Case Report Intravenous fluorescein as a cause of immunoglobulin E-mediated anaphylactic shock A. Breidablik 1 , G. H. de Pater 2,3 , C. Walther 2 , A. Nopp 4 and A. B. Guttormsen 2,3 1 Department of Anaesthesiology and Intensive Care, Central Hospital of Sogn og Fjordane, Førde, Norway, 2 Department of Anaesthesiology and Intensive Care, Haukeland University Hospital, 3 Department of Surgical Sciences, UiB, Bergen, Norway and 4 Department of Medicine, Clinical Immunology and Allergy Unit, Karolinska Institute, Stockholm, Sweden We report a patient with severe anaphylactic shock immedi- ately after injection of i.v. fluorescein. The patient recovered without sequela. Immunoglobulin E (IgE) mechanism was highly suggestive with significant increase in serum tryptase, positive basophil allergen threshold sensitivity (CD-sens) and histamine release tests towards fluorescein. This is, to our knowledge, the first report where CD-sens has been used to aid in diagnosing an IgE-mediated anaphylactic shock caused by fluorescein. Accepted for publication 17 May 2012 © 2012 The Authors Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation F luorescein angiography (FFA) of retina has been performed for more than 60 years. The tech- nique is widely used and considered safe. 1 Although rare, potentially life-threatening anaphylaxis has occurred after i.v. injection of fluorescein. 2 When sus- pected, treatment of anaphylaxis should start imme- diately. Emergency protocols and trained medical staff are essential for a successful outcome. When- ever a patient has had an anaphylactic reaction, attempts should be made to diagnose the cause and mechanism of the reaction. Re-challenge, serum tryptase (s-tryptase), positive basophil allergen threshold sensitivity test (CD-sens), histamine release test (HRT) and skin-prick tests (SPT) are diag- nostic tools that can help confirm an IgE-mediated anaphylactic reaction. Case report A 67-year-old healthy male without a history of aller- gies and with normal total IgE, but with reported heavy skin reactions after mosquito bites, was sched- uled for a FFA for evaluation of maculopathy. He had been exposed to fluorescein eye drops three times the last year without suspicion of allergy. A nurse injected fluorescein, 100 mg/ml, 2.5 ml i.v. Two minutes later, the patient experienced a sudden attack of sneezing and dyspnoea. Within 8 min, he fainted with compromised circulation and apnoea. During initial physical examination, pulse- less electrical activity (PEA) was suspected and 1 mg of adrenaline was promptly given i.v. Ventilation with 10 l of oxygen flow was maintained with face mask, legs were raised and fluid (Ringer’s acetate – 2.5l) was administered rapidly i.v. He stabilized; blood pressure 80/40 mmHg, sinus rhythm 80–120 beats/min. Increments with adrenaline were admin- istered to maintain blood pressure, in total 0.5 mg. He also received hydrocortisone 200 mg i.v, dex- chlorpheniramine 5 mg i.v. and terbutaline 2.5 mg intramuscularly. Initially, he recovered and complained of chest pain, but very quickly became confused, restless and agitated, produced a lot of thick mucus and oedema was noticed on his lips and tongue. Thick mucus was compromising the airway. Due to risk of airway obstruction and signs of decreased brain perfusion, he was intubated. Tracheal intubation was attempted via direct laryngoscopy (with ketamine 100 mg i.v. + suxamethonium 150 mg i.v.) but failed due to severe intraoral and laryngeal oedema and saliva produc- tion. Intubation via an LMA-Fastrach no.4 (GM Medical NorgeAS, Sande in Vestfold, Norway) was successful. He was transferred to the intensive care unit (ICU) after 1.5 h. During the first hours, he was Acta Anaesthesiol Scand 2012; ••: ••–•• Printed in Singapore. All rights reserved © 2012 The Authors Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2012.02732.x 1