Intraoperative anaphylactic shock in a child with no history of type I hypersensitivity.

Abstract

Natural rubber latex is the second most implicated agent in intraoperative anaphylactic reactions. This report describes a case of intraoperative anaphylaxis occurring in a non-atopic fourteen-year-old girl undergoing multiple surgical procedures, but without spina bifida, in which latex surgical gloves were the main culprit for the anaphylactic reactions. Clinical manifestations of an anaphylactic reaction were also experienced during the examination of the possible cause of intraoperative anaphylaxis by skin prick testing with a latex allergen extract. Skin tests with anesthetics were negative. Specific IgE to latex was positive at 92.9 kUA/L (class 5). The molecular basis for the reported intraoperative anaphylaxis was ascribed to three low-molecular mass latex allergens (10-15 kD) detected in the brand of latex surgical gloves used during the operation. Given the potential of a dramatic outcome, latex allergy testing as a regular preoperative measure may contribute to the reduction of anaphylactic reactions during surgical interventions.

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Copyright© 2008, IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY. All rights reserved. 97
CASE REPORT
Iran J Allergy Asthma Immunol
June 2008; 7(2): 97-99


Intraoperative Anaphylactic Shock in a Child with
No History of Type I Hypersensitivity

Marina Atanasković-Marković1, Marija Gavrović-Jankulović2, Tanja Ćirković Veličković2, Olja Vučković3,
Petar Ivanovski1, Branimir Nestorivić1, Goran Čuturilo1, and Dušica Simić4

1 Department of Allergology and Pulmonology, University Children’s Hospital, Belgrade, Serbia
2 Department of Allergology, Faculty of Chemistry, University of Belgrade, Serbia
3 Department of Allergology, Institute for Immunology and Virology, Torlak, Belgrade, Serbia
4 Department of Anesthesiology, University Children’s Hospital, Belgrade, Serbia

Received: 6 October 2007; Received in revised form: 21 November 2007; Accepted: 26 December 2007


ABSTRACT

Natural rubber latex is the second most implicated agent in intraoperative anaphylactic
reactions.
This report describes a case of intraoperative anaphylaxis occurring in a non-atopic
fourteen-year-old girl undergoing multiple surgical procedures, but without spina bifida, in
which latex surgical gloves were the main culprit for the anaphylactic reactions. Clinical
manifestations of an anaphylactic reaction were also experienced during the examination of
the possible cause of intraoperative anaphylaxis by skin prick testing with a latex allergen
extract. Skin tests with anesthetics were negative. Specific IgE to latex was positive at 92.9
kUA/L (class 5). The molecular basis for the reported intraoperative anaphylaxis was
ascribed to three low-molecular mass latex allergens (10-15 kD) detected in the brand of
latex surgical gloves used during the operation.
Given the potential of a dramatic outcome, latex allergy testing as a regular preoperative
measure may contribute to the reduction of anaphylactic reactions during surgical
interventions.

Keywords: Intraoperative anaphylaxis; Latex allergy; Latex gloves

INTRODUCTION

Due to its increasing frequency and severity type I
hypersensitivity has been recognized as an international
health problem in the last decade. After muscle
relaxants, natural rubber latex (NRL) is the second
most implicated agent in intraoperative anaphylactic

Corresponding Author: Marina Atanasković-Marković, MD;
University Children’s Hospital, Belgrade, Serbia. Tel: (+381 11)
2 187157, Fax: (+381 11) 2 684672, E-mail: marinaa@EUnet.yu

reactions
anaphylactic reactions is increasing despite the
preventive measures undertaken.1 The prevalence of
IgE mediated NRL sensitization among the general
population is estimated to be less than 1%, but up to
17% of anaphylactic reactions have been recorded
during surgical interventions.
manifestation of intraoperative anaphylactic reactions
differs from anaphylactic reactions outside anesthesia
such as cardiovascular collapse seems to be the more
and the incidence of latex-related
The clinical

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M. Atanasković-Marković, et al.
98/ IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY Vol. 7, No. 2, June 2008
common event.2 The population at-risk to develop
anaphylaxis to latex during surgical procedures
includes patients with spina bifida and/or urogenital
abnormalities, persons with increased exposure to latex
such as healthcare workers, patients who have
undergone multiple surgical procedures or persons with
certain plant-derived food allergies especially "tropical"
fruit allergies.3
Currently, thirteen latex (Hevea brasiliensis, Hev b)
allergens have been implicated in the clinical
manifestations of latex allergy. Eight of them – Hev b
1, 2, 3, 4, 5, 6, 7 and 13, are the most significant latex
allergens among healthcare workers, as they elicit the
highest prevalence of IgE antibody specificities
detected in the skin and blood.4

