Immunoglobulin E‐Mediated Hypersensitivity Reaction to Ketamine

Abstract

This case represents a likely immunoglobulin E-mediated type I hypersensitivity reaction to ketamine, supported by elevated tryptase levels and positive intradermal skin testing. The interpretation of these results and likely mechanism of the hypersensitivity reaction are described. The patient and treating team were advised against subsequent use of ketamine, due to the risk of serious adverse systemic reaction with repeat exposure.

The Case of Ketamine Allergy

“…Adverse drug reactions are often immune-mediated hypersensitivity reactions, as opposed to anaphylactic reactions, which are mediated by IgE and classified as type I allergic reactions. 5 , 8 The clinical criteria for anaphylaxis generally include urticaria and one of the following: respiratory distress, hypoxia, hypotension, or associated symptoms of organ dysfunction. Symptoms occur within minutes to hours after allergen exposure.…”

“…Although no tryptase level was confirmed in our case, the temporal relationship of symptoms to ketamine exposure point to significant histamine release and possible IgE-mediated anaphylaxis. 5 However, an in-vitro study performed by Fell et al demonstrated that ketamine directly increases histamine efflux in the brain, without mediation by IgE. 9 One small study used the Prausnitz-Kutzner test to confirm that a ketamine allergic reaction was indeed not mediated by an IgE mechanism, and was more likely to result from direct ketamine stimulation of mast cells.…”

Immediate hypersensitivity reaction to Ketamine in children with history of atopic disease

“…Occasional case reports have demonstrated hypersensitivity reactions to ketamine. [8][9][10][11] This patient developed erythema, face edema and difficulty breathing following the administration of ketamine intravenously. The onset of the reaction was immediate and the intradermal test showed a positive reaction to ketamine, though it was not certain that the patient had previous exposure to ketamine.…”

“…Although skin tests are usually performed 4-6 weeks after an acute reaction, it took a great deal of time to explain the necessity of the test to patient's parents. In reference to the literature, a study by Ozcan et al 11 conducted intradermal tests 12 weeks after the reaction. The ketamine concentrations for skin tests vary in different studies.…”

“…2 Guyer et al 12 suggested that the ketamine concentration for a skin prick test should be 10 mg/mL and 0.25 mg/mL for the intradermal test. Ozcan et al 11 performed intradermal tests for ketamine at concentrations of 1 mg/mL and 0.1 mg/mL.…”