI: 10.2217/fon-2016-0255] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The combined technique (radioisotope and blue dye) is the gold standard for sentinel lymph node biopsy (SLNB) and there is wide variation in techniques and blue dyes used. We performed a systematic review and meta-analysis to assess the need for radioisotope and the optimal blue dye for SLNB. A total of 21 studies were included. The SLNB identification rates are high with all the commonly used blue dyes. Furthermore, methylene blue is superior to iso-sulfan blue and Patent Blue V with respect to false-negative rates. The combined technique remains the most accurate and effective technique for SLNB. In order to standardize the SLNB technique, comparative trials to determine the most effective blue dye and national guidelines are required.
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Affiliation(s)
- Mirjam Cl Peek
- Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | | | - Bauke Anninga
- Division of Cancer Studies, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK.,Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
| | - Rose Baker
- School of Business, 612, Maxwell Building, University of Salford, Salford, M5 4WT, UK
| | - Michael Douek
- Division of Cancer Studies, King's College London, Guy's Hospital Campus, Great Maze Pond, London, SE1 9RT, UK.,Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, London, UK
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Vasques PHD, Alves MM, Aquino RGFD, Torres RVA, Bezerra JLM, Brasileiro LP, Pinheiro LGP. Comparison between hemosiderin and Technetium-99 in sentinel lymph node biopsy in human breast cancer. Acta Cir Bras 2015; 30:785-90. [DOI: 10.1590/s0102-865020150110000010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
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Hamelin A, Vial-Dupuy A, Lebrun-Vignes B, Francès C, Soria A, Barete S. [Acute blue urticaria following subcutaneous injection of patent blue dye]. Ann Dermatol Venereol 2015; 142:670-4. [PMID: 26372548 DOI: 10.1016/j.annder.2015.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/15/2015] [Accepted: 08/05/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patent blue (PB) is a lymphatic vessel dye commonly used in France for sentinel lymph node detection in breast cancer, and less frequently in melanoma, and which may induce hypersensitivity reactions. We report a case of acute blue urticaria occurring within minutes of PB injection. PATIENTS AND METHODS Ten minutes after PB injection for sentinel lymph node detection during breast cancer surgery, a 49-year-old woman developed generalised acute blue urticaria and eyelid angioedema without bronchospasm or haemodynamic disturbance, but requiring discontinuation of surgery. Skin testing using PB and the anaesthetics given were run 6 weeks after the episode and confirmed PB allergy. PB was formally contra-indicated. DISCUSSION Immediate hypersensitivity reactions to PB have been reported for between 0.24 and 2.2% of procedures. Such reactions are on occasion severe, chiefly involving anaphylactic shock. Two mechanisms are probably associated: non-specific histamine release and/or an IgE-mediated mechanism. Skin tests are helpful in confirming the diagnosis of PB allergy. CONCLUSION Blue acute urticaria is one of the clinical manifestations of immediate hypersensitivity reactions to patent blue dye. Skin tests must be performed 6 weeks after the reaction in order to confirm the diagnosis and formally contra-indicate this substance.
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Affiliation(s)
- A Hamelin
- Service de dermatologie-allergologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France.
| | - A Vial-Dupuy
- Service de dermatologie-allergologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - B Lebrun-Vignes
- Centre de pharmacovigilance, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - C Francès
- Service de dermatologie-allergologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; Sorbonne universités, UPMC université Paris 6, 4, place Jussieu, 75005 Paris, France
| | - A Soria
- Service de dermatologie-allergologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; Sorbonne universités, UPMC université Paris 6, 4, place Jussieu, 75005 Paris, France; Unité mixte de recherche de santé (UMRS) CR7, centre d'immunologie et des maladies infectieuses-Paris (Cimi-Paris), 75013 Paris, France; Institut national de santé et de recherche médicale (Inserm) U1135, Cimi-Paris, 75013 Paris, France
| | - S Barete
- Service de dermatologie-allergologie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France; Sorbonne universités, UPMC université Paris 6, 4, place Jussieu, 75005 Paris, France; Unité fonctionnelle de dermatologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
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Basophil activation test in the diagnosis of patent blue V anaphylaxis. Ann Allergy Asthma Immunol 2015; 115:78-9. [PMID: 26123425 DOI: 10.1016/j.anai.2015.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/29/2015] [Accepted: 05/04/2015] [Indexed: 11/20/2022]
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Brockow K, Sánchez-Borges M. Hypersensitivity to contrast media and dyes. Immunol Allergy Clin North Am 2015; 34:547-64, viii. [PMID: 25017677 DOI: 10.1016/j.iac.2014.04.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article updates current knowledge on hypersensitivity reactions to diagnostic contrast media and dyes. After application of a single iodinated radiocontrast medium (RCM), gadolinium-based contrast medium, fluorescein, or a blue dye, a hypersensitivity reaction is not a common finding; however, because of the high and still increasing frequency of those procedures, patients who have experienced severe reactions are nevertheless frequently encountered in allergy departments. Evidence on allergologic testing and management is best for iodinated RCM, limited for blue dyes, and insufficient for fluorescein. Skin tests can be helpful in the diagnosis of patients with hypersensitivity reactions to these compounds.
