|Year : 2019 | Volume
| Issue : 2 | Page : 72-74
Rose and Life: Anaphylaxis Following Rose-Thorn Prick Injury
Neeraj Kumar1, Amarjeet Kumar1, Sanjeev Kumar2
1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, India
2 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Patna, India
|Date of Submission||22-Jan-2019|
|Date of Acceptance||18-Mar-2019|
|Date of Web Publication||27-Sep-2019|
Dr. Amarjeet Kumar
Room No 503, Hostel No 11, AIIMS Campus, Patna, Bihar
We report a case of rose-thorn prick injury in a 60-year-old woman. She presented within hours of exposure to rose-thorn prick and after ruling out all other possible reasons of anaphylaxis. We initiated conservative mode of treatment with moist oxygen inhalation through face mask, nebulized adrenalin, intravenous corticosteroids, antihistaminic, and fluid resuscitation. She was immediately shifted to the intensive care unit in view of any airway obstruction and further hemodynamic monitoring. To the best of our knowledge, this is the first reported case of anaphylactic shock caused by rose-thorn injuries. Hence, to combat these life-threatening situations, proper education and training are given to healthcare personnel's and preparation of pre-filled adrenaline syringes for auto-injection should be kept ready in such places, especially in resuscitation areas.
Keywords: Anaphylaxis, dermatitis, rose-thorn prick
|How to cite this article:|
Kumar N, Kumar A, Kumar S. Rose and Life: Anaphylaxis Following Rose-Thorn Prick Injury. J Transl Crit Care Med 2019;1:72-4
| Introduction|| |
Dermatosis caused by plants is relatively common and may occur by various pathogenic mechanisms. Dermatitis due to physical trauma, pharmacological action, irritation, sensitization, mediated by IgE, and induced by light are most commonly encountered. Some plants have their own defense mechanisms in the form of true thorns, pointed leaves, prickles that may injure the skin on direct contact, such as when plants are manipulated or by accident without skin protection. Many plants can provoke urticaria or eczema after contact with the skin through an IgE-mediated mechanism. Proteins present in these plants trigger this reaction. This type of dermatitis (protein contact dermatitis) is often restricted to the skin areas that entered in contact with plants, but respiratory and digestive systemic symptoms may occur (contact urticaria syndrome). Atopic individuals are predisposed to contact urticaria. Pruritus, erythema, edema, and sometimes vesicles appear 30 min after contact.
Angioedema is a serious and potentially life-threatening anaphylaxis reaction. There are many potential triggers for anaphylaxis. Rose-thorn injuries have not been previously reported as a trigger for an acute allergic reaction with angioedema. The thorn on a rose stem provides an excellent device for injecting infectious material into our skin. Plant thorn injuries (pinprick or penetrating) have been associated with a number of bacterial and fungal infections. Infections caused by Enterobacter agglomerans, Sporothrix schenckii, and Actinomycosis produces a sinus that discharges sulfur granules., We report a case of type 1 hypersensitivity reaction to rose thorn.
| Case Report|| |
A 60-year-old woman admitted to the resuscitation area of our institute with chief complaints of difficulty in breathing, tongue swelling, and severe pain of the left upper extremities. On physical examination, a 1.5 cm × 1.2 cm-sized swelling, erythema, urticarial rash, pustular discharge with induration, and marked tenderness over the posterolateral aspect of the left forearm [Figure 1] was seen. A plain radiograph was advised which showed a normal impression, with no evidence of any periosteal reaction or synovitis. The vitals at the time of admission was heart rate 110 bpm, blood pressure 80/30 mm Hg, Spo2 >89% at room air and respiratory rate (RR) 38/min, and her body temperature was 38.0°C. She had a history of rose-thorn prick injury over the forearm. She had no relevant personal history of any atopy.
|Figure 1: Arrow showing site of rose-thorn pricking over the left forearm|
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All urgent laboratory investigations were immediately ordered. Apart from raised total leukocyte count (TLC) (23,000/mm 3), C-reactive protein (CRP) (12.0 mg/dL), erythrocyte sedimentation rate (ESR) (25 mm/h), and serum tryptase (48 μg/L), rest all other routine investigations were within the normal limits. We have started treatment with moist oxygen inhalation through face mask, nebulized adrenalin, intravenous corticosteroids, antihistaminic, fluid resuscitation, and antibiotic therapy with 1.5 g ceftriaxone-sulbactam two times daily, and Metronidazole 100 mL intravenously three times daily was started empirically.
After 48 h of intensive care treatment her TLC count dropped to (11,000/mm 3), CRP (6 mg/dL), ESR (35 mm/h), and serum tryptase value to 3 μg/L (standard value <11.4 μg/L) with marked decrease in swelling, erythema, and redness over the left forearm.
We contend that our patient may have an allergic anaphylactic reaction because she had mucosal and skin findings as she presented within hours of “exposure,” with rose-thorn prick and also we have not identified any causative food or drug for the possible reason of anaphylaxis. She was then shifted to the intensive care unit (ICU) in view of any airway obstruction and further observation. She was discharged 72 h later with improvement in her tongue and upper limb swelling and with no recurrent allergic symptoms from the ICU.
| Discussion|| |
The thorn injury causes a local inflammatory reaction that can last for a long time even when plant thorn is removed from the site of the injury and histological examination of the tissue suggested a strong inflammatory reaction with granulation tissue. In cases where the thorn was not observed (as in our case) in the tissue, necrotic and granulation tissue could be seen that contained aggregations of mononuclear cells. Anaphylaxis is a severe, potentially fatal, systemic allergic reaction that occurs suddenly after contact with allergy-causing agents like substance. The venom injected during stinging by insects, such as bees and ants, is a very common allergy-causing substance leading to severe life-threatening conditions have been reported. Thorn fragment can causes Type 1 hypersensitivity reactions in the form of anaphylaxis, urticaria, and angioedema. Type 1 reactions are mediated by mast cells degranulation with release of mediators such as histamine and slow reacting substance (SRS-A). A stinging by crown-of-thorns starfish Acanthaster planci venom causes anaphylaxis leading to death have been reported.
Rose-thorns prick causes foreign body reaction can lead to chronic tenosynovitis, bursitis, and aseptic monoarticular synovitis in relation to the site of the puncture. The thorn fragments cannot be phagocytosed during the initial inflammatory response resulting in their encapsulation and a granulomatous response.
In our case, we report Type 1 hypersensitivity reaction in the form of hypotension, tachycardia, tongue swelling, urticarial, and pustular lesion over the left forearm following rose-thorn injury. Degranulation of mast cell was confirmed by elevated serum tryptase levels. Hence, to save lives, we need to provide education regarding prevention and enabling prompt response to possible anaphylaxis, including preparation of adrenaline for auto-injection, especially in resuscitation areas to combat these life-threatening situations.
| Conclusion|| |
The possibility of penetrating injury with plant material should always be considered, and careful attention to the history of injury must be made. As this case demonstrates, avoidance of contact with the rose thorn is important to avoid injury. For the diagnosis and classification of anaphylaxis reaction, complete and accurate history of exposures before an anaphylactic episode must be obtained. To the best of our knowledge, this is the first case of anaphylactic shock caused by rose-thorn injuries reported in the literature.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that her names and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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