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Generalised delayed-type hypersensitivity and cross-reactivity: case report A 7-year-old girl developed generalised delayed-type hypersensitivity following administration of lidocaine/ epinephrine as local anaesthetics (LAs) during dental restoration procedure. Further, she also developed similar generalised delayed-type hypersensitivity following skin test with bupivacaine due to cross reactivity of local anaesthetics. The girl had received 1.7mL of 2% lidocaine [lignocaine] (amide LA) with 1:80 000 epinephrine [adrenaline] via buccal infiltration before a dental restoration procedure. After 2–3 hours, her parents observed swelling of her face and eyelids (angioedema). Thereafter, on that night, she developed a pruritic, erythematous rash on the arms and face, which was suspected as generalised delayed-type hypersensitivity reaction. The reaction resolved spontaneously after one week. She did not have any other symptom like urticaria, wheeze, gastrointestinal complaints, shortness of breath, cardiovascular compromise or neurologic changes. Upon anamnesis, it was noted that there was no history of atopy, or any recent exposure to other new medications, food or environmental allergens. Also, she had a history of chronic mild dry skin, and she had tolerated unspecified LAs in the past (also as a part of the dental treatments), but her parents were not sure which specific LAs she had received. Therefore, she was referred to a paediatric allergy service for evaluation of the hypersensitivity. Skin tests were performed using intradermal injection, epicutaneous prick, atopy topical patch for 48–72 hours and a SC provocative challenge with lidocaine (containing methylparaben and other preservatives) and epinephrine injected into the right arm. The tests were initially negative. However, on the next day, she developed several non-urticarial, non-pustular, non-vesicular, pruritic, patchy, blanchable, flat, erythematous lesions located at and scattered distal to the injection sites including the skin overlying the right medial malleolus. Thereafter, the skin testing and SC challenge to preservative-free 0.5% bupivacaine was performed using epicutaneous prick, SC provocative challenge and intradermal injection method, to which she did not exhibit any immediate localised reaction. However, she subsequently developed a similar generalised rash to bupivacaine (albeit occurring at other skin areas), confirming hypersensitivity to amide LAs (cross reactivity) [final outcome not stated]. Thereafter, atopy patch and SC provocation testing with preservative-free 2% chloroprocaine (ester LA) was performed, which showed no reaction. It was then determined that she exhibited crossreactivity pattern manifesting a generalised delayed-type hypersensitivity to an amide LA drug (bupivacaine), following previous delayed hypersensitivity reaction to another amide LA drug (lidocaine, used in the form of lidocaine/epinephrine). Author comment: "A seven-year-old girl developed angioedema and a generalized, erythematous rash several hours af