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Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Biedersteiner Strasse 29, Munich 80802, Germany.
| | - Mario Sánchez-Borges
- Allergy and Clinical Immunology Department, Centro Médico Docente La Trinidad, Clínica El Avila, 6a transversal de Altamira, piso 8, consultorio 803, Caracas 1060, Venezuela
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Gumus M, Gumus H, Jones SE, Jones PA, Sever AR, Weeks J. How long will I be blue? Prolonged skin staining following sentinel lymph node biopsy using intradermal patent blue dye. ACTA ACUST UNITED AC 2014; 8:199-202. [PMID: 24415970 DOI: 10.1159/000352092] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Blue dye used for sentinel lymph node biopsy (SLNB) in breast cancer patients may cause prolonged skin discoloration at the site of injection. The aim of this study was to assess the duration of such skin discoloration. PATIENTS AND METHODS 236 consecutive patients who had undergone breast conserving surgery and SLNB for breast cancer were reviewed prospectively from January 2007 to December 2009. RESULTS Of the 236 patients, 2 had undergone bilateral surgery, and 41 had been examined in consecutive yearly reviews. Blue discoloration remained visible at the injection site after 12, 24, and > 36 months in 36.5, 23.6, and 8.6% of the patients, respectively. CONCLUSION The use of patent blue for identification of the sentinel lymph node in patients undergoing breast cancer surgery may result in prolonged discoloration of the skin at the injection site.
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Affiliation(s)
- Metehan Gumus
- Department of General Surgery, Dicle University, Medical School, Yenişehir, Diyarbakır, Turkey
| | - Hatice Gumus
- Department of Radiology, Dicle University, Medical School, Yenişehir, Diyarbakır, Turkey
| | - Sue E Jones
- Department of Surgery, Maidstone Hospital, Hermitage Lane, Maidstone, United Kingdom
| | - Peter A Jones
- Department of Surgery, Maidstone Hospital, Hermitage Lane, Maidstone, United Kingdom
| | - Ali R Sever
- Department of Radiology, Maidstone Hospital, Hermitage Lane, Maidstone, United Kingdom
| | - Jennifer Weeks
- Department of Radiology, Maidstone Hospital, Hermitage Lane, Maidstone, United Kingdom
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BRENET O, LALOURCEY L, QUEINNEC M, DUPOIRON D, JAYR C, ROSAY H, MAVOUNGOU P, MONNIN D, ANCEL B, MAGET B, LOUVIER N, MALINOVSKY JM. Hypersensitivity reactions to Patent Blue V in breast cancer surgery: a prospective multicentre study. Acta Anaesthesiol Scand 2013; 57:106-11. [PMID: 23216362 DOI: 10.1111/aas.12003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2012] [Indexed: 12/01/2022]
Abstract
BACKGROUND An increasing number of immediate hypersensitivity reactions (HSR) have been reported after the use of Patent Blue V (PBV) for breast cancer surgery. This is the first study to publish prospective data with systematic allergological assessment. METHODS We conducted a multicentre study in 10 French cancer centres for over 6 months. All patients scheduled for breast surgery with injection of PBV were included in the study. Patients were screened for past medical history, atopy, and known food and drug allergies. When suspected HSR or unexplained reactions occurred after injection of PBV, blood samples were taken, and plasma histamine and serum tryptase concentrations were measured. HSR to PBV was suggested if skin tests performed 6 weeks later were positive. RESULTS Nine suspected HSR to PBV were observed in 1742 patients. Skin tests were positive in six patients, giving an incidence of 0.34%. Four grade I and two grade III HSR were observed, both requiring intensive care unit treatment. Mean onset time of the reaction was 55 ± 37 min. Plasma histamine was elevated in four patients, while serum tryptase was normal. We found no risk factors associated with HSR to PBV. CONCLUSION An incidence rate of one in 300 HSR to PBV was observed for patients exposed to PBV during sentinel lymph node detection. This rate is higher than rates reported after the use of neuromuscular blocking agents, latex or antibiotics.
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Affiliation(s)
| | | | | | | | - C. JAYR
- Cancer Center of Saint Cloud; France
| | | | | | | | | | | | | | - J.-M. MALINOVSKY
- Department of Anesthesia and Intensive care; Pôle URAD; Hôpital Maison Blanche; CHU de Reims; France
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Caimmi S, Caimmi D, Cardinale F, Indinnimeo L, Crisafulli G, Peroni DG, Marseglia GL. Perioperative allergy: uncommon agents. Int J Immunopathol Pharmacol 2012; 24:S61-8. [PMID: 22014927 DOI: 10.1177/03946320110240s309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Anesthesia may often be considered as a high-risk procedure and anaphylaxis remains a major cause of concern for anesthetists who routinely administer many potentially allergenic agents. Neuromuscular blocking agents, latex and antibiotics are the substances involved in most of the reported reactions. Besides these three agents, a wide variety of substances may cause an anaphylactic reaction during anesthesia. Basically all the administered drugs or substances may be potential causes of anaphylaxis. Among them, those reported the most in literature include hypnotics, opioids, local anesthetics, colloids, dye, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Iodinated Contrast Media (ICM), antiseptics, aprotinin, ethylene oxyde and formaldehyde, and protamine and heparins. No premedication can effectively prevent an allergic reaction and a systematic preoperative screening is not justified for all patients; nevertheless, an allergy specialist should evaluate those patients with a history of anesthesia-related allergy. Patients must be fully informed of investigation results, and advised to provide a detailed report prior to future anesthesia.
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Affiliation(s)
- S Caimmi
- Department of Pediatrics, University of Pavia, Italy.
