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Anaphylactic reaction following intra-urethral administration in an elderly patient: case report An 84-year-old man experienced an anaphylactic reaction after receiving intra-urethral chlorhexidine/lidocaine/ methylparaben/propylparaben [Instillagel] prior to laser ablation of a recurrent transitional cell bladder carcinoma; the reaction was attributed to the chlorhexidine component. The man had previously received chlorhexidine uneventfully. His current procedure was conducted according to standard procedure, with administration of gentamicin, saline skin preparation, and intra-urethal application of chlorhexidine/lidocaine/methylparaben/propylparaben 11mL. The carcinoma was simply ablated with a laser, and a latex catheter was inserted to ease postoperative pain. However, while awaiting discharge, a sudden deterioration in his clinical state occurred, with hypoxia, tachycardia, hypotension, cerebral obtundation and widespread hyperaemia of the skin [time to reaction onset not stated]. The man was immediately given oxygen, IV fluids, hydrocortisone, salbutamol, metaraminol and chlorphenamine. His condition subsequently improved and then stabilised. He was admitted to the ICU for observation. His serial mast cell tryptase levels were 11.6 µg/L, 8.1 µg/L and 2.9 µg/L at 4, 8 and 24 hours after deterioration, respectively. After 24 hours of observation, he was discharged to home. He subsequently underwent challenge tests to lidocaine, chlorhexidine, latex and gentamicin. A strongly positive response was noted to 2% chlorhexidine skin preparation, with an indeterminate reaction noted to gentamicin. There was no discernible reaction to latex or lidocaine. He was given a medic alert bracelet stating "Chlorhexidine allergy – avoid gentamicin/aminoglycosides", with the advice that all subsequent procedures will be considered high risk. Author comment: "Although cases of anaphylactic and anphylactoid reactions to the chlorhexidine component of Instillagel have been documented previously, this case highlights both the necessity to recognise this collection of signs swiftly and that previous repeated exposure to intraurethral chlorhexidine with no evidence of allergy does not exclude the diagnosis". Dyer JE, et al. Anaphylactic reaction to intraurethral chlorhexidine: sensitisation following previous repeated uneventful administration. Annals of the Royal College of Surgeons of England 95: e105-6, No. 6, 2013. Available from: URL: http://dx.doi.org/10.1308/003588413X13629960047597 - United 803096508 Kingdom

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Reactions 7 Dec 2013 No. 1481