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      Perioperative Anaphylaxis to Chlorhexidine during Surgery and Septoplasty

      case-report

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          Abstract

          Chlorhexidine is an antiseptic and disinfectant used in surgical and clinical practice since 1954 and is available in aqueous or alcoholic solutions 0.5%–4.0% and has a broad-spectrum activity. Despite their widespread use, allergic reactions with chlorhexidine are rarely reported. We describe a case of anaphylaxis with chlorhexidine during a septoplasty, turbinectomy, and maxillary sinusectomy. The patient presented with periorbital edema, hives, hypotension, and wheezing. Immediately after the diagnosis of anaphylaxis promethazine, hydrocortisone, and epinephrine were administered with immediate clinical improvement. This case highlights the importance of assessing whether there is a previous clinical history of hypersensitivity to chlorhexidine in patients who will undergo surgical procedures.

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          A comparison of the irritant and allergenic properties of antiseptics.

          Jean-Marie Lachapelle (2014)
          Over recent years, interest in the use of antiseptics has been reinforced as these molecules are not concerned by the problem of bacterial resistance. Whereas the in vitro efficacy of antiseptics has been well-studied, much less is known regarding their irritant and allergenic properties. This review provides an update on the comparative irritant and allergenic properties of commonly-used antiseptics in medicine nowadays. All antiseptics have irritant properties, especially when they are misused. Povidone-iodine has an excellent profile in terms of allergenicity. Allergic contact dermatitis is uncommon but is often misdiagnosed by practitioners, who confuse allergy and irritation. Chlorhexidine has been incriminated in some cases of allergic contact dermatitis; it is considered a relatively weak allergen, although it may rarely cause immunological contact urticaria and even life-threatening anaphylaxis. Octenidine is considered a safe and efficient antiseptic when used for superficial skin infections, however, aseptic tissue necrosis and chronic inflammation have been reported following irrigation of penetrating hand wounds. Polihexanide is an uncommon contact allergen as regards irritant and/or allergic contact dermatitis but cases of anaphylaxis have been reported. Considering the data available comparing the irritant and allergenic properties of major antiseptics currently in use, it should be acknowledged that all antiseptics may induce cutaneous side-effects. The present article reviews the most recent safety data that can guide consumers' choice.
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            IgE-mediated allergy to chlorhexidine.

            Holger Mosbech, P. Skov, M Krøigaard … (2007)
            Investigations at the Danish Anesthesia Allergy Centre have included testing for allergy to chlorhexidine since 1999. To investigate whether measurement of IgE and histamine release confirm an IgE-mediated mechanism for chlorhexidine allergy. Twenty-two patients with clinical history suggestive of chlorhexidine allergy were included. Skin tests with chlorhexidine and tryptase measurements were performed during initial investigations. Sera were analyzed retrospectively for IgE and histamine release (passive sensitization) to chlorhexidine. Twelve patients were skin test positive and 10 were skin test negative. Of the skin test-positive patients, 11 of 12 had IgE to chlorhexidine and 7 of 11 had a positive histamine release test. None of the skin test-negative patients had specific IgE or positive histamine release to chlorhexidine. Skin test-positive patients had higher median age (64 vs 49 y) and were mainly male (11/12 vs 6/10). In both groups, 8 patients had hypotension, but bronchospasm mainly appeared in skin test-negative patients (1/12 vs 6/10). Reactions occurred more often during urologic surgery in skin test-positive patients (5/12 vs 0/10). Baseline tryptase was higher in skin test-positive patients (median, 11.5 vs 3.7 microg/L), and 6 of 7 patients had elevated IgE to chlorhexidine in serum at the time of reaction. This study confirms that chlorhexidine allergy is IgE-mediated and that measurement of specific IgE and histamine release are good adjuncts to skin testing in patients with clinical history suggesting chlorhexidine allergy. IgE and histamine release can be used to support the diagnosis of allergy to chlorhexidine.
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              IgE-mediated chlorhexidine allergy: a new occupational hazard?

              Vasantha Nagendran, Lene Garvey, Theresa Onyekwe … (2009)
              Chlorhexidine is an effective antimicrobial agent commonly used in UK hospitals, primarily for skin decontamination. Recent UK infection control guidelines recommend the use of 2% chlorhexidine solution in specific clinical settings, thus increasing chlorhexidine use by health care workers (HCWs). Chlorhexidine has been widely reported to cause IgE-mediated allergic reactions (from urticaria and angioedema to anaphylaxis) among patients undergoing surgery/invasive procedures. Despite its widespread use in health care settings, there are no reports of clinically confirmed occupational IgE-mediated chlorhexidine allergy. To identify cases of chlorhexidine allergy among health care workers. A questionnaire was distributed among HCWs in wards and operating theatres at a UK district general hospital to raise awareness of potential chlorhexidine allergy and to invite those with possible clinical allergy to come forward for further testing. Diagnosis was based on an appropriate clinical history with positive serum-specific IgE to chlorhexidine and/or positive skin prick testing. Four cases of occupational IgE-mediated allergy to chlorhexidine were identified. Despite its excellent antimicrobial properties, chlorhexidine is an occupational allergen. We suggest that chlorhexidine allergy be included in the differential diagnosis of HCWs presenting with work-related allergic symptoms. Increased awareness and easier access to chlorhexidine-specific IgE serological testing should facilitate early diagnosis of affected HCWs, allowing appropriate avoidance measures to be instigated--thus reducing the risk of potentially severe allergic reactions in the future.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Case Rep Otolaryngol
                Journal ID (iso-abbrev): Case Rep Otolaryngol
                Journal ID (publisher-id): CRIOT
                Title: Case Reports in Otolaryngology
                Publisher: Hindawi
                ISSN (Print): 2090-6765
                ISSN (Electronic): 2090-6773
                Publication date (Print): 2017
                Publication date (Electronic): 19 March 2017
                Volume: 2017
                Electronic Location Identifier: 9605804
                Affiliations
                1Hospital Evandro Ribeiro, Rua Catarina de Castro, 75 Morro da Glória, 36036-060 Juiz de Fora, MG, Brazil
                2Serviço de Alergia e Imunologia Clínica Hospital Maternidade Therezinha de Jesus e Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Alameda Salvaterra, 200 Salvaterra, 36033-003 Juiz de Fora, MG, Brazil
                3Instituto de Ensino Superior Presidente Tancredo de Almeida Neves (IPTAN), Avenida Leite de Castro, 1101 Fábricas, 36301-182 São João del Rei, MG, Brazil
                4Escola de Medicina e Cirurgia da Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Silva Ramos, 32 Tijuca, 20270-330 Rio de Janeiro, RJ, Brazil
                Author notes
                *Fernando Monteiro Aarestrup: fmaarestrup@ 123456hotmail.com

                Academic Editor: Richard T. Miyamoto

                Author information
                http://orcid.org/0000-0001-9226-8271
                Article
                DOI: 10.1155/2017/9605804
                PMC ID: 5376445
                SO-VID: 56c44830-8107-418d-aab5-6fd5e49d61d6
                Copyright © Copyright © 2017 Ana Paula Teixeira de Abreu et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 6 September 2016
                Date revision received : 20 February 2017
                Date accepted : 27 February 2017
                Categories
                Subject: Case Report

                Data availability:

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