BackgroundAnaphylaxis is difficult to diagnose in the absence of skin or mucosal signs and symptoms. We report two cases of anaphylaxis under general anesthesia, in which the initial presentation was in the form of respiratory signs, followed by skin manifestations 10–15 min later. Diagnosis of anaphylaxis was delayed because skin symptoms were absent early on in the presentation.Case presentationIn the first case, a 23-year-old male patient with jaw deformity was scheduled to undergo maxillary alveolar osteotomy. After intubation, auscultation indicated a sudden decrease in breath sounds, together with severe hypotension. Approximately 10 min later, flushing of the skin and urticaria on the thigh appeared and spread widely throughout the body. In the second case, a 21-year-old female patient with jaw deformity was scheduled to undergo maxillomandibular osteotomy. Twenty minutes after the start of dextran infusion, her lungs suddenly became difficult to ventilate, and oxygen saturation decreased to 90%. Approximately 15 min later, flushing of the skin and urticaria were observed.ConclusionIn both cases, there was a time lag between the appearance of respiratory and skin symptoms, which resulted in a delay in the diagnosis, and hence, treatment of anaphylaxis. Our experience highlights the fact that it is difficult to diagnose anaphylaxis under general anesthesia.
Although general anesthesia is indispensable during modern surgical procedures, the mechanism by which inhalation anesthetics act on the synaptic membrane at the molecular and cellular level is largely unknown. In this study, we used yeast cells to examine the effect of isoflurane, an inhalation anesthetic, on membrane proteins. Bap2, an amino acid transporter localized on the plasma membrane, was endocytosed when yeast cells were treated with isoflurane. Depletion of RSP5, an E3 ligase, prevented this endocytosis and Bap2 was ubiquitinated in response to isoflurane, indicating an ubiquitin‐dependent process. Screening all the Rsp5 binding adaptors showed that Art2 plays a central role in this process. These results suggest that isoflurane affects Bap2 via an Art2‐Rsp5‐dependent ubiquitination system.
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