Vancomycin
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Anaphylaxis: case report A 22-year-old man developed anaphylaxis during an empirical antibiotic therapy with vancomycin. The man presented with redness and pain of the knee, 7 days after a successful anterior ruciate ligament reconstruction. The results of microscopic examination were consistent with gram-positive cocci in the exudate fluid, leading to a diagnosis of pyogenic knee arthritis. He underwent an emergency lavage and debridement of the right knee under general anaesthesia. He was administered ketamine, propofol and remifentanil for induction as well as maintenance of the anaesthesia. Additionally, he was administered rocuronium bromide [rocuronium] to facilitate placement of the laryngeal mask airway. After establishing peripheral nerve block with levobupivacaine, the surgery was started, and an empiric treatment with IV vancomycin 2g was initiated. Nine minutes later, by the time vancomycin was about to finish, his HR increased and the tidal volume decreased. Subsequently, the laryngeal mask airway was removed and tracheal intubation was performed. However, the tidal volume did not increase. An obstructive pattern was observed on a capnogram. Shortly after the intubation, his BP decreased to 57/29mm Hg and his HR increased further to 106 beats/minute. The man was repeatedly administered ephedrine and phenylephrine. However, his respiratory pattern and haemodynamics did not change drastically. The tidal volume and haemodynamics returned to normal, while preparation of epinephrine for administration. The hemodynamic instability lasted only for 10 minutes. He was then administered dexamethasone 6.6mg to prevent a recurrence of anaphylactoid response. Following surgery, he was shifted to the ICU. An anaphylaxis induced by vancomycin was undeniable, and vancomycin was replaced with linezolid. On postoperative day 1, following resolution of the anaphylaxis, he was discharged. No recurrence of anaphylactoid response was noted. On postoperative day 2, exudate fluid came positive for methicillin-sensitive Staphylococcus aureus, and the antibiotic therapy was changed to cefazolin. Investigations showed elevated plasma histamine and tryptase levels, measured during anesthesia. A diagnosis of vancomycininduced anaphylaxis was made. Author comment: "The present patient was diagnosed as having [vancomycin] induced anaphylaxis". Noguchi S, et al. Serum Tryptase Cannot Differentiate Vancomycin-Induced Anaphylaxis From Red Man Syndrome. Journal of Clinical Immunology 39: 855-856, No. 8, Nov 2019. Available from: URL: http://doi.org/10.1007/ 803441764 s10875-019-00707-3 - Japan
0114-9954/19/1784-0001/$14.95 Adis © 2019 Springer Nature Switzerland AG. All rights reserved
Reactions 21 Dec 2019 No. 1784
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