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Sanan N, Lee J, Baxter C, Jeskey J, Hostoffer R. Delayed and protracted allergic reaction to oral lidocaine. Ann Allergy Asthma Immunol 2019; 123:413-414. [PMID: 30878625 DOI: 10.1016/j.anai.2019.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 02/19/2019] [Accepted: 03/06/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Neha Sanan
- University Hospitals Cleveland Medical Center, Cleveland, Ohio.
| | - Jenny Lee
- Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Christina Baxter
- Nova Southeastern University College of Osteopathic Medicine Davie, Florida
| | - Jack Jeskey
- Lake Erie College of Osteopathic Medicine, Bradenton, Florida
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2
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Armentia A, Martín-Armentia B, Martín-Armentia S, Ruiz-Muñoz P, Quesada JM, Postigo I, Conde R, González-Sagrado M, Pineda F, Castillo M, Palacios R, Tejedor J. Cocaine Allergy in Drug-Dependent Patients and Allergic People. J Allergy Clin Immunol Pract 2017; 6:201-207. [PMID: 28863944 DOI: 10.1016/j.jaip.2017.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adverse reactions to local anesthetics (LAs), especially esters, are not uncommon, but true allergy is rarely diagnosed. To our knowledge, currently there is no reliable method of determining IgE-mediated hypersensitivity to LAs and cocaine. OBJECTIVE To assess the clinical value of allergy tests (prick, IgE, challenges, and arrays) in people suffering hypersensitivity reactions (asthma and anaphylaxis) during local anesthesia with cocaine derivatives and drug abusers with allergic symptoms after cocaine inhalation. METHODS We selected cocaine-dependent patients and allergic patients who suffered severe reactions during local anesthesia from a database of 23,873 patients. The diagnostic yield (sensitivity, specificity, and predictive value) of allergy tests using cocaine and coca leaf extracts in determining cocaine allergy was assessed, taking a positive challenge as the criterion standard. RESULTS After prick tests, specific IgE, and challenge with cocaine extract, 41 of 211 patients (19.4%) were diagnosed as sensitized to cocaine. Prick tests and IgE to coca leaves (coca tea) had a good sensitivity (95.1% and 92.7%, respectively) and specificity (92.3 and 98.8%, respectively) for the diagnosis of cocaine allergy and LA-derived allergy. CONCLUSIONS Cocaine may be an important allergen. Drug abusers and patients sensitized to local anesthesia and tobacco are at risk. Both prick tests and specific IgE against coca leaf extract detected sensitization to cocaine. The highest levels were related to severe clinical profiles.
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Affiliation(s)
- Alicia Armentia
- Allergy Unit, Rio Hortega University Hospital, University of Valladolid, Valladolid, Spain.
| | - Blanca Martín-Armentia
- Allergy Unit, Rio Hortega University Hospital, University of Valladolid, Valladolid, Spain
| | - Sara Martín-Armentia
- Allergy Unit, Rio Hortega University Hospital, University of Valladolid, Valladolid, Spain
| | - Pedro Ruiz-Muñoz
- San Juan de Dios Center, Palencia and Castile-Leon Association for the Aid of Drug Abusers (ACLAD), Valladolid, Spain
| | - Jorge Martínez Quesada
- Immunology, Microbiology and Parasitology Department, University of the Basque Country, Vitoria, Spain
| | - Idoia Postigo
- Immunology, Microbiology and Parasitology Department, University of the Basque Country, Vitoria, Spain
| | - Rosa Conde
- Research Unit, Rio Hortega University Hospital, Valladolid, Spain
| | | | | | | | | | - Jesús Tejedor
- Government Delegation, Community of Castile and Leon, Valladolid, Spain
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3
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Tupker RA, Fransen M, van Zuuren EJ. [Suspected allergy to a local anaesthetic: how often is allergy proven?]. Ned Tijdschr Geneeskd 2014; 158:A7556. [PMID: 25004784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine the percentage of proven allergy for local anaesthetics (LA) in patients who were tested because of a clinical suspicion of LA allergy. DESIGN Retrospective multicentre case series. METHOD All patients from two hospitals who were seen from 2004 through 2013 for a possible allergy to local anaesthetics. Their records were analyzed for the probable type of allergic reaction and allergy tests were performed. Distinction was made between skin prick tests (SPT), intradermal tests (IDT), subcutaneous provocation tests and epicutaneous tests (patch tests). RESULTS 53 patients were included. The most common symptoms were dizziness (n = 14) and collapse (n = 12). Urticaria, oedema and/or erythema were seen in 25 patients, whilst 2 patients had a drop in blood pressure. In 4 patients an IgE-mediated allergy was proven by means of provocation testing. SPT and IDT were not predictive. In 1 patient a delayed-type allergy was established by patch testing. CONCLUSION IgE-mediated and delayed-type allergic reactions are rarely caused by LA. IgE-mediated reactions can be proven by provocation testing. Patch testing is used when a delayed type reaction is suspected.
