This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Levy, J. H. Search for Related Content PubMed PubMed Citation Articles by Levy, J. H.

---

LETTER TO THE EDITOR

Skin Testing Performed in Individuals Cannot be Compared with Responses from Anaphylactic Patients

Emory University School of Medicine; Department of Anesthesiology; Atlanta, GA; jlevy1{at}emory.edu

In Response:

Dewachter et al.1 suggest specific concerns are warranted regarding the interpretation of skin tests with neuromuscular blocking agents (NMBAs) based on my comments. They note the studies I cite in my review were performed in control patients who did not experience an immediate hypersensitivity reaction and suggest that skin tests only refer to the histamine release properties induced by NMBAs.2 My comments only relate to false positive skin tests that occur with NMBAs that complicate interpretation of skin tests, but in no way invalidate the use of skin testing as a tool to evaluate patients after anaphylactic reactions assuming correct dilutions of agents are used. Dewachter is incorrect in noting positive skin tests are entirely related to histamine release because the steroidal derived agents can cause false positive cutaneous responses independent of histamine release.3,4 We also noted opioid mediated cutaneous responses with fentanyl and sufentanil unrelated to histamine release.5 False positive skin tests are part of the problem when skin testing, and further emphasize the need to ensure appropriate dilutions. Please note that my review never suggested skin testing performed in patients with a history of immediate hypersensitivity reactions was not reliable. Unfortunately, skin testing may not identify the pathophysiological mechanism of the reaction, the culprit allergen if a false positive response occurs. Although potential crossreactivity can occur among the NMBAs due to similarities of structures, skin testing is widely used to determine the potential culprit agent responsible for the reaction. However, skin testing must be performed at appropriate dilutions to avoid a false positive responses, this was the point of a prior editorial.6 Finally, I am confused by the last statement of the authors suggesting the "the results of skin tests performed in individuals cannot and should not be compared with anaphylactic patients." This seems at odds with your earlier comments.

REFERENCES

1. Dewachter P, Monton Faivre C. Skin testing performed in individually cannot be compared with responses from anaplylactic patients. Anesth Analg 2008;107:XXX
2. Levy JH, Adkinson NF Jr. Anaphylaxis during cardiac surgery: implications for clinicians. Anesth Analg 2008;106:392–403[Abstract/Free Full Text]
3. Levy JH, Adelson D, Walker B. Wheal and flare responses to muscle relaxants in humans. Agents Actions 1991;34:302–8[Web of Science][Medline]
4. Levy JH, Gottge M, Szlam F, Zaffer R, McCall C. Weal and flare responses to intradermal rocuronium and cisatracurium in humans. Br J Anaesth 2000;85:844–9[Abstract/Free Full Text]
5. Levy JH, Brister NW, Shearin A, Ziegler J, Hug CC Jr, Adelson DM, Walker BF. Wheal and flare responses to opioids in humans. Anesthesiology 1989;70:756–60[Web of Science][Medline]
6. Levy JH. Anaphylactic reactions to neuromuscular blocking drugs: are we making the correct diagnosis? Anesth Analg 2004;98:881–2[Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Levy, J. H. Search for Related Content PubMed PubMed Citation Articles by Levy, J. H.