Abstract
We herein present a patient with delayed-type allergic hypersensitivity against prilocaine leading to spreading eczematous dermatitis after subcutaneous injections for local anesthesia with prilocaine. Prilocaine allergy was proven by positive skin testing and subcutaneous provocation, whereas the evaluation of other local anesthetics - among them lidocaine, articaine and mepivacaine - did not exhibit any evidence for cross-reactivity.Interestingly, our patient repeatedly tolerated strictly deep subcutaneous injection of prilocaine in provocation testing while patch and superficial subcutaneous application mounted strong allergic responses. We hypothesize, that lower DC density in deeper cutaneous compartments and/or different DC subsets exhibiting distinct functional immunomodulatory properties in the various layers of the skin may confer to the observed absence of clinical reactivity against prilocaine after deep subcutaneous injection.The term compartment allergy indicates that the route of allergen administration together with the targeted immunologic environment orchestrates on the immunologic outcome: overt T-cell mediated allergy or clinical tolerance.
Highlights
Local anesthetics (LA) are extensively used drugs with a safe application profile and only rare objective side effects
Depending on the application route, immunologic sensitization against antigenic LA determinants is conferred by distinct antigen presenting cells in different skin compartments, namely Langerhans cells (LCs) in the epidermal compartment and interstitial, dermal dendritic cells (DCs) in deeper subcutaneous tissue
Immunological studies have shown that epidermal LCs express CD1a, Langerin and E-cadherin while dermal interstitial DCs are positive for DC-sign, CD11b, factor XIIIa and CD14 [5] and differ in their expression of characteristic immune-regulatory toll like receptors (TLRs)
Summary
Local anesthetics (LA) are extensively used drugs with a safe application profile and only rare objective side effects. Intradermal skin testing with other local anesthetics harbouring different chemical structures both of the amide and ester type (lidocaine 1%, mepivacaine 1%, bupivacaine 0,5%, procaine 1%, articaine 1%) remained negative during 4 days reading. Provocation To verify clinical relevance, we challenged the patient with subcutaneous injections of XylonestTM 1% (prilocaine) and as control the negatively tested and formerly tolerated UltracainTM 1% (articaine) (1 ml each as one single dose at the lateral upper arm) after instruction and written informed consent. Incremental inflammatory reactions after 1-4 days were provoked by superficial subcutaneous injection of prilocaine (Figure 1a), so that diagnosis of delayed-type allergy against prilocaine without cross-reactivity against other local anesthetics of different substance groups was made.
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