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Affiliation(s)
- Ron A Tupker
- St. Antonius Ziekenhuis, afd. Dermatologie, Nieuwegein
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4
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Carroll ME, Zlebnik NE, Anker JJ, Kosten TR, Orson FM, Shen X, Kinsey B, Parks RJ, Gao Y, Brimijoin S. Combined cocaine hydrolase gene transfer and anti-cocaine vaccine synergistically block cocaine-induced locomotion. PLoS One 2012; 7:e43536. [PMID: 22912888 PMCID: PMC3422258 DOI: 10.1371/journal.pone.0043536] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 07/23/2012] [Indexed: 11/24/2022] Open
Abstract
Mice and rats were tested for reduced sensitivity to cocaine-induced hyper-locomotion after pretreatment with anti-cocaine antibody or cocaine hydrolase (CocH) derived from human butyrylcholinesterase (BChE). In Balb/c mice, direct i.p. injection of CocH protein (1 mg/kg) had no effect on spontaneous locomotion, but it suppressed responses to i.p. cocaine up to 80 mg/kg. When CocH was injected i.p. along with a murine cocaine antiserum that also did not affect spontaneous locomotion, there was no response to any cocaine dose. This suppression of locomotor activity required active enzyme, as it was lost after pretreatment with iso-OMPA, a selective BChE inhibitor. Comparable results were obtained in rats that developed high levels of CocH by gene transfer with helper-dependent adenoviral vector, and/or high levels of anti-cocaine antibody by vaccination with norcocaine hapten conjugated to keyhole limpet hemocyanin (KLH). After these treatments, rats were subjected to a locomotor sensitization paradigm involving a “training phase" with an initial i.p. saline injection on day 1 followed by 8 days of repeated cocaine injections (10 mg/kg, i.p.). A 15-day rest period then ensued, followed by a final “challenge" cocaine injection. As in mice, the individual treatment interventions reduced cocaine-stimulated hyperactivity to a modest extent, while combined treatment produced a greater reduction during all phases of testing compared to control rats (with only saline pretreatment). Overall, the present results strongly support the view that anti-cocaine vaccine and cocaine hydrolase vector treatments together provide enhanced protection against the stimulatory actions of cocaine in rodents. A similar combination therapy in human cocaine users might provide a robust therapy to help maintain abstinence.
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Affiliation(s)
- Marilyn E. Carroll
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Natalie E. Zlebnik
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Justin J. Anker
- Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Thomas R. Kosten
- Departments of Medicine, Psychiatry & Neuroscience, and Pathology & Immunology, Baylor College of Medicine and Veterans Administration Medical Center, Houston, Texas, United States of America
| | - Frank M. Orson
- Departments of Medicine, Psychiatry & Neuroscience, and Pathology & Immunology, Baylor College of Medicine and Veterans Administration Medical Center, Houston, Texas, United States of America
| | - Xiaoyun Shen
- Departments of Medicine, Psychiatry & Neuroscience, and Pathology & Immunology, Baylor College of Medicine and Veterans Administration Medical Center, Houston, Texas, United States of America
| | - Berma Kinsey
- Departments of Medicine, Psychiatry & Neuroscience, and Pathology & Immunology, Baylor College of Medicine and Veterans Administration Medical Center, Houston, Texas, United States of America
| | - Robin J. Parks
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Yang Gao
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Stephen Brimijoin
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
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5
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Abstract
True allergic reactions to local anesthetics are rare adverse reactions. At the most, they represent less than 1% of all adverse local anesthetic reactions. When true allergic reactions have been confirmed, the reactions are most commonly the type I anaphylactic and type IV delayed hypersensitivity responses. The type I immediate hypersensitivity reactions are the most severe and may be life-threatening. In the event a potential allergic reaction occurs in a dental office, the dentist needs to properly evaluate the events leading up to the reaction and provide a differential diagnosis. A referral should be given to any patient when an allergic reaction cannot be ruled out as an intravascular injection, toxic overdose, psychogenic reaction, or an idiosyncratic event.
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Affiliation(s)
- Steven J Speca
- Department of Anesthesiology, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA 15261, USA.
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6
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Lahlou J, Bensghir M, Belyamani L, Boulahri T, Drissi Kamili N. [Immunoallergic transitory paraplegia after regional anaesthesia]. Ann Fr Anesth Reanim 2009; 28:172. [PMID: 19201568 DOI: 10.1016/j.annfar.2008.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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7
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Abstract
Adverse reactions to local anesthetics are relatively common, but true IgE-mediated hypersensitivity is extremely rare. Fortunately, the vast majority of adverse reactions occur via nonimmunologic means, but considerable confusion still exists among providers. We conducted a review of the literature to determine if earlier estimates of IgE-mediated allergy are consistent with current reports and whether current management strategies are consistent with these findings. We identified several confounding variables involved in the evaluation, including the roles of preservatives/additives, epinephrine, latex, and inadequate testing procedures. These problems may cause significant diagnostic challenges for clinicians. It is in fact much more likely that there is an alternate diagnosis, and in many cases clinicians can begin the evaluation in the office. When local anesthetic allergy is still suspected, the patient should be referred to an allergist for testing to determine if the suspected culprit drug can be safely used, or, if necessary, identify a suitable alternative.
