Anaphylactic-like reaction to methylene blue: case report and review of perioperative hypersensitivity reactions

Plast Reconstr Surg. 2012 Jul;130(1):98e-105e. doi: 10.1097/PRS.0b013e318254b2b8.


Background: Anaphylaxis and anaphylactic-like reactions in the perioperative period are a significant concern for anesthesiologists and surgeons. With an incidence as high as one in 3500 and a mortality rate of 3 to 6 percent, proper management of these reactions is essential. The available surgical literature provides varied and unclear guidelines for determining the nature of these reactions and has no consensus treatment algorithm. The authors present a rare case of hypersensitivity reaction to methylene blue during cleft lip repair. A review of current literature for best-practice evaluation and management guidelines follows.

Methods: Literature review was performed using search terms including "anaphylaxis," "hypersensitivity," "allergy," "perioperative," and "intraoperative." Results from basic science literature, case reports, and clinical studies were used, as were personal communications with leading investigators in allergy and immunology.

Results: Despite variations in incidence, reporting, evaluation, and management, the authors found that immediate treatment should include epinephrine, steroids, and histamine-1- and histamine-2-blocking agents. In the event of reactions with characteristics of anaphylaxis, obtaining tryptase levels 1, 4, and 24 hours after the event provides the most accurate biochemical evidence. Skin-prick and intradermal testing by an allergy specialist should be performed 6 or more weeks after the reaction.

Conclusions: With the unique exposure risks in the perioperative period, it is the surgeon's responsibility to aid in the proper immediate and short-term treatment of anaphylaxis and anaphylactic-like reactions. Proper biochemical evaluation at the time of reaction can be critical in helping the patient avoid future reactions and should not be overlooked.

Clinical question/level of evidence: Therapeutic, V.

Publication types

  • Case Reports

MeSH terms

  • Anaphylaxis / chemically induced*
  • Anaphylaxis / immunology
  • Anatomic Landmarks
  • Cleft Lip / diagnosis
  • Cleft Lip / surgery*
  • Drug Hypersensitivity / complications*
  • Drug Hypersensitivity / immunology
  • Enzyme Inhibitors / adverse effects
  • Follow-Up Studies
  • Humans
  • Infant, Newborn
  • Male
  • Methylene Blue / adverse effects*
  • Plastic Surgery Procedures / methods*
  • Preoperative Period
  • Skin Tests


  • Enzyme Inhibitors
  • Methylene Blue