Antithymocyte globulin
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Anaphylactic shock: case report A 67-year-old woman developed anaphylactic shock during immunosuppressive treatment with antithymocyte globulin. The woman, who had an end-stage renal disease was scheduled for living-donor kidney transplant surgery. She underwent a smooth and an uneventful induction and maintenance of anaesthesia [specific drugs not stated]. She started receiving IV antithymocyte globulin 75mg infusion after pre-medications with diphenhydramine, paracetamol [acetaminophen], methylprednisolone and famotidine. Within minutes of the initiation of antithymocyte globulin infusion, she developed profound hypotension, tachycardia and respiratory acidosis. A suspicion of anaphylactic shock secondary to antithymocyte globulin therapy was considered. The woman’s antithymocyte globulin therapy was discontinued immediately. Although, her airway was intact with a good endotracheal tube position, she showed the bilateral wheezing and difficulty in ventilation. Her peak airway pressures increased. An intraoperative trans-esophageal echocardiogram only showed a hyperdynamic left ventricle. Her hypotension was resistant to colloid and crystalloid fluid boluses, and she required multiple vasopressors (including norepinephrine, epinephrine and vasopressin) to maintain her BP. Her kidney transplant procedure was post-ponded and her family members were informed about the intraoperative events. She remained intubated and was shifted to the surgical ICU. She was maintained on high doses of vasopressors, other supportive measures and ventilator support to optimise haemodynamic status. She received a high dose of unspecified steroids. She also underwent one session of plasmapheresis, after that she developed an underlying retroperitoneal hematoma, which needed re-exploration and showed generalised oozing without active haemorrhage. Her vasopressors therapy was weaned off within 48 hours of the event. After 72 hours of the initial event and after treatment with basiliximab induction, she became haemodynamically stable and then successfully underwent living-kidney transplantation. On further discussion, she revealed a significant exposure to pet (rabbits) previously. Her intraoperative immunologic studies showed a significant result for elevated histamine and tryptase. She also showed an elevated anti-rabbit protein. Saeed MI, et al. Severe intraoperative anaphylaxis related to thymoglobulin during living donor kidney transplantation. Antibodies 9: 1-5, No. 3, Sep 2020. Available from: 803501022 URL: http://doi.org/10.3390/antib9030043
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Reactions 12 Sep 2020 No. 1821
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