Fentanyl and Ancef
Question:
11/1/2018
I have a 22 year-old female who had lumpectomy for adenoma. She received Fentanyl and Ancef during surgery. She developed a bright, red, itchy rash starting on her face and spread 5 days after surgery. She had taken Oxycodone 2 days before onset of rash. A BX revealed a vascular lymphocytic infiltrate with rare eosinophils, c/w drug reaction. Previous lumpectomy in 2014 with same drugs used by same surgeon. No issues with the first lumpectomy. Skin testing for Cefazolin and other Cephalosporins were negative. More than likely she will need more lumpectomies. Has Marcine without issues since. What are my options for testing?
Answer:
I am grateful to David A. Khan, MD, FAAAAI, who provided the following response and references. I hope this information is helpful to you.
Numerous medications and other exposures can cause perioperative drug reactions.(1) This case is different in that the main problem was a persistent rash. This would be very unusual for an opiate reaction of which most are pseudoallergic reactions that do not typically cause persistent rashes and tend to cause more mast cell mediated problems such as urticaria, angioedema, pruritus, and erythema. One possibility is still the cefazolin. A negative immediate skin test would not exclude a delayed drug exanthem. Delayed intradermal skin tests may be of some benefit but the negative predictive value of these tests is not clearly established.(2) Given that this was a benign exanthem with negative immediate skin tests (assuming done with appropriate concentrations and were intradermal tests) a drug challenge could be performed with a full dose of cefazolin to determine drug tolerance. Since cefazolin is so commonly used in surgical cases, this would be appropriate.
There may have been some other exposure as well to a contact agent including a disinfectant. Careful review of the potential exposures from the Medical record, not just from the anesthesia report would be important.(3) Furthermore, it is possible that the rash had nothing to do with the medications or other exposures from surgery and a skin biopsy cannot definitively prove drug causality.
References
1. Guyer AC, Saff RR, Conroy M, Blumenthal KG, Camargo CA, Jr., Long AA, et al. Comprehensive allergy evaluation is useful in the subsequent care of patients with drug hypersensitivity reactions during anesthesia. J Allergy Clin Immunol Pract. 2015;3(1):94-100.
2. Romano A, Gaeta F, Valluzzi RL, Caruso C, Alonzi C, Viola M, et al. Diagnosing nonimmediate reactions to cephalosporins. J Allergy Clin Immunol. 2012;129(4):1166-9.
3. Kannan JA, Bernstein JA. Perioperative anaphylaxis: diagnosis, evaluation, and management. Immunol Allergy Clin North Am. 2015;35(2):321-34.
Jacqueline A. Pongracic, MD, FAAAAI