CASE PRESENTATION

We report the case of a 14-year-old girl who
developed anaphylactic shock during surgery due to
latex-containing surgical gloves. The patient had no
previous history of allergy, and no family history of
allergic disease. She had undergone multiple surgical
procedures, and was suffering from neurogenic bladder
and vesicouretral reflux grades IV. Fifteen minutes
after induction of anesthesia and a few minutes after
coming in contact with surgical gloves, there was an
acute onset of increased airway pressure, oxygen
desaturation, tachycardia, and profound hypotension, as
well as bronchospasm and generalized urticaria.
Resuscitation with manual ventilation and oxygen,
intravenous fluids and an infusion of epinephrine,
aminophylline and corticosteroids was successful. Six
weeks later she was referred to our allergology
department in order to detect the possible causes of
intraoperative anaphylaxis and to determine safe
alternative drugs (anesthetics) for the future. The child
underwent skin prick
concentration of commercially available latex extract,
tropical fruits (Torlak Institute for Immunology and
Virology, Belgrade, Serbia), as well as with a panel of
anesthetic drugs used for endotracheal anesthesia
(nesdonal, leptosukcin, pavulon, fentanil, flormidal).
Skin tests were interpreted as positive if a wheal larger
than 3 mm in diameter accompanied by erythema was
present 20 minutes later. Histamine hydrochloride was
used as the positive control and 0.9% sodium chloride
as the negative control. Commercially available assays
for specific IgE (ImmunoCAP System, Phadia AB,
tests with a standard
Uppsala, Sweden) were performed for latex and
tropical fruits. Levels of specific IgE greater than 0.35
kU/L were considered positive. To identify the
molecular basis of the anaphylaxis a latex extract was
prepared from the same commercial brand of latex
surgical gloves as those used during the operation. The
latex proteins were transferred on to a nitrocellulose
membrane (ImmobilonTM-NC Millipore Corporation,
Billerica, MA) after separation by analytical 15% SDS-
PAGE. After incubation with the patient sera (dilution
1:4), IgE-binding proteins were detected with alkaline
phosphatase labeled anti-human
Steinheim, Germany).
The patient responded positively to skin prick testing
with latex (wheal 15 × 30 mm) at a concentration of
5000 PNU. Thus, hypotension, bronchospasm and an
urticarial rash on her arm, face and neck as well as
swelling of the lip appeared within 5 min after
application. This required immediate administration of
anti-shock therapy. After treatment, her symptoms
reduced considerably within 1 h and were completely
resolved after 12 h. Skin tests with the above mentioned
anesthetics were negative leading to the conclusion that
the anaphylaxis was not drug induced. Skin tests and
specific IgE to fruits were all negative, so latex-fruit
allergy was also ruled out. The specific IgE to latex was
positive (к82:92,9 kUA/L) class 5. Three IgE-binding
bands with molecular masses between 10-15 kD were
identified in the immunoblot for the self-prepared latex
extract (Figure 1).
IgE (Sigma,

Figure 1. Detection of low-molecular mass latex allergens
in the surgical gloves: A) IgE binding bands, C) control.

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Intraoperative anaphylaxis
Vol. 7, No. 2, June 2008 IRANIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY /99
DISCUSSION

This is the first report describing a child with no
history of type I hypersensitivity and no family history
of allergy, who experienced intraoperative anaphylaxis
and six weeks later repeated the anaphylactic reaction
during skin testing. Surprisingly, in spite of the high
level of specific IgE there had been no previous clinical
manifestations of latex allergy. We were able to detect
three IgE-binding proteins responsible for the
anaphylactic reaction during the surgery, which
according to their molecular mass corresponded to Hev
b 1, Hev b 6, and Hev b 8.
Absolute avoidance of latex is the only safe
approach to treat those who belong to a high-risk group
or who are already allergic, as pretreatment with
antihistamines and corticosteroids, used successfully
for the prevention of reactions to radiocontrast material,
are not proven to be as effective in the prevention of
anaphylactic reactions to latex.2 The diagnosis of latex
allergy must be kept in mind in every case of
perioperative anaphylaxis, even if the patient does not
belong to a risk group.5 For many years there has been
concern about the low sensitivity of diagnostic latex
skin test reagents and IgE anti-latex serology assays.
However, by employing a combination of recombinant
latex allergens it was possible to identify latex allergy
in healthcare workers with 93% sensitivity and 100%
specificity.4 Accordingly, the use of a selected panel of
recombinant proteins seems to be a promising concept,
as it may significantly improve the diagnostic
sensitivity of in vitro assays.
The key elements of NRL allergy prevention
include an adequate history, testing for latex allergy in
high-risk patients, preadmission measures and the
establishment of a latex-free environment while the
individual is hospitalized in the operating and recovery
rooms.2 Nevertheless, due to the possible absence of a
positive history of type I hypersensitivity, as occurred
in our case, a potential high-risk patient may be
overlooked during the preadmission procedure.
Therefore we would strongly recommend in vitro
testing for latex hypersensitivity as a compulsory
measure during preoperative evaluation of the patient.

ACKNOWLEDGEMENTS

The study was supported by Grant 142020 from the
Ministry of Science and Environmental Protection,
Republic of Serbia.

REFERENCES

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2. Lieberman P. Anaphylactic reactions during surgical and
medical procedures. J Allergy Clin Immunol 2002; 110(2
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3. Lavaud F. Cross-sensitization between latex and fruits. J
Allergy Clin Immunol 1996; 98(2):473-4.
4. Sussman GL, Beezhold DH, Kurup VP. Allergens and
natural rubber proteins. J Allergy Clin Immunol 2002;
110(2 supple):S33-9.
5. Demaegd J, Soetens F, Herregods L. Latex allergy: a
challenge for anaesthetists. Acta Anaesthesiol Belg. 2006;
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