Q:

7/3/2014
I have a 63 year-old male with spinal stenosis needing L2-L5 fusion/laminectomy in OR received Versad, Fentanyl, Diprivan, Lidocaine, Neoephredine,Succinylcholine and Latex foley having rash on chest and abdomen 45 minutes later. He received Decadron, and Hibiclens was used to clean area of incision with subsequent urticaria. Patient received H1, H2, Solucortef and Benadryl with resolution of hives. He had no respiratory or cardiovascular problems. I ordered tryptase, histamine, IgE to Egg, IgE to Soybean and IgE to Latex. My understanding is to wait to skin test for two weeks. What other work up would you advise? The patient also has history of childhood asthma, seasonal allergic rhinitis/conjunctivitis and throat closure with lentils and green peas. Have you seen any urticaria with Hibiclens?

A:

Thank you for your inquiry.

The last question you asked is the easiest to answer. In my opinion, the Hibiclens (chlorhexidine) is a very likely candidate. Several cases of anaphylaxis as well as urticaria due to chlorhexidine have been reported. The mechanism underlying these reactions does involve IgE, and there is a skin test protocol you can use. It is in the references copied below (1-4).

Of course, any of the agents that you mentioned could be responsible, and the next most likely candidate in my opinion would be succinylcholine. You are correct in your intent to skin test to all of the agents involved. Two of these agents (chlorhexidine and succinylcholine) also have ImmunoCAP tests available, and they should be ordered.

We have had a number of inquiries regarding perioperative anaphylactic events, and you will find these entries very helpful in obtaining references which will give you skin test concentrations and the general philosophy used in the approach to patients with these types of reactions.

You may access these entries by clicking here and entering "perioperative anaphylaxis" into the search box.

In summary, based on the information you supplied and data we have regarding anaphylactic reactions during operative procedures, the two most likely candidates responsible for the event are chlorhexidine and succinylcholine. There are skin test protocols as well as ImmunoCAPs available for both drugs. You should obtain both tests to these agents, and should skin test to the remainder of the agents where protocols are available. You will find the references for these protocols in the previous entries on our website that are mentioned above. You will also find some skin test information in Reference Number 5 as well in the chapter on "Perioperative Anaphylaxis" (5).

Thank you again for your inquiry and we hope this response is helpful to you.

References:
1. Sokol WN. Nine episodes of anaphylaxis following cystoscopy caused by Cidex OPA (ortho-phthalaldehyde) high-level disinfectant in 4 patients after cystoscopy. Journal of Allergy and Clinical Immunology 2004 (August); 114(2):392-397.

2. Dyer JE, Nafie S, Mellon JK, Khan MA. Anaphylactic reaction to intraurethral chlorhexidine: sensitization following previous repeated uneventful administration. Ann R Coll Surg Engl. 2013 Sep;95(6):e105-6. doi: 10.1308/003588413X13629960047597.

3. Bae YJ1, Park CS, Lee JK, Jeong E, Kim TB, Cho YS, Moon HB. A case of anaphylaxis to chlorhexidine during digital rectal examination. J Korean Med Sci. 2008 Jun;23(3):526-8. doi: 10.3346/jkms.2008.23.3.526.

4. Toomey M. Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: a case report. AANA J. 2013 Jun;81(3):209-14.

5. Lieberman P, Nicklas R, Oppenheimer J, Kemp S, Lang D, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 Update. Journal of Allergy and Clinical Immunology 2010 (September); 126(3):477-480 e42.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology