Immunoglobulin E-Mediated Hypersensitivity Reaction to Ketamine

Trips Through the Skin: Reviewing Cutaneous Drug Reactions to Psychedelics and Hallucinogens

Although psychedelic and hallucinogenic substances have gained popularity for therapeutic use, their dermatologic adverse effects are poorly characterized. This review characterizes the cutaneous reactions associated with psychedelic and hallucinogenic drugs. A review of PubMed and Scopus was conducted from the inception of databases to August 31, 2023. Search terms included drug names and classes (cannabis, MDMA, ecstasy, 3,4-methylenedioxymethamphetamine, psychedelics, hallucinogens, peyote, marijuana, lysergic acid diethylamide, LSD, ketamine, dimethyltryptamine, DMT, phencyclidine, PCP, dextromethorphan, psilocybin, and ayahuasca), and dermatosis terms (dermatitis, contact dermatitis, drug eruption, skin reaction, and urticaria). Studies were included if there was an association with a psychedelic or hallucinogenic and any cutaneous reaction; studies without both components were excluded. Twenty-two studies met inclusion criteria, describing reactions to cannabis (10 studies), MDMA (5 studies), ketamine (4 studies), and psilocybin (3 studies). Forty total patients were included. Among cannabis-related reactions, the most common reaction was type I hypersensitivity by topical exposure (n = 21). Three patients reported type IV hypersensitivity reactions to contact with cannabis or cannabis-derived oils, all of whom experienced vesicular contact dermatitis. Two additional patients presented with an erythema-multiforme-like reaction and acute generalized exanthematous pustulosis after systemic administration, respectively. MDMA was associated with acneiform eruptions (2 cases), an urticarial eruption, a guttate psoriasis-like reaction, a fixed drug eruption, and Stevens-Johnson syndrome (1 case). Four patients reported type I hypersensitivity reactions to ketamine. Four patients reported vesicular eruptions, cyanosis, or widespread jaundice to psilocybin. Of the cases, 8 patients had cutaneous reactions that resolved with drug cessation, 10 resolved with cessation plus treatment, and resolution in 7 cases was not reported. Zero studies were found describing other psychedelic or hallucinogenic compounds. Further research is required to characterize reactions and treatments linked to the variety of extant psychedelics and hallucinogens.

Allergic and other adverse reactions to drugs used in anesthesia and surgery

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.

Molecular pathways underlying tissue injuries in the bladder with ketamine cystitis

Ketamine cystitis (KC) is a chronic bladder inflammation leading to urinary urgency, frequency, and pain. The pathogenesis of KC is complicated and involves multiple tissue injuries in the bladder. Recent studies indicated that urothelium disruption, lamina propria fibrosis and inflammation, microvascular injury, neuropathological alterations, and bladder smooth muscle (BSM) abnormalities all contribute to the pathogenesis of KC. Ketamine has been shown to induce these tissue injuries by regulating different signaling pathways. Ketamine can stimulate antiproliferative factor, adenosine triphosphate, and oxidative stress to disrupt urothelium. Lamina propria fibrosis and inflammation are associated with the activation of cyclooxygenase-2, nitric oxide synthase, immunoglobulin E, and transforming growth factor β1. Ketamine contributes to microvascular injury via the N-methyl-D aspartic receptor (NMDAR), and multiple inflammatory and angiogenic factors such as tumor necrosis factor α and vascular endothelial growth factor. For BSM abnormalities, ketamine can depress the protein kinase B, extracellular signal-regulated kinase, Cav1.2, and muscarinic receptor signaling. Elevated purinergic signaling also plays a role in BSM abnormalities. In addition, ketamine affects neuropathological alterations in the bladder by regulating NMDAR- and brain-derived neurotrophic factor-dependent signaling. Inflammatory cells also contribute to neuropathological changes via the secretion of chemical mediators. Clarifying the role and function of these signaling underlying tissue injuries in the bladder with KC can contribute to a better understanding of the pathophysiology of this disease and to the design of effective treatments for KC.

A 2-year-old girl with periprocedural anaphylaxis

Periprocedural or perioperative anaphylaxis is rare, with an estimated incidence of 1 in 10,000 to 40,000 sedation cases. During such procedures, patients are often exposed to numerous medications, such as antimicrobials, neuromuscular blocking agents, sedative and/or hypnotics, and opioids. The most commonly implicated agents include antibiotics (in the United States) and neuromuscular blocking agents (in Europe). In this article, we explore the differential diagnosis and laboratory investigation of a case of periprocedural anaphylaxis.

Suspected Anaphylactic Reaction to Ketamine in 3 Yucatan Swine (Sus scrofa)

This case series describes the clinical courses of 3 juvenile Yucatan miniature swine (Sus scrofa) that experienced a suspected anaphylactic reaction to ketamine hydrochloride during premedication for protocol-related surgery. All 3 swine rapidly developed diffuse erythema shortly after injection with ketamine-containing drug combinations. Clinical signs ranged from tachycardia and erythema alone to tachycardia and erythema followed by respiratory and cardiac arrest. Ketamine was considered the most likely cause of these reactions because it was the only agent in the premedication sedation combination that was used in all 3 swine. Subsequent intradermal skin testing confirmed this suspicion. With supportive care measures and standard medical interventions for anaphylaxis, all 3 animals recovered well and went on to be successful experimental subjects when an alternative anesthetic regimen that did not contain ketamine was used. To our knowledge, this report is the first description of a suspected adverse ketamine reaction of this type in swine despite the widespread use of the drug in this species. Ketamine anaphylaxis is rare in people, but the few cases described presented with symptoms similar to the clinical signs seen in the pigs in this report. In addition to highlighting a potential adverse drug reaction to ketamine in swine, this case series demonstrates the value of emergency preparedness for even the most routine of procedures.

The Case of Ketamine Allergy

Ketamine is often used for pediatric procedural sedation due to low rates of complications, with allergic reactions being rare. Immediately following intramuscular (IM) ketamine administration, a three-year-old female rapidly developed facial edema and diffuse urticarial rash, with associated wheezing and oxygen desaturation. Symptoms resolved following treatment with epinephrine, dexamethasone and diphenhydramine. This case presents a clinical reaction to ketamine consistent with anaphylaxis due to histamine release, but it is uncertain whether this was immunoglobulin E mediated. This is the only case reported to date of allergic reaction to IM ketamine, without co-administration of other agents.