A CASE OF ANAPHYLAXIS TO SUGAMMADEX SKIN PRICK TESTING

Abstract

<h3>Introduction</h3> Sugammadex is a modified gamma-cyclodextrin gaining increasingly common usage as an anesthetic medication for the rapid reversal of the neuromuscular blocking agents rocuronium and vecuronium. While considered safer than traditional reversal agents, sugammadex is becoming more widely recognized as a rare cause of peri-operative anaphylaxis. There are no standardized skin prick testing protocols or commercially available IgE assays for sugammadex, although previous literature has used an undiluted concentration of 100mg/ml for epicutaneous skin testing. <h3>Case Description</h3> A 57 year old woman with a medical history of anaphylaxis to bee sting experienced peri-operative anaphylaxis upon first time exposure to sugammadex. Despite adequate treatment, she had subsequent rebound anaphylaxis. Four months after her reaction she completed skin prick testing to sugammadex. During the first round of epicutaneous skin prick testing with a diluted concentration of 0.1mg/mL of sugammadex she experienced diffuse hives, throat closer, and hoarseness of voice requiring treatment with epinephrine, diphenhydramine, and steroids. She again had rebound of symptoms shortly thereafter, requiring transfer to the emergency department for monitoring. <h3>Discussion</h3> The evaluation of a patient with peri-operative anaphylaxis can be challenging. As the use of sugammadex increases, clinicians should be aware of its ability to cause anaphylaxis. This case demonstrates anaphylaxis in a sugammadex naive patient, both intra-operatively and then during in-office skin prick testing. The case raises awareness of the possibility for anaphylaxis at a concentration of 0.1mg/ml for epicutaneous skin testing and highlights the need for standardized skin prick testing protocols.