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      Anaphylactic reaction following administration of nose drops containing benzalkonium chloride

      case-report

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          Abstract

          We describe a case of anaphylactic reaction in a 46-year-old female post application of decongestant nose drops containing benzalkonium chloride (BAC). With some latency, the patient complained of cough, dyspnea, sensation of heat, croakiness and pruritus. Since she showed all of these symptoms, typical of an anaphylactic reaction, we proceeded some weeks later with a prick test with solutions containing BAC, a cationic surfactant commonly used as an antibacterial preservative in many medical solutions. The prick test was positive, confirming the assumption of a hypersensitive reaction to BAC.

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          A combined respiratory and cutaneous hypersensitivity syndrome induced by work exposure to quaternary amines.

          T Stauder, Elana Bernstein, Rachel D. Bernstein (1994)
          The quaternary amine, benzalkonium chloride, has been associated with cutaneous and mucosal delayed hypersensitivity reactions and with paradoxical bronchoconstriction after use of aerosolized asthma medications. Until now, quaternary amines have not been reported to cause occupational asthma. We describe a case of occupational asthma caused by prolonged exposure to a cleaning solution containing benzalkonium chloride in the workplace. Single-blind, placebo-controlled, open-room challenges were performed to determine the specific agent responsible for the patient's symptoms. Pulmonary function and epicutaneous challenge tests were also performed. The patient had positive responses to challenges with a liquid toilet bowl cleaner containing benzalkonium chloride but was unreactive to other agents tested. Removal from the workplace resulted in complete resolution of symptoms. The exact mechanisms responsible for occupational asthma induced by quaternary amines remain unknown; however, this case emphasizes the importance of recognizing reactive chemicals as possible causes.
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            Nasal toxicity of benzalkonium chloride.

            Herbert Riechelmann, Tom Deutschle, Anja Stuhlmiller … (2015)
            Benzalkonium chloride (BAC) is added to nasal preparations to prevent microbial contamination. Adverse effects of BAC on human nasal mucosa should be evaluated. The ciliotoxicity of BAC was assessed in isolated human nasal epithelia from 15 donors. The effects of nasal BAC 0.05% (4 x 200 microL/day for 8 days) on nasal saccharin transport time, inflammatory cells and cytokine levels in nasal secretions, and nasal symptom scores were assessed in a randomized, double-blind crossover trial in 16 healthy volunteers. In vitro, BAC was ciliotoxic (p 0.8). No BAC-associated proinflammatory effects were observed. The staining index for myeloperoxidase was 4.8% in the placebo period and 6.3% (p = 0.42) in the BAC period. Also, nasal secretion levels of cytokines and the neuropeptide substance P revealed no BAC-associated differences. Concentrations for interleukin (IL)-6 in the placebo period were 41.5 pg/mL (0.9-91.7 pg/mL) and in the BAC period were 17.6 pg/mL (3.2-65.9 pg/mL; p = 0.46), and concentrations for substance P were 119 pg/mL (58-293 pg/mL) and 131 pg/mL (80-330 pg/mL; p = 0.31), respectively. Immediately after application, BAC caused nasal irritation (p = 0.001), a burning sensation (p = 0.0003), and hypersecretion (p = 0.006). Moreover, BAC caused a persistent sensation of nasal irritation (p < 0.01). BAC in concentrations used in nasal preparations is ciliotoxic. In healthy individuals, the ciliotoxic effect of BAC is neutralized, probably by components of nasal secretions. No BAC-related proinflammatory effects have been observed. At higher doses than normally used therapeutically, BAC caused significant nasal irritation.
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              Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa.

              P Graf (1999)
              Prolonged, repeated use of nasal decongestants for symptomatic relief of allergic rhinitis often results in rhinitis medicamentosa (RM), a condition involving "rebound swelling" and additional congestion. Most decongestant sprays contain the preservative benzalkonium chloride (BKC), which causes toxic reactions in the nose, eyes, ears, and lungs, and may exacerbate the symptoms of allergic rhinitis. Recent studies demonstrate the effects of nasal sprays containing BKC or the decongestant oxymetazoline (OXY) in the development of RM. Using rhinostereometry, a technique that measures nasal mucosal swelling and nasal reactivity (with histamine challenge tests), prolonged use of OXY has been shown to induce nasal mucosal swelling and hyperreactivity. Sustained use of BKC alone induces nasal mucosal swelling and, in combination with OXY, BKC appears to have a long-term adverse effect on nasal mucosa. Its presence may also contribute to the RM resulting from overuse of decongestant sprays. Additional research is needed to confirm the deleterious effects of BKC in nasal products. However, these potential effects may be points of clinical differentiation in the treatment of allergic rhinitis and prevention of RM.
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                Author and article information

                Contributors
                Elke Mezger
                Olaf Wendler
                Susanne Mayr
                Alessandro Bozzato
                Journal
                Journal ID (nlm-ta): Head Face Med
                Journal ID (iso-abbrev): Head Face Med
                Title: Head & Face Medicine
                Publisher: BioMed Central
                ISSN (Electronic): 1746-160X
                Publication date Collection: 2012
                Publication date (Electronic): 18 October 2012
                Volume: 8
                Page: 29
                Affiliations
                [1 ]Department of Otorhinolaryngology—Head and Neck Surgery, University of Erlangen, Waldstraße 1, Erlangen 91054, Germany
                Article
                Publisher ID: 1746-160X-8-29
                DOI: 10.1186/1746-160X-8-29
                PMC ID: 3517330
                PubMed ID: 23078861
                SO-VID: 3d17bbfd-3525-4691-b9a0-f6d6aae4b500
                Copyright © Copyright ©2012 Mezger et al.; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 1 August 2012
                Date accepted : 19 September 2012
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Orthopedics
                Keywords: allergy,benzalkonium chloride,anaphylactic reaction
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: allergy, benzalkonium chloride, anaphylactic reaction

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