“Too Many Cooks Spoil the Broth”: The More Antigens Present, the Easier, the Quicker, and the More Severe the Anaphylaxis

Abstract

a 62-year-old woman who experienced an anaphylactic reaction during cataract surgery after intravenous administration of cefuroxime and methylprednisolone. The patient had been receiving 9 different medications before surgery. While not atopic, she had alcoholism, idiopathic hypertension, dyslipidemia, chronic obstructive pulmonary disease, and osteoporosis. One month later, while undergoing a skin prick test with cephalosporins, which was strongly positive for cefuroxime, the patient began to experience severe dyspnea, oropharyngeal tightness, severe bronchospasm, cyanosis, loss of consciousness, and acute elevation of serum tryptase levels with absence of skin manifestations. She was treated with intense antiallergic therapy and respiratory life support.This report raises major issues concerning the risks of skin prick testing, the use of polypharmacy, and anaphylaxis without skin manifestations.1. The frequency of allergic, hypersensitivity, or anaphylactic reactions in patients with a high likelihood of allergy after skin testing is as high as 10% [2]. The authors stated that their case was the only case in the English-language literature of a severe systemic reaction induced by skin prick testing with a cephalosporin. However, we previously reported a case of anaphylaxisassociated acute coronary Kounis syndrome following skin tests (prick tests and intradermal tests) with amoxicillin [3]. The patient in question was a 71-year-old hypertensive man with a history of physical discomfort, vomiting, and generalized hives within minutes of taking an amoxicillin tablet 3 years previously. Approximately 10 minutes after the intradermal tests with amoxicillin, the findings recorded were a papule (9 × 8 mm), physical discomfort, generalized itching, dizziness, hypotension, bowel incontinence, and oppression of the epigastrium. Electrocardiographic changes were recorded in the anterolateral leads, with elevation of troponin and serum tryptase. The specific IgE determinations against ß-lactams (penicillin G, penicillin V, amoxicillin, and ampicillin) that were carried out 2 weeks later yielded positive results (0.35 kU/L) to amoxicillin only. Mast cells and basophils carry surface receptors forimmunoglobulin E (IgE) antibodies. When allergens such as drugs, metal anions, polymers, latex, disinfectants, and infusion materials bridge their corresponding receptor bound IgE antibodies, then mast cells and basophils degranulate and release their inflammatory mediators.

Case Report: Perioperative Kounis Syndrome in an Adolescent With Congenital Glaucoma

“…In a cohort of adult and pediatric patients with this disease, skin was affected in 84% of them, followed by clinical manifestations involving cardiovascular (72%) or respiratory (68%) systems (35,36). In severe anaphylaxis the phenomenon has been hypothesized due to the state of shock that prevents or delays the released anaphylactic mediators from reaching and acting on the skin, thus inducing redness, rash and/or itching (37,38). The absence of skin lesions can also occur in KS, in which rash has been described in 26.8% of cases, preceded by chest pain (86.8%) and anaphylaxis (53%) (3,39,40).…”