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Manson AL, Juneja R, Self R, Farquhar-Smith P, MacNeill F, Seneviratne SL. Anaphylaxis to Patent Blue V: a case series. Asia Pac Allergy 2012; 2:86-9. [PMID: 22348211 PMCID: PMC3269606 DOI: 10.5415/apallergy.2012.2.1.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 01/14/2012] [Indexed: 11/04/2022] Open
Abstract
Blue dyes such as Patent Blue V (PBV) have been used in medical procedures for decades, and in the United Kingdom they are routinely utilised in sentinel lymph node biopsy (SLNB) for staging the axilla in early breast cancer. However, it has long been recognised that such dyes are associated with anaphylaxis. It has recently been estimated in a prospective study that allergy to PBV occurs with a frequency of 0.9%. Since repeated SLNB (and therefore further exposure to PBV) is increasingly being advocated for the small proportion of patients who develop a local (in-breast) recurrence, and because anaphylaxis can be life-threatening, it is important that those individuals that are allergic to PBV are recognised on their first medical exposure. The measurement of serum mast-cell tryptase (MCT) and skin prick test (SPT) are used in the investigation of suspected anaphylaxis because positive results are supportive of type-1 mediated hypersensitivity. Here we report the clinical features, MCT results and SPT results that pertain to a series of four patients referred to our drug allergy clinic with suspected anaphylaxis following SLNB. We recommend that all patients that show clinical evidence of allergy following exposure to PBV are referred to a specialist drug allergy service for further evaluation to investigate the cause.
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Affiliation(s)
- Ania L. Manson
- Department of Clinical Immunology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - Rohit Juneja
- Department of Anaesthesia, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Robert Self
- Department of Anaesthesia, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Paul Farquhar-Smith
- Department of Anaesthesia, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Fiona MacNeill
- Department of Breast Surgery, The Royal Marsden NHS Foundation Trust, London, SW3 6JJ, UK
| | - Suranjith L. Seneviratne
- Department of Clinical Immunology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK
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Caffarelli C, Stringari G, Pajno GB, Peroni D, Franceschini F, Iacono ID, Bernardini R. Perioperative Allergy: Risk Factors. Int J Immunopathol Pharmacol 2011; 24:S27-34. [DOI: 10.1177/03946320110240s305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Perioperative anaphylactic as well as anaphylactoid reactions can be elicited by drugs, diagnostic agents, antiseptics, disinfectants and latex. In some individuals, allergic reactions occur in the absence of any evident risk factor. Previous history of specific safe exposure to a product does not permit to exclude the risk of having a reaction. We have systematically reviewed characteristics in the patient's history or clinical parameters that affect the risk of developing reactions during anesthesia. Evidence shows that patients with previous unexplained reaction during anesthesia are at risk for perioperative allergic reactions. An allergic reaction to an agent is associated with previous reaction to a product that is related with the culprit agent. Multiple surgery procedures, professional exposure to latex and allergy to fruit are associated with an increased frequency of latex allergy. It has been shown that in some instances, allergic perioperative reactions may be more common in atopic patients and in female.
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Affiliation(s)
- C. Caffarelli
- Pediatric Clinic, Department of Pediatrics, University of Parma, Parma, Italy
| | - G. Stringari
- Pediatric Clinic, Department of Pediatrics, University of Parma, Parma, Italy
| | - G. B. Pajno
- Allergy Unit, Department of Pediatrics, University of Messina, Messina, Italy
| | - D.G. Peroni
- Department of Pediatrics, University of Verona, Verona, Italy
| | - F. Franceschini
- Pediatric Unit, “Ospedali Riuniti“, University Hospital, Ancona, Italy
| | - I. Dello Iacono
- Pediatric Unit, “Fatebenefratelli” Hospital, Benevento, Italy
| | - R. Bernardini
- Pediatric Unit, “San Giuseppe” Hospital, Empoli, Florence, Italy
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Howard JD, Moo V, Sivalingam P. Anaphylaxis and other Adverse Reactions to Blue Dyes: A Case Series. Anaesth Intensive Care 2011; 39:287-92. [DOI: 10.1177/0310057x1103900221] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report three cases of anaphylaxis during anaesthesia confirmed on intradermal testing to be related to patent blue V dye (Guerbet – Chemical Abstract Service 3536-49-0). All three cases were associated with moderate to severe hypotension. Two cases had delayed onset, and two were associated with a rash. None of the cases were associated with bronchospasm. In all three patients the interference with pulse oximetry readings contributed to difficulties in management. We recommend the use of a test dose of blue dye prior to surgery, as suggested in the manufacturer's product information. We also recommend high vigilance for possible allergic reactions when patent blue dyes are used for sentinel lymph node mapping, because the presentations may be atypical and the reduced pulse oximetry readings may be a distraction.
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Affiliation(s)
- J. D. Howard
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - V. Moo
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - P. Sivalingam
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Lavaud F, Mouton C, Ponvert C. Les tests cutanés dans le bilan diagnostique des réactions d’hypersensibilité peranesthésiques. ACTA ACUST UNITED AC 2011; 30:264-79. [DOI: 10.1016/j.annfar.2010.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Guilloux L, Benoit Y, Aimone-Gastin I, Ponvert C, Beaudouin E. [Control of the biological diagnostic assessment. Immunoglobulin E]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:294-304. [PMID: 21392931 DOI: 10.1016/j.annfar.2010.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Affiliation(s)
- L Guilloux
- Unité d'immuno-allergologie, laboratoire Mérieux, avenue Tony-Garnier, Lyon, France.
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22
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Mertes PM, Karila C, Demoly P, Auroy Y, Ponvert C, Lucas MM, Malinovsky JM. [What is the reality of anaphylactoid reactions during anaesthesia? Classification, prevalence, clinical features, drugs involved and morbidity and mortality]. ACTA ACUST UNITED AC 2011; 30:223-39. [PMID: 21353759 DOI: 10.1016/j.annfar.2011.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- P-M Mertes
- Service d'anesthésie-réanimation chirurgicale, hôpital Central, CHU de Nancy, 29 avenue de Lattre-de-Tassigny, Nancy cedex, France.
