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A 72-year-old woman with a medical history of allergic rhinitis, food allergy, non-IgE-mediated reactions to medications, spinal stenosis and previous laminectomy presented to our institution for thoracic decompression laminectomy, facetectomy and foraminotomy. During the procedure, 5 min after chlorhexidine application and prior to surgical incision, she developed a blanching urticaria on her back (figure 1). The patient had no associated angio-oedema, hypotension, respiratory failure or anaphylaxis.
Surgery was cancelled. She was treated with diphenhydramine 50 mg intravenously and dexamethasone 4 mg intravenously once. The urticaria resolved within 2 h (figure 1). The patient denied adverse reactions during previous surgeries. Anaesthesia records revealed she had received cefazolin and ciprofloxacin preoperatively, as well as fentanyl, lidocaine, midazolam, propofol and rocuronium after induction of general anaesthesia but prior to her reaction. Laboratory workup showed tryptase level within normal limits (<1.0 µg/L) and negative serum-specific latex IgE (<0.35 KU/L). A repeat tryptase was within normal limits 24 h after her initial reaction.
The patient was evaluated in the allergy outpatient clinic within 4 weeks of the initial reaction. Skin testing to all suspected agents was non-diagnostic: fentanyl, lidocaine, midazolam, propofol, rocuronium, penicillin G, prepen, cefazolin, levofloxacin and chlorhexidine gluconate 1%/4% were included in the evaluation. Owing to the concern of non-IgE-mediated release of mediators1 and the possibility of false negatives on skin testing, the anaesthesia team was recommended to avoid chlorhexidine in future surgeries.
The patient underwent a repeat surgery with the use of povidone-iodine as an alternative antiseptic agent. There were no further adverse reactions.
Competing interests: None.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.