Anaphylaxis and mastocytosis.
From the case report by Weingarten, Volcheck and Sprung of a reaction to intravenous contrast in a patient with systemic mastocytosis (1), it is not clear that the reaction described was anaphyalactoid as suggested. Patients with mastocytosis are still at risk of an anaphylactic reaction if given an agent to which they are allergic. It may be true that "patients with mastocytosis tend to have more severe anaphylactic and anaphylactoid reactions to offending substances" but it has not been established that they get more severe anaphylactic reactions than normal patients.The rise in mast cell tryptase to 67 ng/ml at four hours suggests that the peak level (usually at about one to two hours) may have been well over 100 ng/ml, three to four times the subsequent baseline level of 30 ng/ml and would support a diagnosis of an anaphylactic rather than an anaphylactoid reaction. It is surprising that subsequent intradermal testing of the antiseptic skin preparation for the procedure and of the radiocontrast were not done to establish if there was actual allergy.
It would have been of particular interest to know what dye, if any, was used for the subsequent neuroangiogram which was uneventful.
Patients with mild asymptomatic mastocytosis can certainly get extreme reactions as has already been reported in this Journal (2). However, it is important to exclude anaphylaxis from a reaction.
References
(1.) Weingarten TN, Volcheck GW, Sprung J. Anaphylactoid reaction to intravenous contrast in patient with systemic mastocytosis. Anaesth Intensive Care 2009; 37:646-649.
(2.) Russell WJ, Smith WB. Pseudoanaphylaxis. Anaesth Intensive Care 2006; 34:801-803.
W. J. Russell
Adelaide, South Australia
Anaphylaxis and mastocytosis--Reply
We wish to thank Dr Russell for his interest in our recent case report addressing unrecognised mastocytosis in a patient manifesting as an anaphylactoid reaction to the administration of iodinated radiocontrast material (1). In his letter to the editor, Dr Russell expresses concern that the reaction described was in reality an anaphylactic reaction. We respectfully disagree with him as the patient was subsequently evaluated with skin testing to the anaesthetic agents used and these were negative. In this situation, the negative skin tests, use of a latex-free operating room and timing of the event in relation to the administration of the radiocontrast material are consistent with an anaphylactoid reaction. Radiocontrast skin testing is not performed in the United States and this practice is based on recommendations from the American Academy of Allergy, Asthma and Immunology (2). The updated statement from the Academy regarding the diagnosis and management of anaphylaxis states: "Clinically, radiocontrast media reactions are identical to immediate hypersensitivity IgE-mediated reactions (anaphylaxis), but do not appear to involve IgE or any other immunologic mechanism" (2). Skin testing to radiocontrast material only tests for IgE-mediated reaction and therefore is not helpful. Clinically, it is well known that pre-treatments with steroids and antihistamines do not prevent a reaction in those with type I (IgE-mediated) food and medication allergy. Therefore, our patient tolerating a subsequent administration of radiocontrast after appropriate pretreatment argues that the reaction was an anaphylactoid reaction and not IgE-mediated.
Antiseptic skin preparations, particularly chlorhexidine, have been reported as a cause of intraoperative anaphylaxis (3). However, the correct concentration for testing and mode of testing (skin prick vs intradermal) has not been optimally determined because of false positive irritant reactions. Blood testing for specific IgE to chlorhexidine has poor predictive value (4). The timing of the reaction in this patient makes a reaction to skin preparation extremely unlikely. We also disagree that the measured tryptase levels support a diagnosis of an anaphylactic rather than an anaphylactoid reaction. Although tryptase levels in general rise to higher levels in an anaphylactic reaction as opposed to an anaphylactoid reaction, high levels can also be seen in anaphylactoid reactions (5).
Dr Russell is correct that the current literature has not definitively determined that patients with mastocytosis have more severe anaphylactic and anaphylactoid reactions than other patients. However, based on the mast cell burden of patients with mastocytosis, it follows that they have the potential for more severe reactions. Indeed, Dr Russell has previously reported a case of a patient who had mild mastocytosis yet developed a severe reaction (6).
We agree that it is important that following any perioperative reaction to exclude anaphylaxis. That is why our patient underwent an evaluation by an allergist and allergy testing following her reaction.
References
(1.) Weingarten TN, Volcheck GW, Sprung J. Anaphylactoid reaction to intravenous contrast in patient with systemic mastocytosis. Anaesth Intensive Care 2009; 37:646-649.
(2.) Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol 2005; 115:S483-523.
(3.) Garvey LH, Roed-Petersen J, Husum B. Anaphylactic reactions in anaesthetised patients--four cases of chlorhexidine allergy. Acta Anaesthesiol Scand 2001; 45:1290-1294.
(4.) Aalto-Korte K, Makinen-Kiljunen S. Symptoms of immediate chlorhexidine hypersensitivity in patients with a positive prick test. Contact Dermatitis 2006; 55:173-177.
(5.) Mertes PM, Laxenaire MC, Alla F. Anaphylactic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology 2003; 99:536-545.
(6.) Russell WJ, Smith WB. Pseudoanaphylaxis. Anaesth Intensive Care 2006; 34:801-803.
T. N. WEINGARTEN
G. W. VOLCHECK
J. SPRUNG
Rochester, United States
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| Author: | Russell, W.J. |
|---|---|
| Publication: | Anaesthesia and Intensive Care |
| Article Type: | Report |
| Geographic Code: | 1USA |
| Date: | Nov 1, 2009 |
| Words: | 875 |
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