Journal of Allergy and Immunology

Case Report Open Access

Twenty minutes after administration of the ocular drops, the Anaphylaxis after First Exposure to patient developed conjunctival erythema and facial flushing as well as Ophthalmic Cyclopentolate 1% angioedema (Figure 1). It was followed with respiratory distress and wheezing. The patient was transferred to the adjacent emergency room. She had a heart rate of 185 beats per minute, respiratory rate of 30 per Alexandra Langlois* and Moshe Ben Shoshan minute, blood pressure of 121/66 mmHg and saturation of 100%. She was Division of Pediatric Allergy and Immunology, Department of Pediatrics, treated with intramuscular epinephrine 0,01 mg/kg, diphenhydramine Montreal Children’s Hospital, McGill University Health Center, Canada 1mg/kg and prednisolone 1mg/kg. Both eyes were flushed with normal *Corresponding author: Alexandra Langlois, saline. Following treatment there was rapid resolution of symptoms. Email: [email protected] She was monitored in the Emergency Department for four hours and was discharged home. Tryptase levels drawn after arrival to the Received: 23 December 2016; Accepted: 03 February 2017; Published: 15 February 2017 emergency department were within the normal limits (5.3mcg/L normal range: 0.0-13.5 mcg/L). A month later she was assessed in the Allergy clinic. The tryptase was repeated and was 4.8 mcg/L (normal range: Abstract 0.0-13.5 mcg/L). This does not represent a significant variation. Skin Rationale: Cyclopentolate is a synthetic antimuscarinic drug that prick test with a 1% cyclopentolate hydrochloride at a dilution of 1/10 in has been used commonly since 1950 as a mydriatic topical agent in normal saline was positive (wheal and erythema size: 4 mm and 10 mm ophthalmologic procedures. The most commonly used 1% solution respectively. Wheal and erythema size for negative control (saline) and induces very few side effects with the exception of symptoms related positive control (histamine) were 0/0 and 5/10 respectively). to its pharmacologic properties. We report a case of infant presenting The parents were advised to avoid cyclopentolate and have a with anaphylaxis shortly after topical administration of cyclopentolate bracelet indicating her hypersensitivity. 1% for cycloplegic refraction and dilated fundus exam. Discussion Methods: Skin prick tests were performed with 1% cyclopentolate hydrochloride at a dilution of 1/10 in normal saline, negative control Toxic effects related to pharmacologic properties of antimuscarinic (saline) and positive control (histamine). topical agents are well described in the literature and include tachycardia, hypertension, flushing and potentially effects on the central Results: This patient presented to emergency department with nervous system such as hallucinations, ataxia, dysarthria and confusion. anaphylaxis shortly after topical administration of cyclopentolate 1% However, IgE-mediated reactions to cyclopentolate have been described for cycloplegic refraction and dilated fundus exam in Ophthalmology so far in only 2 papers [1,2]. Given the frequent use of this topical clinic. She presented conjunctival erythema, facial flushing and agent it is crucial to be aware of the diagnosis and management of IgE- angioedema. This was followed with respiratory distress and mediated reactions to cyclopentolate. wheezing. Both eyes were flushed with saline and she received a standard anaphylaxis treatment including epinephrine. Skin prick test The reaction presented by our patient fulfills the consensus definition with a 1% cyclopentolate hydrochloride 1/10 dilution was positive of anaphylaxis [3-5]. The positive skin test conducted according with wheal and erythema size: 4 mm and 10 mm respectively. Wheal to a previously validated protocol [1] provides a safe and reliable and erythema size for negative control and positive control were 0/0 confirmatory test for the diagnosis of cyclopentolate allergy. Topical and 5/10 respectively. cyclopentolate drops gain entrance to the systemic circulation within minutes of application by absorption through the cornea, conjunctiva, Conclusions: This is one of the rare case reports of cyclopentolate nasolacrimal mucosa and gastrointestinal tract [6]. Our patient reacted anaphylaxis. Although it is commonly used in clinical practice, there is on first exposure to cyclopentolate and had never