RESUMO
JUSTIFICATIVA E OBJETIVOS: Embora crescente a incidência de alergia ao látex na população em geral, eventos graves de anafilaxia durante alguns procedimentos cirúrgicos felizmente ainda são raros, porém com morbidade e mortalidade elevados. Não apenas a prevenção, mas o diagnóstico, o pronto tratamento e o acompanhamento dos pacientes acometidos por esse evento representam um desafio para o anestesiologista. O presente relato teve por objetivo descrever um caso de anafilaxia grave ao látex e discutir seu diagnóstico e tratamento. RELATO DO CASO: Paciente do sexo feminino, 39 anos, branca com suspeita diagnóstica de apendicite, é levada para procedimento de urgência sob raquianestesia. Aproximadamente 30 minutos após o início da cirurgia, apresentou quadro de anafilaxia com parada cardiorrespiratória, revertida após tratamento. Um dos cuidados foi o isolamento de eventuais agentes causais, sendo que, posteriormente, a paciente foi encaminhada para unidade de terapia intensiva e evoluiu sem sequelas. A dosagem de IgE-RAST (Radioallergosorbent Test) específico para o látex mostrou-se positiva. A paciente foi encaminhada para acompanhamento com o alergologista. CONCLUSÕES: O anestesiologista deve concentrar esforços na anamnese, mesmo em procedimentos de urgência, estando consciente das limitações que se apresentam nessas ocasiões. O prognóstico de anafilaxia depende do pronto início do tratamento adequado e o diagnóstico não se limita ao momento do evento, mas sim à determinação do fator causal. Criar um meio de acompanhar esses pacientes, a exemplo de outros centros internacionais, parece ser o caminho a ser seguido.
BACKGROUND AND OBJECTIVE: Despite the increase of latex allergy in general population, severe anaphylactic events during some surgical procedures are still rare; however, they are associated with increased morbidity and mortality. Prevention, diagnosis, treatment, and follow-up of patients affected by this event represent a challenge for anesthesiologists. The objective of this report was to describe a case of severe latex-induced anaphylactic reaction and discuss its diagnosis and treatment. CASE REPORT: This is a 39-year-old Caucasian female patient, with a diagnostic suspicion of appendicitis, who underwent an emergency surgery under spinal anesthesia. Approximately 30 minutes after beginning the surgery, the patient developed an anaphylactic reaction with cardiorespiratory arrest, which was reversed after treatment. Possible causative agents were isolated and, posteriorly, the patient was transferred to the intensive care unit, evolving without sequelae. Latex-specific IgE-RAST (Radioallergosorbent Test) was positive. The patient was referred to an allergist for follow-up. CONCLUSIONS: Anesthesiologists should focus on patient's history, even in urgent procedures, being aware of the limitations arising on these situations. The prognosis of anaphylaxis depends on prompt initiation of adequate treatment; diagnosis is not limited to the event occasion, but to the determination of the causative factor. Creating the means of following-up these patients, similar to other international centers, seems to be the example to be followed.
JUSTIFICATIVA Y OBJETIVOS: Aunque exista un aumento en la incidencia de alergia al látex en la población en general, los eventos graves de anafilaxia durante algunos procedimientos quirúrgicos por suerte todavía son raros, aunque con un nivel de morbilidad y mortalidad elevados. La prevención, el diagnóstico, el rápido tratamiento y el seguimiento de los pacientes afectados por ese evento, representan un reto para el anestesiólogo. El presente relato intentó describir un caso de anafilaxia grave al látex y discutir su diagnóstico y tratamiento. RELATO DEL CASO: Paciente del sexo femenino, 39 anos, blanca y con sospecha diagnóstica de apendicitis, que fue derivada a quirófano para un procedimiento urgente bajo raquianestesia. Aproximadamente 30 minutos después del inicio de la cirugía, presentó un cuadro de anafilaxia con parada cardiorrespiratoria, revertida posteriormente al tratamiento. Uno de los cuidados tomados fue el aislamiento de eventuales agentes causales, siendo que, posteriormente, la paciente fue derivada a la Unidad de Cuidados Intensivos y evolucionó sin secuelas. La dosificación de IgE-RAST (Radioallergosorbent Test), específico para el látex fue positiva. La paciente fue derivada para seguimiento con el alergista. CONCLUSIONES: El anestesiólogo debe concentrar sus esfuerzos en la anamnesis, aunque en los procedimientos de urgencia, sea consciente de las limitaciones que se presentan en esas ocasiones. El pronóstico de anafilaxia depende del rápido inicio del tratamiento adecuado, y el diagnóstico no se restringe al momento del evento, sino a la determinación del factor causal. Crear un medio de seguimiento para esos pacientes, como lo hacen otros centros internacionales, parece ser el camino que debe ser secundado.