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Seghatchian J, Struff WG, Reichenberg S. Main Properties of the THERAFLEX MB-Plasma System for Pathogen Reduction. Transfus Med Hemother 2011; 38:55-64. [PMID: 21779206 PMCID: PMC3132980 DOI: 10.1159/000323786] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 12/23/2010] [Indexed: 11/19/2022] Open
Abstract
Methylene blue (MB) treated plasma has been in clinical use for 18 years. The current THERAFLEX MB-Plasma has a number of improved features compared with the original Springe methodology. This overview embodies: the biochemical characteristics of MB, the mechanism of the technology, toxicology, pathogen reduction capacity, current position in clinical setting and status within Europe. The THERAFLEX MB (TMB) procedure is a robust, well standardised system lending itself to transfusion setting and meets the current guidelines. The pathogen kill power of the TMB system, like the other available technologies, is not limitless, probably in order of 6 log for most enveloped viruses and considerably less for non-enveloped ones. It does not induce either new antigen or grossly reducing the function and life span of active principle in fresh frozen plasma (FFP). The removal of the residual MB at the end of the process has the beneficial effect of reducing potential toxic impacts. Clinical haemovigilance data, so far, indicate that cell-free MB plasma is effective in all therapeutic setting requiring FFP, besides inconsistent thrombotic thrombocytopenia purpura data, without serious side-effects or toxicity. The current system is in continuous improvement e.g. regarding virus reduction range, illumination device, software used, and process integration in the blood bank setting.
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Affiliation(s)
- Jerard Seghatchian
- Blood Components Technology & Haemostasis/Thrombosis Consultancy, London, UK
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Nubret K, Delhoume M, Orsel I, Laudy JS, Sellami M, Nathan N. Anaphylactic shock to fresh-frozen plasma inactivated with methylene blue. Transfusion 2011; 51:125-8. [DOI: 10.1111/j.1537-2995.2010.02800.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Telgenkamp B, Japink D, van Haaren E. Cardiac Arrest after Patent Blue V Injection for Sentinel Lymph Node Biopsy in Breast Cancer. ACTA ACUST UNITED AC 2010; 5:411-413. [PMID: 21494408 DOI: 10.1159/000322658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
SUMMARY: BACKGROUND: Sentinel lymph node biopsy (SLNB) is a widely accepted method to determine lymph node status in for instance breast cancer, cervical cancer, or cutaneous melanomas. Although injection of blue dyes facilitates successful detection of sentinel nodes, they have also been shown to cause adverse reactions. CASE REPORT: A 62-year-old female patient was referred to the surgical department of the Atrium Medical Centre with a suspicious lesion located in the right breast, detected during population-based screening. Immediately after injection of patent blue V, the patient developed tachycardia on top of preexisting supraventricular tachycardia and showed an instant drop in blood pressure, after which cardiac arrest occurred. These clear symptoms of anaphylactic shock required prompt treatment, and the patient was treated accordingly. CONCLUSIONS: Anaphylactic shock after injection of patent blue V remains a serious adverse event and warrants awareness. Immediate action with ephedrine, antihistamines, and subsequently corticosteroids can stabilize the patient. Tc-99m, isosulphan blue, and methylene blue can alternatively be used for SLNB, although also not without side effects.
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Affiliation(s)
- Bjorn Telgenkamp
- Department of Surgery, Atrium Medical Centre, Heerlen, The Netherlands
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Barthelmes L, Goyal A, Sudheer P, Mansel R. Investigation of anaphylactic reaction after patent blue V dye injection. Breast 2010; 19:516-20. [DOI: 10.1016/j.breast.2010.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Revised: 04/19/2010] [Accepted: 05/25/2010] [Indexed: 10/19/2022] Open
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Rughani MG, Swan MC, Adams TS, Middleton MR, Cassell OC. Adverse reactions to Patent Blue V dye used in sentinel lymph node biopsy for Melanoma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2010. [DOI: 10.1007/s00238-010-0515-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pinheiro LGP, Oliveira Filho RSD, Vasques PHD, Filgueira PHDO, Aragão DHP, Barbosa PME, Beserra HEO, Cavalcante RV. Hemosiderin: a new marker for sentinel lymph node identification. Acta Cir Bras 2010; 24:432-6. [PMID: 20011826 DOI: 10.1590/s0102-86502009000600002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 07/15/2009] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate and present our initial results of a new marker (hemosiderin) for mammary sentinel lymph node identification in an experimental model. METHODS Skins mapped like a lymphatic duct draining to the axilla in patients submitted to breast biopsy, in our mastology service, stimulated us to try it in an animal model (female dogs). Our theory was that some blood derivate (hemosiderin) was captured by macrophages and accessed the lymphatic ducts in direction to the axilla. Six female dogs of no defined race were studied. We injected 0,2 ml of technetium on both superior mammary glands. After ten minutes, a 2,5 ml solution of hemolized blood (hemosiderin) from the own animal was injected in the subareolar lymphatic plexus on the left superior mammary gland and 2,5 ml of patent blue concomitantly and equally on the contralateral gland. Ten minutes after, incisions on both axillae were made to search, through the lymphatic mapping and a gamma probe, the sentinel lymph nodes. RESULTS Seven brown sentinel lymph nodes were identified and also radiomarked on the left axilla. Six blue sentinel lymph nodes were identified and also radiomarked on the right axilla. CONCLUSION Preliminary studies of a potential new dye for sentinel lymph node identification are presented. It may be the change of the current use of the blue dyes and their severe side-effects on patients submitted to sentinel lymph node biopsies.
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Mertes PM, Tajima K, Regnier-Kimmoun MA, Lambert M, Iohom G, Guéant-Rodriguez RM, Malinovsky JM. Perioperative anaphylaxis. Med Clin North Am 2010; 94:761-89, xi. [PMID: 20609862 DOI: 10.1016/j.mcna.2010.04.002] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The incidence of immune-mediated anaphylaxis during anesthesia ranges from 1 in 10,000 to 1 in 20,000. Neuromuscular blocking agents are most frequently incriminated, followed by latex and antibiotics, although any drug or substance used may be a culprit. Diagnosis relies on tryptase measurements at the time of the reaction and skin tests, specific immunoglobulin E, or basophil activation assays. Treatment consists of rapid volume expansion and epinephrine administration titrated to symptom severity.
