Diagnostic Approach Identifying Hydroxyethyl Starch (HES) Triggering a Severe Anaphylactic Reaction during Anesthesia in a 15-Year-Old Boy

Introduction

Anaphylactic and anaphylactoid reactions during anesthesia are rare but potentially life-threatening complications. The exact incidence is difficult to ascertain, with reports ranging from 1/5 000–1/20 000 anaesthetics for all age groups (Mertes PM et al., Eur J Anaesthesiol 2002; 19: 240–262). The correct identification of the causative agent is not easy due to the fact that various drugs are given within a short time frame during anaesthesia, including contact with desinfectants, local anaesthetics and latex. Recently, suggestions for standard diagnostic approaches in adverse reactions to drugs have been made (Kroigaard M et al., Acta Anaesthesiol Scand 2007; 51: 655–670). Diagnostic work-up is recommended for all patients with at least a moderate anaphylactic reaction (hypotension, tachycardia, bronchial hyperreactivity) and should include a detailed history of the event, previous allergies and underlying conditions. Unfortunately all currently available diagnostic approaches (IgE, skin-prick-test, tryptase) leave a significant percentage of non-diagnostic results and false positive or negative outcomes.

Over the last decade, studies on basophil activation tests (BAT) have been published which focus on their diagnostic value in clarifying hypersensitivity reactions to various allergens and drugs, including neuromuscular blocking agents, β-lactam-antibiotics and non-steroidal anti-inflammatory drugs. The BAT is based on flow cytometric quantification of allergen-induced CD63 or CD203 expression or measurement of histamine or sulfidoleukotriene release by ELISA.

We report here the history of a 15-year-old boy who was evaluated for a severe perioperative anaphylactic reaction. We were able to identify the causing drug by a provocation test and by a positive basophile activation test with significant upregulation of CD63.