Case Presentation: A 17-year-old female was admitted for L4-L5 discectomy. Following intubation, the patient developed hypotension and facial edema one minute after administration of cefazolin and 30 minutes after administration of rocuronium, fentanyl, lidocaine, and propofol. She was treated with intravenous epinephrine bolus and drip, fluids and steroids, followed by PICU admission. Serum tryptase level obtained during the hypotensive episode was 55 mcg/L; drug-induced anaphylaxis was initially suspected; however, allergy consultation elicited a history of hives and sneezing with exposure to low temperatures (showers, cold foods and drinks), raising the possibility of cold-induced anaphylaxis precipitated by low temperature in the OR and infusion of cold fluids. She recovered promptly and was discharged from the hospital within 24 hours with allergy outpatient evaluation recommended for 4-6 weeks later.
Discussion: Antibiotics like cefazolin remain the most common cause of peri-operative anaphylaxis, identified in 40-55% of reactions. Our patient had no prior drug allergy but reported immediate allergic symptoms triggered by exposure to cold. Approximately a third of patients with cold-induced urticaria experience anaphylaxis, usually in the setting of whole-body cooling, e.g., rapid immersion in cold water. In patients with cold-induced urticaria, avoidance of cooling and infusion of warm fluids during peri-operative period is necessary to ensure normothermia. Following 4-6 weeks of potential refractory period, a complete allergy evaluation, including drug and ice cube testing, should be performed
Conclusions: Peri-operative anaphylaxis occurs in 1:7000-1:10,000 surgical cases. Antibiotics and neuromuscular agents are the most often identified triggers; the inciting agent remains unknown in 30-50% if cases. It is important to recognize, treat and prevent cold-induced anaphylaxis in the peri-operative setting.