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Affiliation(s)
- P M Mertes
- Service d'Anesthésie-Réanimation Chirurgicale, CHU de Nancy, Hôpital Central, 29 Avenue de Lattre de Tassigny, 54035 Nancy Cedex, France.
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30
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Haque RA, Wagner A, Whisken JA, Nasser SM, Ewan PW. Anaphylaxis to patent blue V: a case series and proposed diagnostic protocol. Allergy 2010; 65:396-400. [PMID: 19930233 DOI: 10.1111/j.1398-9995.2009.02248.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patent blue V is widely used in the identification of sentinel lymph nodes in patients with breast cancer and other malignancies. Individual case reports of allergy to patent blue V have been described in the medical literature since the 1960s. However, there is little data on clinical features and little experience of which allergy tests are appropriate or useful. We gathered all cases of patent blue V allergy that had been seen and diagnosed in the Department of Allergy, Addenbrooke's Hospital over a 3-year period. We collected clinical details of each case including skin test results. For comparison we recruited 12 healthy control subjects who then underwent skin testing to patent blue V. Six cases of patent blue V allergy were identified, all occurring during sentinel lymph node identification for breast carcinoma. All 6 had positive skin prick tests to neat patent blue V (25 mg/ml). Skin prick testing with a 1 : 10 dilution (2.5 mg/ml) produced positive results in 3 of 4 patients tested, and intradermal testing at a 1 : 100 dilution was (0.25 mg/ml) was positive in all patients tested. Of 12 control subjects, 11 had negative skin prick tests to both neat and 1 : 10 patent blue V with one subject showing a positive reaction to the higher concentration only. On the basis of our experience of patent blue V allergy, we propose a diagnostic protocol that can be safely and reliably utilised in centres equipped for allergy testing.
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Affiliation(s)
- R A Haque
- Department of Allergy, Addenbrooke's Hospital, Cambridge, UK
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31
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Hunting AS, Nopp A, Johansson SGO, Andersen F, Wilhelmsen V, Guttormsen AB. Anaphylaxis to Patent Blue V. I. Clinical aspects. Allergy 2010; 65:117-23. [PMID: 19793057 DOI: 10.1111/j.1398-9995.2009.02192.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The dye Patent Blue V (PBV) is increasingly used for staging procedures in operable breast cancer, but is reported to cause adverse reactions. The aim of this study was to present the clinical features and the results of follow-up examinations in patients with such reactions. METHODS We studied nine patients with hypersensitivity reactions to PBV between 1999 and 2006 who were identified through the Norwegian network for reporting and investigating allergic reactions during anesthesia. RESULTS We observed incidences of 0.5% (7/1418) for all kinds of PBV reactions and 0.4% (5/1418) for anaphylaxis. Typical clinical features included: (i) cardiovascular and/or cutaneous symptoms, (ii) a delay in symptoms, compared to the time of dye injection, (iii) poor response to ephedrine and intravenous fluid, and (iv) need for adrenaline administration, sometimes prolonged, for circulatory stabilization. Cutaneous manifestations were noted in five of the seven patients with anaphylaxis and two additional patients without circulatory instability. During anaphylactic reactions, serum tryptase was increased in six patients and normal in one. Serum tryptase was normal in one patient with skin symptoms only. Skin prick tests to PBV were positive in all eight patients tested, including the two with skin manifestations only. CONCLUSION The clinical features and the results of follow-up studies strongly suggest that these reactions are IgE mediated.
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Affiliation(s)
- A S Hunting
- Division of Anaesthesiology and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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Barthelmes L, Goyal A, Newcombe RG, McNeill F, Mansel RE. Adverse reactions to patent blue V dye - The NEW START and ALMANAC experience. Eur J Surg Oncol 2009; 36:399-403. [PMID: 19939618 DOI: 10.1016/j.ejso.2009.10.007] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 08/14/2009] [Accepted: 10/08/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Blue dye with or without isotope has been widely used to identify the sentinel lymph node(s) in breast cancer. Patent blue V is used in the UK while its isomer isosulfan blue is used in the US. The allergic potential of isosulfan blue is well documented (1.4% adverse reactions) but that of patent blue V is less clearly defined. METHODS In this paper we review the adverse reactions of patent blue V in 7,917 patients who participated in the NEW START training programme and the ALMANAC trial. All patients underwent sentinel lymph node biopsy for breast carcinoma using patent blue V in combination with (99m)Tc-albumin colloid. RESULTS In total, 72 of 7,917 (0.9%) patients experienced adverse reactions : non-allergic reactions were observed in 4 (0.05%) patients, 23 (0.3%) patients had minor grade I allergic skin reactions (urticaria, blue hives, pruritus, or generalised rash) and 16 (0.2%) had grade II reactions (transient hypotension/bronchospasm/laryngospasm). Severe Grade III reactions (severe hypotension requiring vasopressor support and/or change/abandoning of planned procedure and/or HDU/ITU admission) were noted in 5 (0.06%) patients. The type of adverse reaction was not specified in 24 (0.3%) patients. No mortality was recorded. CONCLUSION The allergic potential of patent blue V dye compares favourably with isosulfan blue however both the surgeon and anaesthetist need to be alert to the risk of allergic reactions.
