Twenty years’ experience with anaphylaxis-like reactions to local anesthetics: genuine allergy is rare

Publication date: Available online 12 April 2018
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Axel Trautmann, Matthias Goebeler, Johanna Stoevesandt
BackgroundAnaphylaxis-like reactions occur within minutes after application of local anesthetics (LA), most commonly during dental interventions. Impressive symptoms including respiratory distress or loss of consciousness frequently give rise to a suspicion of allergy and may prompt patients and treating physicians to refuse future LA injections.ObjectiveNon-allergic mechanisms are responsible for the majority of LA-induced immediate-type reactions. In view of the preponderance of non-allergic reactions, the question arises whether genuine LA allergy may be missed during routine testing procedures.MethodsWe retrospectively evaluated clinical data and test results from patients referred to our allergy clinic within the past 20 years for diagnostic work-up of LA-induced immediate-type reactions.ResultsOf 402 evaluated patients, 29 had an episode of acute urticaria within 30 minutes after LA injections, the remaining 373 had a history of mainly subjective cutaneous, respiratory, cardiovascular, and neurological complaints. Of the patients reporting urticaria with or without angioedema, 14 were diagnosed with a spontaneous episode of urticaria, 13 had allergic or non-allergic reactions to other agents and 2 had IgE-mediated LA allergy. LA allergy was definitely excluded by 771 subcutaneous provocation tests with skin test negative LA, thereby demonstrating the high predictive value of negative intradermal testing.ConclusionsSkin testing and provocative LA challenge are useful to exclude LA allergy, and this testing procedure seems to be appropriate to identify the extremely rare cases with IgE-mediated LA allergy.