been in contact with not much awareness of the allergenic potential of this agent. Clinicians other antimuscarinic agents. However, lack of prior known exposure and in particular ophthalmologists should be aware of the risk of IgE- does not rule out the possibility of an IgE-mediated reaction. It is not mediated reactions associated with the use of topical cyclopentolate. clear what is the underlying mechanism for reactions occurring after first exposure but the clinical presentation and the improvement with prompt Keywords: Cyclopentolate hydrochloride; Antimuscarinic epinephrine treatment as well as subsequent positive confirmatory drug; Anaphylaxis; Type 1 hypersensitivity; IgE-mediated allergy; skin test are sufficient to define this reaction as cyclopentolate induced Adverse drug reaction Background Cyclopentolate is a synthetic antimuscarinic drug that has been used commonly since 1950 as a mydriatic topical agent in diagnostic procedures [1,2]. During this time very few side-effects have been reported with the most commonly used 1% solution [2]. However, more recently a few case reports suggest that IgE-mediated reactions to topical 1% solution of cyclopentolate may occur [1,2]. We report a case of infant presenting with anaphylaxis shortly after topical administration of cyclopentolate 1% for cycloplegic refraction and dilated fundus exam. Case Presentation Figure 1: The patient developed conjunctival erythema, facial An 11-month-old girl was assessed due to suspected strabismus in flushing and angioedema. the Ophthalmology clinic in our hospital. There was no past history of atopy and this was her very first exposition to cycloplegic medication. She was administered cyclopentolate hydrochloride 1% ocular drops Copyright © 2017 The Authors. Published by Scientific Open Access Journals LLC. in both eyes. Langlois and Ben Shoshan Volume 1, Issue 1 J Allergy Immunol 2017; 1:004 anaphylaxis [7-9]. Similar to other cases of anaphylaxis, the main 2. Jones LW, Hodes DT. Possible allergic reactions to cyclopentolate treatment is prompt administration of intramuscular epinephrine. hydrochloride: case reports with literature review of uses and adverse reactions. Ophthalmic Physiol Opt. 1991; 11:16-21. In conclusion, the case described exemplifies challenges related to diagnosis and management of cyclopentolate induced allergic 3. Simons FE, Ardusso LR, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF, et al. World Allergy Organization Anaphylaxis Guidelines: 2013 update of reactions. Although it is commonly used in clinical practice, there is the evidence base. Int Arch Allergy Immunol 2013; 162:193-204. not much awareness of the allergic potential of this agent. Clinicians and in particular ophthalmologists should be aware of the risk of IgE- 4. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF, Jr., Bock mediated reactions associated with the use of topical cyclopentolate. SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report--second National Institute of Allergy and Consent Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006; 47:373-380. Written informed consent was obtained from the patient for 5. Ben Shoshan M, Clarke AE. Anaphylaxis: past, present and future. Allergy. publication of this case report and accompanying image. A copy of 2010; 66: 1-14. the written consent is available for review by the Editor-in-Chief of this journal 6. Lahdes K, Huupponen R, Kaila T, Salminen L, Iisalo E. Systemic absorption of ocular scopolamine in patients. J Ocul Pharmacol. 1990; 6:61-66. Conflict of Interests 7. Saritas A, Erbas M, Gonen I, Candar M, Ozturk O, Kandis H, et al. Asystole The author(s) declare that they have no competing interests. after the first dose of ceftriaxone. Am J Emerg Med. 2012; 30:1321.e3-4. 8. Ernst MR, van Dijken PJ, Kabel PJ, Draaisma JM. Anaphylaxis after first References exposure to ceftriaxone. Acta Paediatr 2002; 91:355-356. 1. Tayman C, Mete E, Catal F, Akca H. Anaphylactic reaction due to 9. Adriaensens I, Vercauteren M, Soetens F, Janssen L, Leysen J, Ebo D. cyclopentolate in a 4-year-old child. J Investig Allergol Clin Immunol. Allergic reactions during labour analgesia and caesarean section anaesthesia. 2010; 20:347-348. Int J Obstet Anesth. 2013; 22:231-242.

Citation: Langlois A, Shoshan MB. Anaphylaxis after First Exposure to Ophthalmic Cyclopentolate 1%. J Allergy Immunol 2017; 1:004.