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Affiliation(s)
- Joshua F Phillips
- Department of Pediatrics, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA.
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8
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Boren E, Teuber SS, Naguwa SM, Gershwin ME. A critical review of local anesthetic sensitivity. Clin Rev Allergy Immunol 2007; 32:119-28. [PMID: 17426367 DOI: 10.1007/bf02686088] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 10/22/2022]
Abstract
With their ability to block pain signals to the brain, local anesthetics (LAs) have made possible many surgical procedures and interventions once thought impossible. LAs are generally safe and well tolerated when used correctly by trained professionals. However, adverse reactions do occur, and may generate a referral to an Allergist for evaluation of LA allergy. LA structure, classification, and metabolism will be briefly reviewed. A critical analysis of the studies and case reports involving LA allergy found via PubMed search for "local anesthetic allergy" and "local anesthetic hypersensitivity" will be discussed. In addition, the clinical evaluation of a patient with concern for a LA allergy will be examined.
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Affiliation(s)
- Eric Boren
- Division of Rheumatology, Allergy, and Clinical Immunology, Department of Internal Medicine, University of California at Davis School of Medicine, Davis, CA, USA
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Heurich M, Mousa SA, Lenzner M, Morciniec P, Kopf A, Welte M, Stein C. Influence of pain treatment by epidural fentanyl and bupivacaine on homing of opioid-containing leukocytes to surgical wounds. Brain Behav Immun 2007; 21:544-52. [PMID: 17174527 DOI: 10.1016/j.bbi.2006.10.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Revised: 10/17/2006] [Accepted: 10/19/2006] [Indexed: 11/22/2022] Open
Abstract
Endogenous opioids released from leukocytes extravasating into injured tissue can interact with peripheral opioid receptors to inhibit nociception. Animal studies have shown that the homing of opioid-producing leukocytes to the injured site is modulated by spinal blockade of noxious input. This study investigated whether epidural analgesia (EDA) influences the migration of beta-endorphin (END) and/or met-enkephalin (ENK)-containing leukocytes into the subcutaneous wound tissue of patients undergoing abdominal surgery. In part I patients received general anesthesia combined either with intra- and postoperative EDA (with bupivacaine and fentanyl) or with postoperative patient controlled intravenous analgesia (PCIA; with the opioid piritramide). In part II patients received general anesthesia combined with either epidural fentanyl or bupivacaine which was continued postoperatively. Samples of cutanous and subcutanous tissue were taken from the wound site at the beginning, at the end and at various times after surgery, and were examined by immunohistochemistry for the presence of END and ENK. We found that (i) epidural bupivacaine, fentanyl and PCIA provided similar and clinically acceptable postoperative pain relief; (ii) compared to PCIA, epidural bupivacaine or fentanyl did not change the gross inflammatory reaction within the surgical wound; (iii) opioid-containing leukocytes were almost absent in normal subcutaneous tissue but migrated to the inflamed wound tissue in ascending numbers within a few hours, reaching a peak at about 24 h after surgery; (iv) compared to PCIA, EDA resulted in significantly decreased homing of END-containing leukocytes to the injured site at 24 h after surgery; and (v) the magnitude of this decrease was similar regardless of the epidural medication. These findings suggest that nociceptive but not sympathetic neurons are primarily involved in the attraction of opioid-containing leukocytes during early stages of inflammation.
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MESH Headings
- Adjuvants, Anesthesia/immunology
- Adjuvants, Anesthesia/pharmacology
- Aged
- Analgesia, Patient-Controlled
- Analgesics, Opioid/immunology
- Analgesics, Opioid/therapeutic use
- Anesthesia, Epidural
- Anesthetics, Local/immunology
- Anesthetics, Local/therapeutic use
- Bupivacaine/immunology
- Bupivacaine/therapeutic use
- Cell Movement/drug effects
- Cell Movement/immunology
- Enkephalin, Methionine/drug effects
- Enkephalin, Methionine/immunology
- Enkephalin, Methionine/metabolism
- Female
- Fentanyl/immunology
- Fentanyl/therapeutic use
- Humans
- Leukocytes/drug effects
- Leukocytes/immunology
- Leukocytes/metabolism
- Longitudinal Studies
- Male
- Middle Aged
- Nociceptors/drug effects
- Nociceptors/immunology
- Pain, Postoperative/immunology
- Pain, Postoperative/prevention & control
- Pirinitramide/therapeutic use
- Subcutaneous Tissue/immunology
- Sympathetic Fibers, Postganglionic/drug effects
- Sympathetic Fibers, Postganglionic/immunology
- Wound Healing/drug effects
- Wound Healing/immunology
- beta-Endorphin/drug effects
- beta-Endorphin/immunology
- beta-Endorphin/metabolism
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Affiliation(s)
- Martin Heurich
- Klinik für Anaesthesiologie und operative Intensivmedizin, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, D-12200 Berlin, Germany.