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Affiliation(s)
- L Barthelmes
- Department of Surgery, School of Medicine, Cardiff University, Cardiff, UK
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33
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Anaphylactic shock during the sentinel lymph node procedure for cervical cancer. Gynecol Oncol 2009; 114:375-6. [DOI: 10.1016/j.ygyno.2009.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 04/17/2009] [Accepted: 04/22/2009] [Indexed: 01/08/2023]
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Mertes P, Lambert M, Guéant-Rodriguez R, Aimone-Gastin I, Mouton-Faivre C, Moneret-Vautrin D, Guéant J, Malinovsky J, Demoly P. Perioperative Anaphylaxis. Immunol Allergy Clin North Am 2009; 29:429-51. [DOI: 10.1016/j.iac.2009.04.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mertes PM, Malinovsky JM, Mouton-Faivre C, Bonnet-Boyer MC, Benhaijoub A, Lavaud F, Valfrey J, O'Brien J, Pirat P, Lalourcey L, Demoly P. Anaphylaxis to dyes during the perioperative period: Reports of 14 clinical cases. J Allergy Clin Immunol 2008; 122:348-52. [DOI: 10.1016/j.jaci.2008.04.040] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 04/05/2008] [Accepted: 04/30/2008] [Indexed: 10/22/2022]
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Varghese P, Abdel-Rahman AT, Akberali S, Mostafa A, Gattuso JM, Carpenter R. Methylene blue dye--a safe and effective alternative for sentinel lymph node localization. Breast J 2008; 14:61-7. [PMID: 18186867 DOI: 10.1111/j.1524-4741.2007.00519.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sentinel lymph node (SLN) biopsy has emerged as an effective diagnostic tool in axillary staging in breast cancer. The commonly used technique employs isosulfan blue/patent blue V combined with radioactive colloid tracer. Methylene blue (MB) is a less expensive and readily available alternative dye. The study evaluated the safety and efficacy of MB in SLN localization. A retrospective study of 329 patients with early breast cancer who had SLN localization as part of an ethically approved prospective evaluation study of SLN localization technique was carried out. Lymph node positive, tumors >2 cm on clinical and radiological evaluation, those with previous breast and axillary surgery, neo-adjuvant chemotherapy were excluded from the study. One hundred seventy three patients underwent SLN localization using 1 mL of 1% MB, and a combined MB-radio colloid tracer technique was used in the other 156 patients. Allocation to the groups was by simple randomization. Injection of the dye and radioisotope was into the subdermal plane in the sub-areolar region. Patients underwent breast conservation surgery or mastectomy with SLN directed four node axillary sampling +/- axillary clearance. The lymph node was examined by standard microscopy. There were no reported complications with the use of MB aside from temporary tattooing. The technique failed in eight patients giving an identification rate of 97.6%. Ten of the 258 (3.9%) patients had false-negative SLN, with negative predictive value of 96.1%, sensitivity of predicting further axillary disease of 73%, specificity of 87.3%, and overall accuracy of 85.7%. Reported adverse reaction to isosulfan blue/patent blue V varied from minor to severe anaphylactic reactions (1-3%) requiring vigorous resuscitation. Subdermal sub-areolar injection of MB is safe and effective readily available dye for SLN localization in axillary staging of breast cancer with no major adverse reaction.
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Affiliation(s)
- Philip Varghese
- Breast Unit, St Bartholomew's Hospital, Queen Mary University of London, United Kingdom.
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Abstract
Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
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Lavie A, Desouches C, Casanova D, Bardot J, Grob JJ, Legré R, Magalon G. Mise au point sur la prise en charge chirurgicale du mélanome malin cutané. Revue de la littérature. ANN CHIR PLAST ESTH 2007; 52:1-13. [PMID: 17030081 DOI: 10.1016/j.anplas.2006.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2006] [Accepted: 08/01/2006] [Indexed: 12/20/2022]
Abstract
Nowadays managing a cutaneous malignant melanoma can concern different kind of physicians: dermatologists, general or plastic surgeons The primary surgical procedure is a major step of the treatment. Biopsy must be total to properly determine the thickness of the tumor in case of malignancy. Wide local excision of the scar is often necessary to decrease the local and general recurrence rates. Wide local excision must be performed conforming to its own surgical rules. Managing tumor located on the face or limb extremities is a matter of plastic surgery. Sentinel node biopsy has succeeded to elective lymph node dissection. This procedure allows research of lymphatic spreading of the disease. Practice of sentinel node biopsy must be achieved in a protocolar way. Topography of the lesion can modified achievement and results of this procedure. Prognosis benefit of sentinel biopsy is now clear. Elective lymph node dissection is only performed in case of invaded sentinel node or clinically invaded lymph nodes. Local or locoregional recurrences mainly respond to surgical treatment using wide excision. However, alternative solutions are being evaluated (isolated limb perfusion).
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Affiliation(s)
- A Lavie
- Service de chirurgie plastique et réparatrice, hôpital de La Conception, 147, boulevard baille, 13385 Marseille cedex 05, France.
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Keller B, Yawalkar N, Pichler C, Braathen LR, Hunger RE. Hypersensitivity reaction against patent blue during sentinel lymph node removal in three melanoma patients. Am J Surg 2007; 193:122-4. [PMID: 17188103 DOI: 10.1016/j.amjsurg.2006.03.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 03/22/2006] [Accepted: 03/22/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND In order to identify the sentinel lymph node (SLN) in melanoma patients intradermal injection of a radiocolloid tracer and a blue dye are commonly used. Life-threatening side effects such as allergic reactions to the injected dye have been described. We report 3 cases with systemic allergic reactions. METHODS Three patients suffering from systemic reactions such as hypotension and rash during SLN biopsy were tested for sensitisation against patent blue and methylene blue with skin prick, scratch, and intradermal test. RESULTS All 3 patients showed positive skin tests to patent blue confirming allergic reaction to the injected dye. In addition, all patients showed positive skin tests with methylene blue indicating immunologic cross-reactivity between patent blue and methylene blue. CONCLUSIONS Although allergic reactions to blue dye during SLN biopsy are rare, they may be life threatening. It is important that the attending anesthetist is aware of this.
