D1.320 - IgE-mediated Perioperative Anaphylaxis to Latex with Concomitant Local Anesthetic Hypersensitivity in a Mexican Teenager: a Policy-Changing Case Report

Background

Perioperative anaphylaxis (PA) is a rare but potentially fatal hypersensitivity reaction.¹ It occurs at a lower incidence in children, estimated at 1:2,100 to 1:36,479 anesthetics.² Despite its severity, standardized perioperative anaphylaxis protocols and systematic allergy work-ups are not routinely implemented in many pediatric centers in Mexico.

We describe a pediatric case of grade III PA according to the Ring and Messmer classification. Skin testing and drug challenges were performed according to the recommendations of Garvey LH et al.³

Clinical case

An 11-year-old boy with anorectal malformation, tethered spinal cord, neurogenic bladder, and a history of 11 previous surgical procedures underwent elective bladder augmentation with urinary diversion. Approximately 20 minutes after the start of anesthesia, following the administration of ceftriaxone, midazolam, fentanyl, lidocaine, propofol, cisatracurium, sevoflurane, and dexmedetomidine, capnography revealed an obstructive ventilatory pattern characterized by increased peak airway pressures and a sudden decrease in end-tidal CO₂. Laryngeal edema was observed during endotracheal tube replacement. He subsequently developed generalized erythema, diminished peripheral pulses, delayed capillary refill, and progressive hypotension.

Intramuscular epinephrine and intravenous hydrocortisone were administered immediately, followed by a continuous epinephrine infusion throughout surgery. Acute serum tryptase was 18.5 µg/L, with a baseline of 3.2 µg/L, consistent with PA.

Targeted history revealed prior perioral erythema after balloon inflation and oral allergy-like symptoms following banana ingestion. 

All administered medications were evaluated; the skin-prick test was positive to latex, and the intradermal test was positive to lidocaine. A graded challenge with ropivacaine was well tolerated. A drug allergy passport was issued with recommendations for future procedures.

Conclusion

To our knowledge, this is the first fully investigated pediatric PA from Mexico, which reveals systemic gaps: absent preoperative latex-risk screening, non-routine tryptase, and siloed anesthesia-allergy care. We advocate mandatory tryptase sampling, high-risk latex protocols for urogenital/spinal patients, and collaborative registries to drive national standards. Final diagnosis: IgE-mediated anaphylaxis to latex with a concomitant local anesthetic hypersensitivity.