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10
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Abstract
Eczema is common in the elderly people who often use topical medicaments. Previous studies in the elderly people have noted allergic positive patch tests in between 43% and 64% of those tested. We set out to assess whether medicament contact allergies are more common in elderly patients. We undertook a retrospective age-stratified study of all patients patch tested at the Royal Hallamshire Hospital, Sheffield, between January 1994 and July 2005. We confirmed that contact allergy to topical medicaments is more common in those aged more than 70 years compared with the younger age groups. There was no sex difference. The commonest problematic allergen types found in medicaments were fragrances and preservatives. The most frequent individual allergens were fragrance mix, Myroxylon pereirae, lanolins, local anaesthetic agents, neomycin and gentamicin, and tixocortol pivolate. The pattern of medicament contact allergens was similar to that of the younger age groups except that multiple allergic positives were more frequent and sensitivities to local anaesthetics and Myroxylon pereirae were proportionally more common. Elderly patients were more likely to have multiple contact allergies than the younger ones. Care needs to be taken when prescribing topical medicaments to elderly patients with eczema, especially for preparations that contain perfumes, lanolins, and local anaesthetics.
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Affiliation(s)
- Carl M Green
- Department of Dermatology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
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12
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13
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Palma-Carlos AG, Medina M, Palma-Carlos ML. Prevalence of drug allergy in an out-patient population. Eur Ann Allergy Clin Immunol 2006; 38:142-5. [PMID: 17058844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The prevalence of drug allergy in an out-patient population has been studied, 448 cases were diagnosed mainly to NSAIDS and beta-lactams and local anesthetics, sulfa drugs, quinolones and others. Clinical history and skin tests are sufficient to diagnose most cases of drug allergy.
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14
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González-Delgado P, Antón R, Soriano V, Zapater P, Niveiro E. Cross-reactivity among amide-type local anesthetics in a case of allergy to mepivacaine. J Investig Allergol Clin Immunol 2006; 16:311-3. [PMID: 17039671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
Among the various adverse reactions to local anesthetics, IgE-mediated reactions, particularly to the more commonly used amide group, are extremely rare. We report the case of a 39-year-old man who suffered itching and generalized urticaria with facial angioedema 15 minutes after administration of mepivacaine. Skin tests revealed a strong positive reaction to mepivacaine, lidocaine, and ropivacaine, but negative reactions to bupivacaine and levobupivacaine. Furthermore, double-blind placebo-controlled subcutaneous challenge with bupivacaine and levobupivacaine was well tolerated. We conclude that an extensive allergologic study must be carried out in rare cases of true allergic reaction to amide-type local anesthetics in order to rule out cross reactivity.
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15
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Noormalin A, Shahnaz M, Rosmilah M, Mujahid SH, Gendeh BS. IgE-mediated hypersensitivity reaction to lignocaine - a case report. Trop Biomed 2005; 22:179-83. [PMID: 16883285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
We report a 7 year old girl who developed ipsilateral left facial swelling immediately after lignocaine injection. Skin prick test showed positive reaction to pure 2% lignocaine hydrochloride and to lignocaine oral dental gel. Specific Immunoglobulin E (Ig E) to lignocaine was detected. Lignocaine is a commonly used anaesthetic agent mainly as local anaesthesia. However type I hypersensitivity to lignocaine is rare and there have been very few cases reported in the literature.
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Affiliation(s)
- A Noormalin
- Allergy & Immunology Research Centre, Institute for Medical Research, Kuala Lumpur
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16
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Prieto A, Herrero T, Rubio M, Tornero P, Baeza ML, Velloso A, Pérez C, De Barrio M. Urticaria due to mepivacaine with tolerance to lidocaine and bupivacaine. Allergy 2005; 60:261-2. [PMID: 15647053 DOI: 10.1111/j.1398-9995.2005.00648.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A Prieto
- Servicio de Alergia, Hospital General Universitario Gregorio, Marañón, C/Dr. Esquerdo, 46, 28007 Madrid, Spain.
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17
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Affiliation(s)
- R B Jacobsen
- Allergy Center, Department of Dermatology, Odense University Hospital, 29 Sdr Boulevard, DK 5000 Odense C, Denmark.