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Affiliation(s)
- Beat Keller
- Department of Dermatology, University of Bern, Inselspital, 3010 Bern, Switzerland
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Scherer K, Studer W, Figueiredo V, Bircher AJ. Anaphylaxis to isosulfan blue and cross-reactivity to patent blue V: case report and review of the nomenclature of vital blue dyes. Ann Allergy Asthma Immunol 2006; 96:497-500. [PMID: 16597088 DOI: 10.1016/s1081-1206(10)60921-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Blue dyes used for lymphatic mapping in sentinel lymph node biopsy cause intraoperative anaphylactic reactions in up to 2.7% of patients. With increasing implementation of this technique, the incidence of anaphylaxis to these dyes can be expected to increase. In the literature, the chemically often unrelated and inconsistently designated dyes have been confused, adding to other inconsistencies in the nomenclature. OBJECTIVE To demonstrate the nomenclature, chemical and physiologic differences, and allergenicity of the various blue dyes used in a medical context. METHODS We describe a patient with an intraoperative grade IV anaphylactic reaction to isosulfan blue. Immediate-type hypersensitivity was proved by positive skin test reactions and CD63 expression to isosulfan blue and cross-reactivity to patent blue V. RESULTS A review of the literature clarified the exact nomenclature of the blue dyes and the possible pitfalls of confusing nomenclature in the context of structurally closely related dyes with different allergenic properties. For the detection of type I hypersensitivity, intracutaneous tests are valuable tools. An IgE-mediated mechanism has been shown recently. In most cases, sensitization exists without known previous exposure in a medical context. This may be due to the widespread use of such dyes in objects of everyday life. Preoperative antiallergic medication use does not prevent anaphylactic reactions but apparently reduces their severity. CONCLUSION For better comparison and precision, the Chemical Abstracts Service number of the respective dye should always be given.
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Affiliation(s)
- Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital, Basel, Switzerland
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Masannat Y, Shenoy H, Speirs V, Hanby A, Horgan K. Properties and characteristics of the dyes injected to assist axillary sentinel node localization in breast surgery. Eur J Surg Oncol 2006; 32:381-4. [PMID: 16515852 DOI: 10.1016/j.ejso.2006.01.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Accepted: 01/26/2006] [Indexed: 12/20/2022] Open
Abstract
AIMS A review of the safety profile of dyes injected to assist in sentinel lymph node biopsy (SLNB) in breast cancer. METHODS A literature search was performed of the medline database 1966-2005 using the Ovid web Gateway detailing the words sentinel node, breast cancer, allergic reactions, blue dye, isosulfan blue, patent blue and methylene blue. RESULTS There are reported side-effects from the parenteral administration of dyes, which range from minor to life threatening in severity. There are differences between the dyes as regards their effects. These aspects are discussed. CONCLUSION Many dyes have been used for SLNB with acceptable identification rates. There are variable side-effects for each of those dyes. Further research is needed to clarify the safety profile of these dyes.
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Affiliation(s)
- Y Masannat
- The Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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Tanaka K, Yamamoto D, Kanematsu S, Okugawa H, Kamiyama Y. A four node axillary sampling trial on breast cancer patients. Breast 2006; 15:203-9. [PMID: 16061382 DOI: 10.1016/j.breast.2005.04.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 04/19/2005] [Accepted: 04/28/2005] [Indexed: 10/25/2022] Open
Abstract
The surgical management of axillary lymph nodes in early breast cancer remains controversial, although several maneuvers have been developed such as axillary node clearance (ANC), four node axillary sampling (4NAS), and sentinel node biopsy. A total of 237 cases of primary breast cancer at stages I and II were studied prospectively to elucidate the correlation between 4NAS and ANC. All calculated values by 4NAS showed high sensitivity, specificity, and overall accuracy as follows in this study: 92.9%, 100% and 98.5% for stage I, and 93.8%, 100% and 98.3% for stage II. Likewise, the false negative (FN) rates were 7.1% for stage I, 6.3% for stage II, 6.7% for T1, 6.4% for T2, 7.4% for N0, 0% for N1, and 6.5% for all cases. These rates were very low, although 7.4% for N0 and 0% for N1 were quite clearly different. This implies that all FN cases were N0, and were caused by micrometastases with normal consistency and size. 4NAS may be as accurate a procedure as ANC in assessing axillary nodal stage.
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Affiliation(s)
- Kanji Tanaka
- Department of Surgery, Kansai Medical University, 10-15, Fumizono, Moriguchi, Osaka 570-8507, Japan.
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Hadar T, Gimmon Z, Shalit M. Giant Blue Urticaria following Injection of Patent Blue Dye for Sentinel Lymph Node Biopsy. Plast Reconstr Surg 2006; 117:1657-9. [PMID: 16641753 DOI: 10.1097/01.prs.0000208867.58053.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Emergency situations following appropriately administered injections and infusions are an uncommon dermatologic problem. Embolia cutis medicamentosa is an uncommon complication following intramuscular injection which leads to infarct-like cutaneous necrosis. It may develop after gluteal injection of corticosteroids, anti-inflammatory agents and antibiotics and has rarely been described following venous sclerotherapy with polidocanol. Hoigné syndrome is a pseudoanaphylactic or pseudoallergic reaction following intramuscular injection of procaine penicillin, with neuropsychiatric problems developing immediately after the injection. Subacute forms following intramuscular or oral administration of structurally-related antibiotics. The intraoperative use of patent blue dye has a 1-2% risk of allergic reactions. The patient must be monitored carefully following injection for the onset the life-threatening immediate reaction. Extravasation of cytostatic agents is a critical iatrogenic problem in oncology with an incidence of up to 6.5%. Every oncologic department should have an understanding of necrotic risk of the various agents and an emergency kit with instructions for immediate steps, also including agent-specific antidotes as available.