Assuntos
Adulto , Feminino , Humanos , Apendicectomia , Anafilaxia/induzido quimicamente , Complicações Intraoperatórias/induzido quimicamente , Complicações Intraoperatórias/imunologia , Hipersensibilidade ao Látex/induzido quimicamenteRESUMO
BACKGROUND AND OBJECTIVE: Despite the increase of latex allergy in general population, severe anaphylactic events during some surgical procedures are still rare; however, they are associated with increased morbidity and mortality. Prevention, diagnosis, treatment, and follow-up of patients affected by this event represent a challenge for anesthesiologists. The objective of this report was to describe a case of severe latex induced anaphylactic reaction and discuss its diagnosis and treatment. CASE REPORT: This is a 39-year-old Caucasian female patient, with a diagnostic suspicion of appendicitis, who underwent an emergency surgery under spinal anesthesia. Approximately 30 minutes after beginning the surgery, the patient developed an anaphylactic reaction with cardiorespiratory arrest, which was reversed after treatment. Possible causative agents were isolated and, posteriorly, the patient was transferred to the intensive care unit, evolving without sequelae. Latex-specific IgE-RAST (Radioallergosorbent Test) was positive. The patient was referred to an allergist for follow-up. CONCLUSIONS: Anesthesiologists should focus on patient's history, even in urgent procedures, being aware of the limitations arising on these situations. The prognosis of anaphylaxis depends on prompt initiation of adequate treatment; diagnosis is not limited to the event occasion, but to the determination of the causative factor. Creating the means of following-up these patients, similar to other international centers, seems to be the example to be followed.
Assuntos
Anafilaxia/induzido quimicamente , Apendicectomia , Complicações Intraoperatórias/induzido quimicamente , Complicações Intraoperatórias/imunologia , Hipersensibilidade ao Látex/induzido quimicamente , Adulto , Feminino , HumanosRESUMO
Hevein (Hev b 6.02) is a major IgE-binding allergen in natural rubber latex and manufactured products. Both tryptophans (Trp(21) and Trp(23)) of the hevein molecule were chemically modified with BNPS-skatole (2-nitrophenylsulfenyl-3-methyl-3(')-bromoindolenine); derivatized allergen failed to significantly inhibit binding of serum IgE in ELISA assays. Similarly, skin prick tests showed that hevein-positive patients gave no response with the modified allergen. Dot blot experiments carried out with anti-hevein mono- and polyclonal antibodies confirmed the importance of Trp(21) and Trp(23) for antibody-recognition, and demonstrated the specific cross-reactivity of other molecules containing hevein-like domains. We also report the structure of Hev b 6.02 at an extended resolution (1.5A) and compare its surface properties around Trp residues with those of similar regions in other allergens. Overall our results indicate that the central part of the protein, which comprises three aromatic and other acidic and polar residues, constitutes a conformational epitope.
Assuntos
Peptídeos Catiônicos Antimicrobianos , Mapeamento de Epitopos/métodos , Epitopos/química , Imunoglobulina E/química , Hipersensibilidade ao Látex/induzido quimicamente , Modelos Moleculares , Lectinas de Plantas/química , Triptofano/química , Alérgenos/química , Alérgenos/imunologia , Alérgenos/toxicidade , Sequência de Aminoácidos , Criança , Pré-Escolar , Simulação por Computador , Cristalografia por Raios X , Humanos , Hipersensibilidade Imediata/induzido quimicamente , Hipersensibilidade Imediata/imunologia , Imunoglobulina E/imunologia , Lactente , Recém-Nascido , Hipersensibilidade ao Látex/imunologia , Dados de Sequência Molecular , Lectinas de Plantas/imunologia , Lectinas de Plantas/toxicidade , Conformação Proteica , Testes Cutâneos , Relação Estrutura-AtividadeRESUMO
Gutta-percha and gutta-balata are derived from the Paliquium gutta and Mimusops globsa trees, respectively, that are in the same botanical family as the rubber tree Hevea brasiliensis. For this reason the potential for immunological cross-reactivity between the gutta-percha and gutta-balata used in endodontics and natural rubber latex (NRL) has been the subject of some controversy, because these products may be used in latex-allergic individuals. The objective of this study was to investigate the potential cross-reactivity between gutta-percha, gutta-balata, and NRL. Physiological extracts of seven commercially available gutta-percha products, raw gutta-percha, raw gutta-balata, and synthetic transpolyisoprene were each analyzed for cross-reactivity with NRL in a competitive radioallergosorbent test inhibition assay. No detectable cross-reactivity was observed with any of the raw or clinically used gutta-percha products. In contrast the raw gutta-balata released proteins that were cross-reactive with Hevea latex. We conclude that the absence of gutta-percha proteins that can react with Hevea latex-specific IgE antibody supports the minimal potential for commercially available gutta-percha to induce allergic symptoms in individuals sensitized to NRL. Because gutta-balata is sometimes added to commercial gutta-percha products caution should be exercised if products containing gutta-balata are used in endodontic care of latex-allergic individuals.