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18
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Vuori A, Salo M, Viljanto J, Pajulo O, Pulkki K, Nevalainen T. Effects of post-operative pain treatment using non-steroidal anti-inflammatory analgesics, opioids or epidural blockade on systemic and local immune responses in children. Acta Anaesthesiol Scand 2004; 48:738-49. [PMID: 15196107 DOI: 10.1111/j.1399-6576.2004.00404.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Many studies have been carried out on the effects of anaesthetic drugs and methods on the immune response, but pain and its relief also affect the immune response. We measured systemic immune responses in the blood circulation and local responses in the surgical wound when non-steroidal anti-inflammatory analgesics (NSAIDs), opioids or epidural blockade was used in the peri-operative treatment of pain. METHODS Responses were measured in 51 children, aged from 2 to 12 years and undergoing major surgery under balanced anaesthesia. Bolus doses of diclofenac intravenously (i.v.) and rectally (NSAID group), continuous i.v. infusion of oxycodone (opioid group) or continuous epidural infusion of bupivacaine + fentanyl (epidural group) were used peri-operatively for pain relief. RESULTS The only difference related to the analgesic method was shorter duration of post-operative leucocytosis and lower phytohaemagglutinin (PHA)-induced lymphocyte proliferative responses in peripheral blood in the opioid group than in the NSAID or epidural groups. By contrast, time-related alterations were seen overall in leucocyte and differential counts, lymphocyte and their subset counts, lymphocyte proliferative responses, and in serum cortisol, C-reactive protein, plasma interleukin-6 and group II phospholipase A2 concentrations and in the appearance of different cell types in the wound. CONCLUSIONS Post-operative pain treatments using diclofenac (NSAID), oxycodone (opioid) and epidural blockade have basically similar effects on systemic and local immune responses with only slight, probably clinically unimportant differences in children undergoing surgery under general anaesthesia.
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MESH Headings
- Analgesia, Epidural/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/immunology
- Analgesics, Opioid/therapeutic use
- Analysis of Variance
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/immunology
- Anesthetics, Local/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/immunology
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Bupivacaine/administration & dosage
- Bupivacaine/immunology
- Bupivacaine/therapeutic use
- Child
- Child, Preschool
- Diclofenac/administration & dosage
- Diclofenac/immunology
- Diclofenac/therapeutic use
- Female
- Fentanyl/administration & dosage
- Fentanyl/immunology
- Fentanyl/therapeutic use
- Finland
- Humans
- Immunity, Cellular/drug effects
- Immunity, Cellular/physiology
- Leukocyte Count
- Male
- Oxycodone/administration & dosage
- Oxycodone/immunology
- Oxycodone/therapeutic use
- Pain, Postoperative/drug therapy
- Pain, Postoperative/immunology
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Affiliation(s)
- A Vuori
- Department of Anesthesia, Loimaa Regional Hospital, Loimaa, Finland.
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19
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Abstract
PURPOSE OF REVIEW Cross-reactivity with drugs is an important clinical problem in drug hypersensitivity. Once a patient is labeled 'drug-allergic' all drugs of the same class are withheld and future therapeutic interventions are limited. Here we review cross-reactivity with drugs at the T cell level. RECENT FINDINGS Analysis of T cell recognition of various classes of drugs (beta-lactam antibiotics, sulfonamides, local anesthetics) using T cell clones suggests that at the T cell level the whole structure, in particular the core and to a lesser degree side chains, are recognized. SUMMARY It is necessary to differentiate cross-reactivity mediated by T cells and antibodies as only the latter seem to recognize side chains exclusively.
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Affiliation(s)
- Jan P H Depta
- Division of Allergology, Clinic of Rheumatology and Clinical Immunology / Allergology, Inselspital, University of Bern, Bern, Switzerland
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20
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Abstract
OBJECTIVES Although true allergic reactions to local anaesthetics are rare in the general population, the importance of the problem among asthmatic children has yet to be documented. SAMPLE AND METHODS Skin prick, intradermal and incremental challenge tests with lidocain were performed in 157 asthmatic children aged 8-15 years and compared with 72 nonasthmatic children of a similar age. All of the asthmatic subjects were allergic to at least one allergen, most frequently pollens and house dust mites. Prick testing began with an undiluted solution in patients without a history of allergy and with 1:100 dilution in those with a reaction history. Following negative prick testing, intradermal or incremental challenge tests were performed. RESULTS A total of 125 patients (80%) had been given local anaesthetics in the past, only three children gave history of an adverse local reaction. At the end of the tests, none of the subjects including controls, were found to have immediate or delayed-type allergy to lidocain. CONCLUSIONS Local anaesthetic allergy does not seem to be a serious problem among asthmatic children and testing in all asthmatic children is not warranted. Those with an adverse reaction history to local anaesthetics should be tested with these drugs.