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Affiliation(s)
- D Dill-Müller
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum des Saarlandes, Homburg/Saar.
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Dewachter P, Mouton-Faivre C, Benhaijoub A, Abel-Decollogne F, Mertes PM. Anaphylactic reaction to patent blue V after sentinel lymph node biopsy. Acta Anaesthesiol Scand 2006; 50:245-7. [PMID: 16430550 DOI: 10.1111/j.1399-6576.2006.00912.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We report a documented grade III IgE-mediated hypersensitivity reaction associated with the use of 2.5% patent blue V dye for sentinel lymph node biopsy during breast cancer surgery. METHODS Immediately after the reaction, when hemodynamic stability was obtained, plasma histamine was measured whereas serum tryptase was not. Six weeks later, with the patient's consent, cutaneous tests to patent blue V dye, methylene blue dye, latex and all drugs used during surgery were performed according to standardized procedures. RESULTS AND CONCLUSION Clinical symptoms, biological assessment results and cutaneous tests positivity confirmed the onset of an anaphylactic reaction due to patent blue V. Of interest, the positivity of the cutaneous tests observed with patent blue V was not found with methylene blue which might be proposed for further investigations in our patient. This case report confirms the need for systematic allergological investigation of all drugs and substances administered during the peri-operative period in case of an immediate hypersensitivity reaction occurring during anesthesia.
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Affiliation(s)
- P Dewachter
- Service d'Anesthésie-Réanimation Chirurgicale, Centre Hospitalier Universitaire (CHU), Nancy, France.
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van Zuuren E, Polderman MCA, Kuijken I. Anaphylaxis to patent blue during sentinel lymph node identification. Contact Dermatitis 2005; 53:171. [PMID: 16128760 DOI: 10.1111/j.0105-1873.2005.0407c.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Esther van Zuuren
- Department of Dermatology, Leiden University Medical Centre, Leiden, the Netherlands.
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Current World Literature. Curr Opin Allergy Clin Immunol 2005. [DOI: 10.1097/01.all.0000175939.68435.7e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kretschmer L, Peeters S, Beckmann I, Thoms KM, Mitteldorf C, Emmert S, Sahlmann CO, Bertsch HP, Neumann C, Meller J. Intraoperative Detektion von Sentinel-Lymphknoten beim malignen Melanom der Haut-Vitalfarbung allein versus Vitalfarbung plus Gammasonde. Intraoperative detection of sentinel lymph nodes in cutaneous malignant melanoma - blue dye alone versus blue dye plus gamma-detection. J Dtsch Dermatol Ges 2005; 3:615-22. [PMID: 16033480 DOI: 10.1111/j.1610-0387.2005.05735.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Compared with intraoperative sentinel lymph node identification using blue dye only, the introduction of a hand-held gamma probe has improved the identification rates. In this retrospective study, further aspects related to the introduction of gamma-guided preparation are analysed in detail. PATIENTS AND METHODS 81 patients who underwent sentinel biopsy using the blue dye technique were compared to 247 patients whose operations were guided by blue dye and gamma probe. RESULTS After the introduction of radio-guided surgery, the sentinel node identification rate increased from 87.7 % to 99.2 % (P < 0.00001). The number of harvested sentinel lymph nodes increased from 1.4 +/- 0.9 to 1.8 +/- 0.09 (P < 0.00001). The "clinical false-negative rate" decreased from 15.8 % to 9.6 %. The percentage of positive completion lymphadenectomy decreased from 50 % to 24.6 %. The risk of postoperative seroma decreased as a consequence of gamma guided preparation (5.1 % versus 15 %, P = 0.01). Regarding overall survival and recurrence-free survival, there were no significant differences between both groups. The 5-year-probability of nodal basin failure was 7.9 % after negative sentinel biopsy and 25.3 % after positive sentinel lymphonodectomy plus consecutive completion lymphadenectomy. CONCLUSIONS Combined application of blue dye and gamma-probe improved sensitivity and decreased the risk of postoperative seroma. The probability of recurrence and survival was not influenced by the technique of intraoperative sentinel node identification.
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Affiliation(s)
- Lutz Kretschmer
- Abteilung Dermatologie und Venerologie, Georg-August-Universität Göttingen, Germany.
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Govaert GAM, Oostenbroek RJ, Plaisier PW. Prolonged skin staining after intradermal use of patent blue in sentinel lymph node biopsy for breast cancer. Eur J Surg Oncol 2005; 31:373-5. [PMID: 15837042 DOI: 10.1016/j.ejso.2004.12.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Revised: 11/25/2004] [Accepted: 12/06/2004] [Indexed: 10/25/2022] Open
Abstract
AIMS To investigate the duration of staining of the skin after intradermal injection of patent blue during sentinel lymph node biopsy (SLNB) for breast cancer. METHODS The clinical data of 33 consecutive patients who underwent a SLNB in combination with breast conserving therapy (BCT) in our hospital were retrospectively reviewed. Also, patients were interviewed at intervals of 3 months until the blue staining of their skin had disappeared. RESULTS At mean follow-up of 18 months (range: 12-28) patent blue was visible at the site of injection after 3, 6, 9 and 12 months in 70, 64, 44 and 41% of the patients, respectively. CONCLUSIONS Use of the intradermal injection technique of patent blue during sentinel lymph node biopsy in BCT may result in remarkably long discolouring of the skin at the site of injection.
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Affiliation(s)
- G A M Govaert
- Department of Surgery, Albert Schweitzer Hospital, P.O. Box 444, NL-3300 AK Dordrecht, The Netherlands
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