|LETTER TO EDITOR
|Year : 2018 | Volume
| Issue : 12 | Page : 998-1000
Intraoperative anaphylaxis due to rupture of ascaris lumbricoides
Rajnish Kumar, Abhyuday Kumar, Umesh Kumar Bhadani, Utpal Anand
Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
|Date of Web Publication||10-Dec-2018|
Dr. Rajnish Kumar
Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar R, Kumar A, Bhadani UK, Anand U. Intraoperative anaphylaxis due to rupture of ascaris lumbricoides. Indian J Anaesth 2018;62:998-1000
|How to cite this URL:|
Kumar R, Kumar A, Bhadani UK, Anand U. Intraoperative anaphylaxis due to rupture of ascaris lumbricoides. Indian J Anaesth [serial online] 2018 [cited 2021 Jan 26];62:998-1000. Available from: https://www.ijaweb.org/text.asp?2018/62/12/998/247119
Anaphylaxis during general anaesthesia is a rare and a potentially life-threatening condition. Intraoperative anaphylactic reaction is very rare. It may occur due to anaesthetic drugs or antibiotics. We present a case of a 15-year-old female weighing 43 kg, American Society of Anesthesiologists-1. She was a known case of chronic pancreatitis scheduled for lateral pancreaticojejunostomy. She had no history of drug allergy and received ceftriaxone 1 g intravenously after skin sensitivity test approximately 30 min before surgery.
In the operating room, non-invasive monitors were attached, and after securing intravenous line Ringer's lactate was started. Her baseline vital parameters were normal. Thoracic epidural catheter was inserted at T11–12 intervertebral space in the sitting position followed by a test dose which was negative. General anaesthesia was induced with intravenous (iv) inj. fentanyl 2 μg/kg and iv inj. propofol 80 mg and tracheal intubation was facilitated by giving iv inj. vecuronium. Anaesthesia was maintained with oxygen, air, sevoflurane and vecuronium. Epidural analgesia was given with 0.25% of 10 mL bupivacaine.
The patient developed sudden tachycardia, with a heart rate of 150 beats/min and blood pressure below 80/50 mm Hg approximately 2 h after the start of anaesthesia. As an emergency measure, rapid infusion of Ringer's lactate along with phenylephrine 40 μg twice was given for hypotension. An increase in airway pressure was noted followed by a decrease in oxygen saturation below 70% and bluish discolouration of bowel. Bilateral wheeze was present on auscultation. Oxygen concentration was increased to 100% and inj. hydrocortisone 200 mg was given intravenously. Intraoperatively, many ascaris worms were extracted from the small intestine. After enquiry from the surgeon, it was found that while preparing Roux Y limb for anastomosis by stapling proximal jejunum, a roundworm present in the jejunal lumen was accidentally crushed. During the removal of round worm from the stapler site, it got torn into pieces and the fluid spread into the peritoneal cavity. We thought crushed worm might be a cause of the above event. She received intravenous chlorpheniramine maleate 10 mg once and adrenaline bolus 100 μg thrice in 2 min interval. Her SpO2 gradually increased to 100% and blood pressure increased to 100/60 mm Hg. No other drugs were administered before anaphylactic reaction developed. The trachea was extubated after reversal of neuromuscular blockade. In the postoperative room, again her heart rate was 140/min and blood pressure was below 90/60 mm Hg. Noradrenalin infusion was started at a dose of 5 μg/min and gradually tapered off in 2 h. The total white blood cell count was 30,000 on first operative day. Hence, the antibiotic was changed to piperacillin-tazobactam 4.5 g thrice a day. She was monitored in the intensive care unit for 3 days. Rest of the hospital stay was uneventful.
Ascaris lumbricoides worm commonly infects children and may present as abdominal cramp, loss of appetite, coughing, wheezing and weight loss. In some cases, it may cause cholecystitis, cholangitis, pancreatitis and intestinal obstruction. The presence of specific IgE to ascaris lumbricoides has been associated with higher total IgE levels and more chances of allergic rhinitis and asthma. We could not find a case report of anaphylactic reaction during anaesthesia due to rupture of ascaris lumbricoides. The authors have reported that ascaris lumbricoides excrete a neurotoxin, which produces spasticity conducing to obstruction. The main mechanism of allergic reaction is an abnormal development of T cells into T-helper 2 cells, which increases activation of IgE, mast cells and eosinophils. Intestinal inflammation can be associated with liberation of other toxins including anaphylatoxin, haemolysins and endocrinolysins by worms. Ascariasis may be associated with pulmonary infiltrates with eosinophilia and intraoperative bronchospasm. Allergic reaction due to helminth is a complication. We should be vigilant for possible worm rupture during surgeries. Early diagnosis and intervention are crucial for successful management of anaphylactic reactions if it occurs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Mehta V, Goyal S, Pandit S, Mittal A, Agrawal A. Sonographic diagnosis of Ascaris lumbricoides infestation as a cause of intestinal obstruction. Indian J Pediatr 2010;77:827.
Minciullo PL, Cascio A, David A, Pernice LM, Calapai G, Gangemi G. Anaphylaxis caused by helminths: Review of the literature. Eur Rev Med Pharmacol Sci 2012;16:1513-8.
Mosiello G, Adorisio O, Gatti C, Boeris Clemen F, Dall'Oglio L, Federici di Abriola, G. Ascariasis as a cause of acute abdomen: A case report. Pediatr Med Chir 2003;25:452-4.
Vijayan VK. Tropical parasitic lung diseases. Indian J Chest Dis Allied Sci 2008;50:49-66.