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21
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Kalghatgi S. Just the berries. Allergy to local anesthetics. Can Fam Physician 2001; 47:1391, 1393. [PMID: 11494926 PMCID: PMC2018533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- S Kalghatgi
- St Martha's Regional Hospital, Antigonish, NS
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Orasch CE, Helbling A, Zanni MP, Yawalkar N, Hari Y, Pichler WJ. T-cell reaction to local anaesthetics: relationship to angioedema and urticaria after subcutaneous application--patch testing and LTT in patients with adverse reaction to local anaesthetics. Clin Exp Allergy 1999; 29:1549-54. [PMID: 10520085 DOI: 10.1046/j.1365-2222.1999.00693.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Local anaesthetics are known to elicit T-cell reactions after epicutaneous application, namely contact dermatitis. In addition, adverse reactions like urticaria and angioedema are rather common after submucosal or subcutaneous injection. The pathogenesis of these side-effects, which appear frequently hours after application, is unknown, but thought to be not immunoglobulin E-mediated, since immediate skin tests are mostly negative. OBJECTIVES We investigated whether patients who developed urticaria and angioedema after subcutaneous application have a T-cell sensitization to local anaesthetics, which might be responsible for the symptoms. METHODS Twenty patients with generalized and/or local cutaneous reactions after LA were examined with intradermal testing using a standard panel of six LAs and patch testing using between seven and nine LAs in vaseline and four LAs in PBS. In 10 patients, a lymphocyte transformation test (LTT) was performed. RESULTS Only 2/20 patients had an immediate skin reaction (positive intradermal test), whereas 6/20 patients had a positive delayed skin reaction (positive patch test). In 6/10 subjects the LTT was positive. CONCLUSIONS Delayed appearance of urticaria and angioedema after subcutaneous application of local anaesthetics may be related to a T cell- mediated sensitization, which might be detected by patch testing or LTT.
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Affiliation(s)
- C E Orasch
- Institute of Immunology and Allergology, University Hospital, Bern, Switzerland
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23
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Abstract
Patients with drug allergy show a specific immune response to drugs. Chemically nonreactive drugs like, for example, local anesthetics are directly recognized by alphabeta+ T cells in an HLA-DR restricted way, as neither drug metabolism nor protein processing is required for T cell stimulation. In this study we identified some of the structural requirements that determine cross-reactivity of T cells to local anesthetics, with the aim to improve the molecular basis for the selection of alternatives in individuals sensitized to a certain local anesthetic and to better understand presentation and T cell recognition of these drugs. Fifty-five clones (52 lidocaine specific, three mepivacaine specific from two allergic donors) were analyzed. Stimulatory compounds induced a down-regulation of the T cell receptor, demonstrating that these non-peptide antigens are recognized by the T cell receptor itself. A consistent cross-reactivity between lidocaine and mepivacaine was found, as all except one lidocaine specific clone proliferated to both drugs tested. Sixteen chemically related local anesthetics (including ester local anesthetics, OH- and desalkylated metabolites) were used to identify structural requirements for T cell recognition. Each of the four clones examined in detail was uniquely sensitive to changes in the structures of the local anesthetic: clone SFT24, i.e., did not recognize any of the tested OH- or desalkylated metabolites, while the clone OFB2 proliferated to all OH-metabolites and other differently modified molecules. The broadly reactive clone OFB2 allowed us to propose a model, suggesting that the structure of the amine side chain of local anesthetics is essential for recognition by the T cell receptor.
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Affiliation(s)
- M P Zanni
- Institute of Immunology and Allergology, Inselspital, Bern, Switzerland
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24
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Abstract
Allergic contact dermatitis is induced by a wide variety of drugs that trigger specific immune responses following topical exposure. Identified chemical structures involved in such reactions include the mercuric and thiosalicylic acid groups of thimerosal, the diphenylketone group of the anti-inflammatory drug ketoprofen, the amide or ester structure of local anesthetics, and the side-chain and thiazolidine ring of beta-lactams. The T cell responses to such compounds involve CD4+ and CD8+ alphabeta+ T lymphocytes and also CD4 /CD8 gammadelta+ T cells. Although "T helper 2" cytokine production by drug-specific human T cells from patients with allergic contact dermatitis has been described, T helper 1-like and T cytotoxic 1-like responses clearly play key roles in this cutaneous reaction.
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Affiliation(s)
- H Lebrec
- INSERM U 461, Faculté de Pharmacie Paris Sud, Châtenay-Malabry, France.
