Allergic Reaction to Latex from Stopper of a Medication Vial

Abstract

Latex hypersensitivity is now recognized as a potential cause of intraoperative anaphylaxis [1,2]. Patients at risk for latex allergy include children with myelodysplasia or congenital urologic anomalies, sensitized health care personnel, and rubber factory workers [3-5]. Latex-sensitive patients can be anesthetized safely if precautions are taken to remove all latex-based products from contact with the patient. In this report we describe a patient with known latex sensitivity who developed an allergic reaction after the administration of a drug from a vial with a latex stopper. Case Report A 16-yr-old girl with myelodysplasia and neurogenic bladder presented for cystoscopy and exploratory laparotomy for placement of a vesicoabdominal wall stoma. Before surgery, the patient had been using latex-based products to perform intermittent bladder catheterization. General anesthesia was induced and an endotracheal tube placed. The patient was hemodynamically stable from the induction of anesthesia throughout cystoscopy and incision of the abdominal wall. After opening the abdominal cavity, the surgeon manipulated the patient's bowels with his hands. At this point, the patient suddenly became bronchospastic and hypotensive, suggesting that she was having an allergic reaction to the surgeon's latex gloves. The patient was resuscitated with fluids, epinephrine, histamine antagonists, glucocorticoids, and bronchodilators. The surgical team then switched to latex-free gloves, and other latex-based products were removed from contact with the patient. The remainder of the operation was uneventful and the patient had an unremarkable postanesthetic course. After recovery from her operation, the patient was referred to an allergist to determine the drug responsible for the anaphylactic event. Results of radioallergoimmunosorbent testing (RAST) for anesthetics, muscle relaxants, and antibiotics were negative. The RAST for the latex antigen was strongly positive, confirming latex sensitivity as the source of the patient's anaphylactic reaction. The surgeon subsequently scheduled the patient for another procedure to be done as a same-day admission. The consulting allergist prescribed preoperative oral doses of diphenhydramine, cimetidine, and prednisone. Upon arrival to the preoperative holding area, the patient informed us that she had taken the prescribed doses of cimetidine and diphenhydramine, but had forgotten to take the prednisone. After discussion with all involved caretakers, it was decided to proceed with the operation after intravenous administration of methylprednisolone. The methylprednisolone vial has two rubber stoppers, one separating the solid and liquid parts. The drug is prepared for injection when the inside stopper is displaced. The outer stopper was carefully removed so that the drug could be drawn up without the needle passing through the stopper. The methylprednisolone was then administered with a glass syringe via a plastic stopcock in the patient's intravenous line. Several minutes after the methylprednisolone had been given, marked erythema developed along the course of the corresponding vein (dorsum of foot to groin). Sensitivity to latex particles in the methyprednisolone was presumed, and the case was cancelled. The patient developed no other allergic manifestations. This patient returned 1 mo later for cystoscopy and revision of the abdominal wall stoma. She had followed the prescribed regimen of oral diphenhydramine, cimetidine, and prednisone. Nonlatex supplies and equipment were used throughout surgery and she had an uneventful course. Discussion Since latex products are ubiquitous, the care of latex sensitive patients is a challenge to their anesthesiologists. General recommendations include: 1. The use of latex-free gloves, catheters, and surgical products (e.g., drains). 2. Avoidance of injection through rubber ports in intravenous tubing. 3. If plastic syringes must be used, the medication should be administered immediately to avoid prolonged contact with the latex coating on the syringe plunger. 4. Avoidance of the use of latex-based airway appliances. 5. Protection of the skin that comes in contact with latex-based blood pressure cuffs or esmarchs with cotton wrapping [1]. Medication vials with latex-based stoppers are usually safe if the rubber stopper is not instrumented [1]. In the case reported here, careful attention was made to avoid instrumentation of the methylprednisolone container's stopper; however, the patient still developed a mild allergic reaction, probably as a result of the mixing procedure which brought the solution into contact with the rubber stoppers. This patient also had an impressively high RAST titer to the latex antigen, 130 ng/mL (normal is < 0.6 ng/mL). Previous reports have suggested that injecting medications via latex-based ports on intravenous tubing can cause allergic reactions [6,7]. To our knowledge, this is the first reported case of an allergic reaction to latex from the stopper of a medication vial. Based upon this experience, we recommend extreme caution when using medication from vials with latex-based stoppers in latex-sensitive patients. Alternative drugs contained in latex-free vials should be used when possible. Our pharmacy now has a methylprednisolone vial which does not require mixing the solid and liquid portions with rubber stoppers.