Near-fatal anaphylaxis caused by human serum albumin in fibrinogen and erythrocyte concentrates

Summary A 40-year-old man developed anaphylactic shock during surgical replacement of a prolapsed mitral valve during gen-eral anaesthesia and an attenuated reaction (Grade 2), three days later during a blood transfusion. Human serumalbumin, a component of the fibrinogen concentrate used postoperatively with the erythrocyte concentrate, was iden-tified as the trigger, confirmed by positive skin prick and intradermal tests. Any anaphylaxis during the peri-opera-tive period should cause the clinician to perform allergy tests for identification of the culprit drug and, sometimes,culprit additive. Testing of human serum albumin, acting as hidden allergen, should be included, especially wherethere has been a blood transfusion. Correspondence to: P. KomerickiEmail: peter.komericki@medunigraz.atAccepted: 26 July 2013 Case report A 40-year-old otherwise healthy man (weight 80 kg,height 173 cm, ASA physical status 1) underwent elec-tive surgical replacement of a prolapsed mitral valveunder general anaesthesia. After a 4-h surgical proce-dure, at the time of skin closure and a few minutes afterintravenous administration of a fibrinogen concentrate(Haemocomplettan P; CSL Behring, Vienna, Austria) –routinely given to prevent blood clotting derangement –the patient developed severe hypotension (systolicblood pressure < 30 mmHg). Administration of crystal-loids (1000 ml Elomel isoton; Fresenius Kabi, Fried-berg, Germany) and colloids (500 ml Voluven 6%;Fresenius Kabi, Bad Homburg, Germany) and externalcardiac massage were ineffective. As it was initiallyassumed that the cardiovascular collapse resulteddirectly from the surgical intervention, an emergency re-sternotomy was performed, but no internal complica-tions were found. A diagnosis of anaphylactic shock wasthen made, and direct cardiac massage applied. Addi-tional administration of 750 ml crystalloid, 500 ml col-loid, 8 mg dimetindene maleate (Fenistil ; NovartisConsumer Health-Gebro, Fieberbrunn, Austria), 500 mgprednisolone 21-hemisuccinate (Solu-Dacortin ; MerckKGAA, Darmstadt, Germany) and one dose of 1 mgadrenaline eventually restored the circulation. Thepatient was transferred to the intensive care unit. Onthe third day of his stay, the patient (the trachea bynow extubated) required a blood transfusion. A fewminutes after commencement of an erythrocyte concen-trate transfusion, the patient developed generalisedpruritic erythema, dyspnoea and hypotension. Thesymptoms rapidly resolved after withdrawal of the infu-sion and treatment with 4 mg dimetindene maleate,500 mg prednisolone 21-hemisuccinate and 500 mlcrystalloid.