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25
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Zanni MP, von Greyerz S, Schnyder B, Wendland T, Pichler WJ. Allele-unrestricted presentation of lidocaine by HLA-DR molecules to specific alphabeta+ T cell clones. Int Immunol 1998; 10:507-15. [PMID: 9620607 DOI: 10.1093/intimm/10.4.507] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
T cells recognize peptide and non-peptide antigens. Drugs represent typical examples of non-peptide antigens. The majority of drug-specific T cells are alphabeta+ TCR T cells and are MHC class I or II restricted. Here we show the existence of drug (lidocaine)-specific T cell clones which proliferate in the presence of antigen-presenting cells (APC) with different HLA alleles. Two clones (SFT24 and E20) were analyzed in detail. They show a narrow dose-dependent proliferation to lidocaine, but not to procaine. With the use of a panel of HLA-typed allogeneic APC, we observed that certain allogeneic APC plus lidocaine lead to a similar, others to partial and some to no proliferation of the lidocaine-specific T cell clones. An APC-independent proliferation could be excluded since both clones proliferated only marginally without APC and increasing the number of APC resulted in a higher proliferation. Blocking experiments with anti-DP, -DQ and -DR antibodies showed that lidocaine is presented in a HLA-DR-restricted way both with autologous or allogeneic APC. Mouse fibroblasts transfected with an allogeneic HLA-DRB1*01 but not HLA-DR-negative mouse fibroblasts could serve as presenting cells. Fixation of APC did not hamper drug presentation, but pulsing of APC with the drug was not possible, indicating that processing is not required and that lidocaine binds in an unstable way to the MHC-peptide complex. This degenerate drug recognition has certain features of superantigen recognition, such as the ability of drugs to bind from the outside to multiple HLA-DR alleles. Such features of drug recognition may open new therapeutic possibilities to intervene with TCR-MHC interactions in a selective way.
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Affiliation(s)
- M P Zanni
- Institute of Immunology and Allergology, Inselspital, Bern, Switzerland
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26
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Suhonen R, Kanerva L. Contact allergy and cross-reactions caused by prilocaine. Am J Contact Dermat 1997; 8:231-5. [PMID: 9358117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Allergic contact dermatitis from local amide anesthetics such as lidocaine (Xylocaine), bupivacaine (Marcaine, Bicain), mepivacaine (Carbocaine), etidocaine (Duranest), and prilocaine (Citanest) is rare. Allergic contact dermatitis from prilocaine has been reported only from EMLA cream. OBJECTIVES We report on a patient sensitized from prilocaine used as a local infiltration anesthetic. METHODS Conventional patch testing with various local amide anesthetics as well as intracutaneous tests with amide anesthetics were performed. RESULTS Patch testing with EMLA cream (as is) (Astra, Sweden), containing prilocaine and lidocaine provoked an allergic patch test reaction, whereas patch testing with lidocaine was negative. Patch testing with Citanest containing 2% prilocaine and adrenaline was positive. Also articaine gave an allergic patch test reaction, whereas mepivacaine, benzocaine, and caine-mix were negative. Intracutaneous tests with prilocaine and articaine were positive. CONCLUSION Our patient had been sensitized from prilocaine and cross-reacted to articaine, but not to other amide anesthetics. Cross-reactions between prilocaine and amide anesthetics were reviewed. As there seem to be no clear rules regarding cross-reactivity among various amide anesthetics, it is safest to test as many amide type anesthetics as possible in case of a delayed type allergy to any member of this family.
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Affiliation(s)
- R Suhonen
- Department of Dermatology, Mikkeli Central Hospital, Mikkeli, Finland
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27
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García JC, Torre F, Sánchez M, Martín JA, Canto G. Fixed drug eruption induced by lidocaine and patch testing. J Investig Allergol Clin Immunol 1997; 7:127-8. [PMID: 9161940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Fixed drug eruption (FDE) is a peculiar drug-induced cutaneous reaction, that characteristically reappears at the same site when the etiologic drug is readministered. We present a case of a 27-year old male who was referred to us after two episodes of erythema on the palms, soles, and genital areas with posterior desquamation after receiving local anesthetics. Skin tests with lidocaine, mepivacaine and bupivacaine were negative. Eight hours after challenge with lidocaine the lesions reoccurred. Patch tests with lidocaine on healthy skin and residual lesions were negative, but 48 hours later the lesions reappeared on the same areas as before. Challenge with mepivacaine and bupivacaine were negative.
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Affiliation(s)
- J C García
- Allergy Service, Hospital Ntra. Sra. de Candelaria, Tenerife, Spain
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28
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Cuesta-Herranz J, de las Heras M, Fernández M, Lluch M, Figueredo E, Umpierrez A, Lahoz C. Allergic reaction caused by local anesthetic agents belonging to the amide group. J Allergy Clin Immunol 1997; 99:427-8. [PMID: 9058702 DOI: 10.1016/s0091-6749(97)70064-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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29
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Bruynzeel DP. [Allergic reactions to local anesthetics]. Ned Tijdschr Tandheelkd 1996; 103:178-80. [PMID: 11921931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
In this article type I and type IV allergic reactions evoked by local anaesthetics are discussed. Contact dermatitis (type IV) reactions are mainly caused by local anaesthetics of the ester-type like procaine. Both contact dermatitis and anaphylactic reactions (type I) can be caused by anaesthetics of the amide-type (e.g. lidocaine), but these reactions are rare. Intra- and epicutaneous tests can be useful to prove allergy, but sometimes provocation tests are necessary. Many reactions are not caused by an allergic mechanism.
