A 51-year-old male patient, weighing 64 kg, visited our outpatient department with the chief complaint of redness and swelling on the right side of the face that had occurred 3 h after a tooth extraction at another dental clinic. Furthermore, the patient complained of continuous throbbing pain associated with difficulty in chewing food and reduced mouth opening. There was no history of systemic illness. On examination, his vitals were stable; extra-orally, diffuse swelling was noted on the right side of the face along with erythema involving the right cheek, chin, and neck region (). The patient had no other symptoms except for mild itching associated with the erythema. Intra-orally, edema was noted around the unhealed socket of 48. Cone-beam computer tomography revealed a 48 root stump. Considering the patient’s history and examination findings, he was transferred to the Department of Dermatology to rule out any allergic reaction/allergen sensitivity before commencing any definitive treatment (surgical extraction of 48) under local anesthesia.\nSkin prick and intradermal tests were performed using the HollisterStier grading system (Allergy Skin Test Guide/HollisterStier - Sliding Guide Miles []) with five LAs: lidocaine, procaine, articaine, bupivacaine, and ropicaine. Wheel-and-flare reaction was noted only to lidocaine (). Therefore, procaine, with a duration of action shorter than that of lidocaine, was used as the LA for performing the surgical extraction of 48. Continuous monitoring of all vitals was performed for 3 h, and no signs of hypersensitivity were noted. Patient was discharged few hours after the procedure; he was instructed to self-monitor the symptoms and report to the emergency department in case of any symptoms or discomfort.
A 54-year-old man presented to the hospital with dyspnea after inhaling butane gas while melting a water pipe during winter. On physical examination, late inspiratory crackles were evident in both auscultated lower lung fields. His history showed no lidocaine allergy, allergic rhinitis, asthma, or allergies to other drugs. On examination, blood pressure was 125/75 mmHg, pulse was 65 beats per minute, oral temperature was 36.5℃, respiratory rate was 18 breaths per minute, oxygen saturation was 76.0%, pH was 7.27, PaO2 was 46.0 mmHg, and PaCO2 was 47.2 mmHg, as the patient breathed ambient air. Total IgE was 129 kU/L. An electrocardiogram revealed a normal sinus rhythm. A pulmonary function test revealed forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) of 78%, FVC of 2.24 L (60%), FEV1 of 1.75 L (62%), and a diffusing capacity for carbon momoxide of 15.1 mL/mmHg (71%) indicating a restrictive pattern. Chest radiographs revealed bilateral patchy opacities, more in the right lung than in the left lung. Computed tomography of the chest revealed multifocal consolidation and ground-glass opacities in all lobes of both lungs, indicating an acute inhalation lung injury (). The patient recovered after oxygen and supportive care. On the fifth day, we planned to conduct a bronchoscopy to diagnose an inhalational lung injury. We used lidocaine aerosol as local anesthesia for reducing the gag reflex. After administering the lidocaine anesthesia, the patient complained of dizziness without urticaria and angioedema and shortness of breath, which was associated with an increased respiratory rate and decreased oxygen saturation. Coarse expiratory wheezes were auscultated on a physical examination. Blood pressure subsequently dropped, and a radial pulse was not palpable. The patient was treated with nebulized salbutamol and systemic steroid. However, the patient did not recover, and blood pressure continued to decrease accompanied by an increase in respiratory rate and a decrease of oxygen saturation () followed by cardiorespiratory arrest. Cardiopulmonary resuscitation (CPR) with epinephrine, inotropics, and fluid therapy was performed immediately, and the patient was admitted to the intensive care unit under tracheal intubation and ventilator treatment. After 2 hours, his CPR tryptase level was 1.68 µg/L. He was extubated safely on the third post-CPR day.