Perioperative anaphylaxis: when the allergological work-up goes negative.

Area of Science:

• Anesthesiology and Immunology
• Investigating rare adverse drug reactions

Background:

• Perioperative anaphylaxis (POA) is a rare but serious complication during anesthesia.
• Identifying the causative agent is crucial for patient management but frequently challenging.
• Standard allergological evaluations fail to identify the cause in 30-60% of POA cases.

Approach:

• Reviewing diagnostic challenges and alternative mechanisms of POA.
• Discussing strategies for re-evaluation when initial workup is negative.
• Highlighting the role of advanced testing and collaborative management.

Key Points:

• Non-IgE mediated mechanisms like IgG, MRGPR-X2, and histamine release can cause POA.
• Negative initial workup necessitates reassessment with the clinical team and exploring differential diagnoses.
• Repeating allergological evaluation with specific IgE or basophil activation tests, and considering drug challenges, can aid diagnosis.

Conclusions:

• Accurate diagnosis of POA requires a systematic approach, especially when initial tests are inconclusive.
• Collaborative efforts between allergists and anesthesiologists are vital for managing patients with suspected POA.
• Further investigation into non-IgE mediated reactions is needed to improve diagnostic yield.