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Affiliation(s)
- D P Bruynzeel
- Afdeling Arbeidsdermatologie/Dermato allergologie, Academisch Ziekenhuis Vrije Universiteit te Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam
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30
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Fennis JF. [Internal medicine and local anesthesia in dentistry. A review of possible side effects]. Ned Tijdschr Tandheelkd 1996; 103:174-7. [PMID: 11921930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
When using local anaesthesia the dentist may be confronted with a variety of side effects, either caused by the anaesthetic solution itself or its additives, including vasoconstrictive drugs such as epinephrine. Early recognition and treatment of these side-effects are essential. Even more important is the possible prevention of such side-effects by a properly taken medical history before using local anaesthesia.
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Affiliation(s)
- J F Fennis
- Afdeling Algemeen Interne Geneeskunde, Academisch Ziekenhuis te Nijmegen, Postbus 9101, 6500 HB Nijmegen
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31
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Abstract
BACKGROUND Adverse drug reactions to local anesthetics are frequently reported. However, little is known about the underlying mechanisms. Therefore we investigated 177 patients with a history of 197 events after application of these drugs. METHODS The diagnostic approach included prick and intracutaneous tests, provocative challenge tests with causative and unrelated local anesthetics, and in selected cases, radioimmunoassays to detect specific IgE. In addition, tests were performed with preservatives, including sodium metabisulfite and parahydroxybenzoic acid ester. RESULTS Results of prick and intracutaneous tests with local anesthetics were all negative. Only three patients reacted after subcutaneous challenge with the causative drug (local anesthetics of the amide type). Although one patient showed a delayed-type response to mepivacaine, two patients had immediate-type reactions to articaine and lidocaine. However, in both cases no specific IgE could be detected. In five patients with positive skin test reactions to preservatives, challenge test results remained negative. CONCLUSION Two immediate-type reactions were not IgE-mediated. In only one of 197 reported adverse reactions were we able to prove delayed-type allergic response. Therefore true allergic reactions caused by local anesthetics are extremely rare.
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Affiliation(s)
- H Gall
- Department of Dermatology, University of Ulm, Germany
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32
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Aldrete JA. Adverse responses to local anaesthetics. Anaesth Intensive Care 1985; 13:442-3. [PMID: 4073469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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33
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Abstract
True allergic reactions to local anesthetics (LAs) probably make up no more than 1% of all adverse LA reactions. A diagnosis of true potential allergic reactivity is made difficult because (1) the history of the prior reaction may be vague or equivocal and (2) the lack of identification of the actual specific LA hapten-carrier complex limits the potential usefulness of immunologic tests. Nonetheless, since avoidance of LAs may be associated with substantial increased pain or increased risk and because true allergic reactions are rare, investigators and clinicians have used skin testing, incremental challenge, or both as a means of identifying a safe LA for a patient with a history of a prior adverse reaction. Review of the literature dealing with LA skin testing and incremental challenge suggests the following: (1) Skin testing with LAs may correlate with a history of an adverse reaction but may produce systemic adverse reactions, especially with undiluted drug. (2) Although false positive skin tests have been reported, most skin-tested patients who subsequently tolerate an LA have a negative skin test to that drug, and false negative skin tests have not been clearly documented. (3) Incremental challenge beginning with diluted LA is a safe and effective means of identifying a drug that a patient with a history of a prior adverse reaction can tolerate. (4) Current concepts of non-cross-reacting LA groups may be useful in the choice of a drug for use in skin testing and incremental challenge. (5) Preservatives in LAs may account for some but probably not the majority of adverse reactions to LAs. On the basis of this literature review, a practical protocol including dilutional skin testing and incremental challenge is presented for use in evaluating patients with prior adverse reactions to LAs.
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34
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Konobevtsev OF, Kondaurov VN, Panikarovskiĭ VV, Kulikova VS, Grigor'ian AS. [Toxicological characteristics of a new collagen-based pyromecaine ointment]. Stomatologiia (Mosk) 1980; 59:27-29. [PMID: 6932748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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35
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Leynadier F, Dry J. [Allergy to local anesthetics]. Inf Dent 1980; 62:1549-60. [PMID: 6933143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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36
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deShazo RD, Nelson HS. An approach to the patient with a history of local anesthetic hypersensitivity: experience with 90 patients. J Allergy Clin Immunol 1979; 63:387-94. [PMID: 447941 DOI: 10.1016/0091-6749(79)90211-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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