Abstracts should rarely be trusted in isolation. Please see the full article:
Anaphylaxis is a severe multisystemic hypersensitivity reaction. It may include hypotension or airway compromise. Anaphylaxis is a
potentially life-threatening cascade caused by the release of
mediators. Hypersensitivity describes an inappropriate immune response
to generally harmless antigens, whereas anaphylaxis represents the
most dramatic and severe form of immediate hypersensitivity [1].
A 37-year-old woman, who was a nurse but not doing her job during that
time, was admitted to emergency service with abdominal pain at night.
She was experiencing pain for the last 5 hours. She revealed that she
had been followed up for a left ovarian cyst 4 cm in diameter, and at
the day of admission, she was controlled again by her gynecologist,
and the size of the cyst increased to approximately 6.3 cm in
diameter. Before the onset of abdominal pain, she felt nausea
accompanied by vomiting. Pain was all over the abdomen. She did not
complain about diarrhea, constipation, dysuria, and urgency. Her last
menstrual period was started 7 days ago. She was in medication of an
oral contraceptive for only 3 days when she was admitted for pain.
In her medical history, 2 ovarian cyst operations and a laparoscopic
cholecystectomy were noted. She had an atopic background, and she had
experienced allergic reactions after administration of atropine,
radiocontrast drugs, and pheniramine. She had undergone in vitro
fertilization 3 years ago. While she was being treated with hormonal
preparations, she was also given corticosteroids because of atopy
history.
She was orientated and cooperated during physical examination. The
Glasgow Coma Score was 15. Her vital signs were as follows: blood
pressure, 140/80 mm Hg; pulse rate, 100 beats per minute (regular);
respirations, 16/min; and body temperature, 36.7°C. In physical
examination, no pathologic finding was noted except diffuse tenderness
in abdominal palpation all over the abdomen that was more prominent at
the right lower quadrant. She had taken no painkiller at home.
During withdrawal of blood samples, an intravenous catheter was
placed, and isotonic fluid containing metoclopramide was started.
After a few minutes, she complained of vertigo and palpitations. Her
fluid was stopped because pulse rate was 140/min and blood pressure
dropped to 100/60 mm Hg. Auscultation revealed diffuse rhonchi. It was
thought to originate from metoclopramide. To rule out ovarian cyst
rupture, she was examined by the attendant gynecologist who did not
think about an acute gynecologic problem. She underwent radiologic
examinations including abdominal ultrasound and computerized
tomography without radiocontrast to rule out acute appendicitis, and
results were within normal limits.
After she returned to the emergency service, she was started on normal
saline without any medication in it. Some minutes later, she
complained again of palpitations and vertigo with chest distress. She
felt like fainting. Her pulse rate increased to 150/min. She had
erythema over the neck and thorax and rhonchi in the lungs. At that
time, it was thought that these complaints were due to normal saline.
As normal saline infusion was stopped, her complaints improved
immediately. To confirm the diagnosis of normal saline allergy, fluid
was started again. After some minutes, she had same complaints and
findings. With 5% dextrose solution, she had no complaints. After the
pain decreased, she was sent home with recommendations.
Two months after discharge, she brought her child to the emergency
service because of trauma, and she informed that she was operated for
her ovarian cyst in another hospital. Her physicians underrated her
warnings about saline allergy and administered normal saline again,
and she experienced a similar clinical picture. Anaphylaxis is a
severe immediate-type generalized hypersensitivity reaction affecting
multiple organ systems and characterized, at its most severe, by
bronchospasm, upper airway angioedema, and/or hypotension [2]. It has
also been defined simply as “a serious allergic reaction that is rapid
in onset and may cause death” [3]. Allergic reactions to medications
represent a specific class of drug hypersensitivity reactions mediated
by immunoglobulin E [4].
In the literature, we found some case reports about allergic reactions
to intravenous fluids containing maltose and corn-derived dextrose
[5], [6], [7]. However, only one case report was found—anaphylactic
shock against isotonic sodium chloride [8].
In conclusion, every substance or medication, even normal saline, can
cause allergic reactions. So we have to be alert while giving
everything to our patients. Physicians should not neglect and
underrate any adverse reactions that can be attributed to any drug,
and they should be alert and observe their patients for a probable
drug allergy especially during parenteral treatments.
As you can see, although the author clearly infers that the patient's allergy was to normal saline as did she, I can think of TONS of confounders in this one case. Site preparation for vascular access being the number one suspect. It is also possible that she possesses a very rare allergy to one of the plastics in any of the materials used. Also despite manufacturer statements, I've long suspected that there are preservatives and other elements within medications that are not reported as evidenced by patients having allergic reactions to the generic or Brand name versions of the same medication.
