Interpreting the results of early skin tests after perioperative anaphylaxis requires special attention: a case report and review of literature

Abstract

Skin tests are the gold standard for detecting the culprit drug of anaphylaxis, and should ideally be performed after an interval of 4–6 weeks after the reaction to avoid false-negative results. However, when re-operation cannot be delayed and early allergy tests are necessary, special attention is required during subsequent anesthesia, because early skin tests tend to produce false-negative results. This report presents a case of rocuronium-induced anaphylaxis in which early skin tests showed negative results for all the drugs tested. The second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia. Ultimately, skin tests and basophil activation tests (BATs) performed after re-operation demonstrated rocuronium as the drug responsible for anaphylaxis. We recommend performing BATs in addition to skin tests to improve the accuracy of diagnosis of anaphylaxis. In this report, we also discuss interpretation of the results of early skin tests and subsequent selection of drugs for anesthesia. After postponement of surgery due to anaphylaxis, we are often required to perform allergy tests at an early stage if re-operation cannot be delayed. In such cases, skin test results alone should not be used to guide subsequent anesthesia management to avoid recurrent anaphylaxis.

Resensitization in suspected penicillin allergy

“…In addition, logistic regression analysis showed that the risk of having RT+ was lower in reactions manifested with symptoms other than anaphylaxis. It is important to take into account that anaphylaxis is known to cause false‐negative STs in the early post‐onset period, as it has been described in postoperative patients, 35 , 36 and this fact may influence the higher rate of resensitization observed in cases reporting anaphylaxis. However, in our study, the interval time between reaction and IE was 36 (12–96) months and no differences were found when comparing this interval in cases reporting anaphylaxis and those reporting other milder entities.…”

“…Patients were retested by STs 34 (28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46) to MD, and 1 to CLV) and 4 in IDT (4 to AX, and 1 to BP-OL).…”

Rocuronium‐Induced Anaphylaxis in the Perioperative Period: A Clinical Review

“…Surgery was canceled, and the patient was transferred to the ICU where their postanesthesia course was complicated; the patient died a week later from multiple organ failure. 34 Considered together, these case reports show that rocuronium-induced anaphylaxis may present with hypotension, 34,38,39,41,68 bronchospasm, 40,44 or both. 34 Although most patients in these case reports experienced either urticaria [39][40][41] or erythema, 34,[38][39][40]68 cutaneal symptoms are not always present in anaphylaxis 19,44 and may not be obvious in a patient who is draped for surgery or whose skin has been cleansed with an iodine-based solution.…”

Perioperative anaphylaxis: when the allergological work-up goes negative

“…When the results are positive, they can effectively guide the subsequent anaesthetic strategy [15]. However, negative results should be interpreted with caution, especially when intraoperative tryptase levels confirm the existence of mast cell activation [16]. Indeed, skin anergy may exist in the early phase after the reaction, which may lead to a high frequency of false negative skin tests.…”