AbstractA case of progressive anaphylactoid reactioncomplicating a local anaesthetic agentadministered to a dental patient is described. Themanagement of the condition is discussed.Key words: Anaphylactic reaction, local anaesthesia,case report.(Received for publication July 1994. Revised October1994. Accepted November 1994.)

IntroductionA n a p hylactoid reaction is a hy p e rsensitivity reaction

occurring after the administration of an anaphylac-togen. The pathomechanism resembles that ofanaphylaxis. It is a Type I hypersensitivity reactionmediated by IgE antibodies capable of releasingb i o l o gically active fa c t o rs such as histamine, va s o a c t i veamine, slow releasing substance of anaphylaxis (SRS-A ; leukotriene L4 and D4), eosinophils chemotacticfactor (leukotriene B4) and basophil kallikrein.

This case report describes a progressive anaphyl-actoid reaction presenting as angioedema of the faceand neck associated with urticarial rash of the angleof the mouth in a patient who received lignocainehydrochloride local anaesthetic solution for the firsttime prior to a dental extraction. Attention is drawnto the management of this unusual but potentiallyfatal complication. The constituents of this agentwere 2% lignocaine hydrochloride solution withepinephrine 1:100 000, sodium chloride 6 mg/mLand sodium metabisulphite 0.5 mg/mL as a reducingagent. The solution did not contain a paraben.

Case repor tA 14 year old female presented at the dental clinic

with an extensive swelling of the left circumorbital,infraorbital, nasolabial and submandibular regi o n swith associated urt i c a rial rash at the angle of the leftside of the mouth four days after extraction of teeth 24and 27 (Fig. 1). An infiltration with one cart ridge of localanaesthetic (lignocaine hy d r o c h l o ride with epinephri n e1:100 000) was used to achieve anaesthesia of the

Australian Dental Journal 1998;43:(3):170-1

A n a p hylactic reaction following administration oflignocaine hy d r o c h l o ride infiltration. Case report

Christopher O. Ogunsalu, BDS, FRACDS*

170 Australian Dental Journal 1998;43:3.

*Senior Registrar, Department of Oral and Maxillofacial Surgery,Cornwall Regional Hospital, Montego Bay, Jamaica.

p o s t e rior and middle superior alveolar nerves, and agr e ater palatine nerve block was also gi ven. Theprocedure was uneventful and at r a u m at i c.

Palpation of the face revealed a slightly tender softswelling of the left side that had crossed the midlineslightly to involve the right nasolabial and sub-mandibular regions. The patient readily volunteeredt h at rashes appeared the day after the dentalextraction. She was immediately admitted to theobservation ward and started on drug therapy basedon the clinical diagnosis of anaphy l a x i s / a n a p hy l a c t o i dreaction. An intravenous line was established toexpand blood volume because of her unstable bloodpressure and pulse rate using 4.3% dextrose innormal saline: 500 mL was to run every 6 hours.I n t r avenous adrenaline 1:100 000 (1.0 mg/mL), 0.5 mLdiluted in 10 mL normal saline was administeredover 15 minutes.1 Intramuscular chlorpheniraminemaleate BP 10 mg 8 hourly combined with solucotef( hy d r o c o rtisone sodium succinate 100 mg) wa sgiven 8 hourly for 3 doses. The vital signs werefrequently monitored and reassurance was given tothe patient regarding the possible outcome of treat-ment. The adrenaline was repeated 30 minutes afterthe initial dose.

Review of the patient 24 hours after commence-ment of the regimen revealed a dramatic regressionof the facial swelling (Fig. 2). The urticarial rasheshad begun to crust. The patient was continued onintramuscular adrenaline 1:1000 (1.0 mg/mL 0.5 mL),c h l o rpheniramine maleate 10 mg and 100 mghydrocortisone as above, 8 hourly for 3 doses. Thepatient was discharged on the third day followingadmission as the swelling had responded consider-ably to the therapy with no relapse. Because thep atient was covered by prophylactic antibiotic(ampicillin 250 mg qds 6 hourly) immediately postextraction for one week the last dose of which wastaken on the day of discharge a diagnosis ofsecondary infection such as acute infective osteitis(the so-called dry socket) was not favoured.

DiscussionSurgical emphysema following removal of alveolar

bone with an air-rotor instrument could give the

group of at risk patients should be placed on anappropriate dose of antihistamine prior to injectionof a local anaesthetic agent solution containingsulphite and for some time thereafter depending onthe clinical situation.

The mainstay of treatment of anaphy l a c t o i dreaction is adrenaline.1 Corticosteroids and anti-histamines could be used in conjunction with adren-aline to help reduce the overall duration of thereaction and may prevent relapse. They should neverbe used to the exclusion of adrenaline in themanagement of anaphylaxis/anaphylactoid reaction.It can be administered subcutaneously, intra-ve n o u s l y, or intramuscularly, depending on theclinical situation. It is safe and effective. The use ofadrenaline intravenously in this case was to counter-act an incipient hypotensive state which could haveterminated in cardiac arrest.

AcknowledgementThe author wishes to thank Dr O. O. Abiose for

editing this paper.

Reference1. Medicine Digest. Medical management of anaphylactoid reaction.

Aust Prescriber 1988;14:20.

Address for correspondence/reprints:Mr Christopher Ogunsalu,

Department of Oral and Maxillofacial Surgery,Cornwall Regional Hospital,

Montego Bay, Jamaica, West Indies.

Australian Dental Journal 1998;43:3. 171

clinical picture in Fig. 1. But in the case underdiscussion the extraction was absolutely uneventfulwithout the use of air-rotor instru m e n t ation toremove bone in order to retrieve root fragments.

All dental practitioners should be aware of thediagnosis and management of emergencies such asanaphylactoid reaction or anaphylaxis that may arisefrom the use of local anaesthetic agents. Resusci-tative drugs such as antihistamine, adrenaline andcorticosteroids should be available at chairside forimmediate use. All patients must be warned prior tolocal anaesthetic agent administration of the possibledanger that follows its use. They should be told toreport back immediately to the clinic if a rash shoulddevelop. Anaphylaxis may develop immediately andis usually immediately life-threatening due tor e s p i r at o ry embarassment. Early symptoms and signsinclude a sensation of warmth, itching especially inthe axilla and groin, and a feeling of anxiety andpanic. These may progress into an erythematous oru rt i c a rial rash, oedema of the face and neck,bronchospasm and laryngeal oedema. The severestate of anaphylactoid reaction may lead to wheezingand dyspnoea hy p e rtension, arrythmia andcardiac arrest may occur.

Lignocaine solution contains sodium bisulphitethat may cause serious allergic type reactions incertain persons although the overall incidence ofsulphite sensitivity in the general population is low.It has been frequently seen in asthmatic or atopicnon-asthmatic persons. For this reason the authorrecommends, as a precautionary method, that this

Fig. 1.Massive oedema with urticarial rash at the left angle of themouth.

Fig. 2.Twenty-four hours post-treatment.