title: Case Report: perioperative immediate hypersensitivity involves not only allergy but also mastocytosis.
abstract: OBJECTIVE
  We report a case of drug-induced immediate hypersensitivity occurring after atracurium injection in a patient with cutaneous mastocytosis.
  
  
  METHODS
  A 69-yr-old woman was scheduled for hysterectomy. She was premedicated with hydroxyzine, and anesthesia was induced with sufentanil, propofol, and atracurium. Within two to three minutes following the injection of atracurium, the patient experienced an episode of generalized erythema and arterial hypotension associated with tachycardia. No bronchospasm was observed. Her cardiovascular signs resolved spontaneously within five minutes, while her cutaneous signs disappeared within 30 min. Anesthesia and surgery remained uneventful. The patient's serum tryptase levels were measured at different time points following the clinical reaction. An in vitro flow cytometry-based basophil activation test was performed with atracurium, and in vivo skin tests to latex and all drugs which were administered just before the clinical reaction were also done. The serum tryptase showed increased concentrations that remained elevated for 24 hr, 48 hr, and even four weeks after the clinical reaction. Atracurium did not induce either CD63 or CD203c upregulation, and the skin tests were negative in response to the medications received (propofol, sufentanil, and atracurium) as well as to latex.
  
  
  CONCLUSIONS
  Allergic hypersensitivity to atracurium was ruled out. Increased tryptase concentrations following the clinical reaction, persistent increased levels of basal serum tryptase, and negative skin tests suggested the onset of mast cell degranulation in a patient with mastocytosis. Immediate reaction occurring in patients with mastocytosis should be investigated in order to identify the mechanism of the reaction, either histamine release due to the disease itself or due to a concurrent drug/agent-induced IgE-mediated mechanism.
authors.affiliation: Department of Anesthesia and Intensive Care, University Hospital, Poitiers, France.
authors.forename: Valérie
authors.initials: V
authors.lastname: Renauld
authors.forename: Véronique
authors.initials: V
authors.lastname: Goudet
authors.forename: Claudie
authors.initials: C
authors.lastname: Mouton-Faivre
authors.forename: Bertrand
authors.initials: B
authors.lastname: Debaene
authors.forename: Pascale
authors.initials: P
authors.lastname: Dewachter
mesh_terms: D000368:Aged; D001279:Atracurium / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D004342:Drug Hypersensitivity / Q000209:etiology*; D005260:Female; D005434:Flow Cytometry; D006801:Humans; D007044:Hysterectomy / Q000379:methods; D007431:Intraoperative Complications / Q000139:chemically induced; D034701:Mastocytosis, Cutaneous / Q000150:complications*; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D053802:Tryptases / Q000097:blood
chemical_list: D003473:Neuromuscular Nondepolarizing Agents; D001279:Atracurium; D053802:Tryptases