Severe anaphylactic reaction to patent blue in breast cancer surgery

Abstract

Sentinel lymph node biopsy in the surgical treatment of initial breast cancer has been increasingly adopted to assess axillary status as a way to replace total lymphadenectomy. The sentinel lymph node can be identified using coloring agents or radiopharmaceuticals. In Brazil, patent blue is the most used dye for this type of procedure, with high rates of identification and safety; however, in some cases, the use of this substance can lead to the occurrence of anaphylactic reactions. The case presented here refers to a 41-year-old female patient admitted for a surgical procedure for total mastectomy associated with sentinel lymph node biopsy with patent blue. After surgical initiation, the patient developed severe anaphylactic shock, staying 21 days in the intensive care unit (ICU) for recovery. Most anaphylactic reactions that occur in the transoperative period are mediated by IgE antibodies, resulting in the degranulation of mast cells and basophils, with the release of mediators such as histamine, prostaglandins, proteoglycans, and cytokines, leading to the clinical manifestations of anaphylaxis. There is evidence that part of the population is allergic to patent blue, and may present with manifestations ranging from hives and pruritus to severe cardiovascular collapse, requiring hospitalization in an ICU. The purpose of this article was to report a case of severe anaphylactic reaction to patent blue and to review the literature regarding this infrequent and potentially serious situation.

Case report: Atypical anaphylactic reaction to Patent Blue V dye during breast cancer surgery

“…This patient never had contact with medical blue dye. In most reported cases there was a lack of previous exposure to PBV dye (2,5,7,11,13). Mechanisms underlying allergic reactions to blue dyes have not been fully elucidated.…”

“…PBV dye, belonging to the family of dyes from triphenylmethane, also known as E131, disulfide blue, or acid blue 3, is extensively used for commercial purposes such as in colorants in everyday objects; as a food additive; in the textile, paper, and agriculture industries; and in cosmetic and medical products; and this can explain prior sensitization (5,8,11). There is evidence that about 2,7% of the population would be allergic to blue dye (7).…”

“…In high-risk patients, preventive anti-allergic medications should be applied before blue dye injection (8). Fortunately, there are no cases of death described in the literature due to an allergic reaction to the PBV dye (7,12).…”

“…The Patent Blue V (PBV) dye is widely used in the identification of sentinel lymph nodes in patients with breast cancer and other malignancies (3)(4)(5). PBV dye can provoke allergic reaction of varying degrees of severity (6,7). Most often these are mild reactions in the form of urticaria or erythema without hemodynamic and respiratory disorders, but sometimes can cause severe life-threating anaphylactic reaction (6,8).…”

“…These reactions occur immediately or a few minutes to several hours after the injection of the dye (9). The most serious allergic reaction is anaphylactic shock with circulatory failure (7,8,10,11).…”