Allergy Asthma Immunol Res.  2009 Oct;1(1):48-50. 10.4168/aair.2009.1.1.48.

Acute urticaria caused by the injection of goat-derived hyaluronidase

• Kim JH
• Choi GS
• Ye YM
• Nahm DH
• Park HS

• KMID: 2133800
• DOI: http://doi.org/10.4168/aair.2009.1.1.48

Abstract

Hyaluronidase is a goat testicular protein that hydrolyzes hyaluronic acid, a structural component of the intercellular matrix. It is commonly used as a spreading factor to improve the diffusion of drugs, including local anesthetics and chemotherapeutics. We experienced a 55-yr-old female with generalized urticaria that developed within 1 hr after the epidural injection of hyaluronidase. She had a history of allergic rhinitis, and had suffered from post-herpetic neuralgia and a herniated disc for several years. To relieve her pain, she had been given epidural injections consisting of mepivacaine hydrochloride, triamcinolone acetonide, and morphine sulfate biweekly for one year. Hyaluronidase had been administered several times with these drugs before this episode of generalized urticaria. Skin prick testing showed a positive response to 1,500 IU/mL of hyaluronidase extract, as compared to histamine. The patient's serum hyaluronidase-specific IgE level, determined using an enzyme-linked immunosorbent assay (ELISA), was markedly elevated, as compared to unexposed healthy controls. An IgE immunoblot analysis using hyaluronidase extract and the patient's serum showed IgE binding components at 31 and 21 kDa, whereas no corresponding IgE binding component was found in healthy controls. An ELISA inhibition test showed significant, dose-dependent inhibition with the serial addition of hyaluronidase extract. This is the first case of an IgE-medicated allergic reaction to goat (Naemorhedus goral raddenus) hyaluronidase, demonstrated by skin testing and a specific IgE and immunoblot assay.

Keyword

hyaluronidase; urticaria; IgE-mediated hypersensitivity

MeSH Terms

Anesthetics, Local
Diffusion
Enzyme-Linked Immunosorbent Assay
Female
Goats
Histamine
Humans
Hyaluronic Acid
Hyaluronoglucosaminidase
Hypersensitivity
Hypersensitivity, Immediate
Immunoglobulin E
Injections, Epidural
Intervertebral Disc Displacement
Mepivacaine
Morphine
Neuralgia
Polysaccharide-Lyases
Rhinitis
Rhinitis, Allergic, Perennial
Skin
Skin Tests
Triamcinolone Acetonide
Urticaria
Anesthetics, Local
Histamine
Hyaluronic Acid
Hyaluronoglucosaminidase
Immunoglobulin E
Mepivacaine
Morphine
Polysaccharide-Lyases
Triamcinolone Acetonide

Figure

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  Fig. 1 Hyaluronidase-specific IgE serum levels, as determined using an enzyme-linked immunosorbent assay (ELISA), in the sensitized patient and 14 normal controls (A). Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and IgE immunoblot analysis of hyaluronidase (B) in serum from the sensitized patient (P), a healthy control (N), and a buffer control (B).

Reference

1. Girish KS, Kemparaju K. The magic glue hyaluronan and its eraser hyaluronidase: a biological overview. Life Sci. 2007. 80:1921–1943.

2. Stern R. Hyaluronidases in cancer biology. Semin Cancer Biol. 2008. 18:275–280.

3. Szepfalusi Z, Nentwich I, Dobner M, Pillwein K, Urbanek R. IgE-mediated allergic reaction to hyaluronidase in paediatric oncological patients. Eur J Pediatr. 1997. 156:199–203.

4. Escolano F, Pares N, Gonzalez I, Castillo J, Valero A, Bartolome B. Allergic reaction to hyaluronidase in cataract surgery. Eur J Anaesthesiol. 2005. 22:729–730.

5. Feighery C, McCoy EP, Johnston PB, Armstrong DK. Delayed hypersensitivity to hyaluronidase (Hyalase) used during cataract surgery. Contact Dermatitis. 2007. 57:343.

6. Leibovitch I, Tamblyn D, Casson R, Selva D. Allergic reaction to hyaluronidase: a rare cause of orbital inflammation after cataract surgery. Graefes Arch Clin Exp Ophthalmol. 2006. 244:944–949.

7. Kempeneers A, Dralands L, Ceuppens J. Hyaluronidase induced orbital pseudotumor as complication of retrobulbar anesthesia. Bull Soc Belge Ophtalmol. 1992. 243:159–166.

8. Avellanal M, Diaz-Reganon G. Interlaminar approach for epiduroscopy in patients with failed back surgery syndrome. Br J Anaesth. 2008. 101:244–249.

9. Schulze C, Bittorf T, Walzel H, Kundt G, Bader R, Mittelmeier W. Experimental evaluation of hyaluronidase activity in combination with specific drugs applied in clinical techniques of interventional pain management and local anaesthesia. Pain Physician. 2008. 11:877–883.

10. Delaere L, Zeyen T, Foets B, Van Calster J, Stalmans I. Allergic reaction to hyaluronidase after retrobulbar anaesthesia: a case series and review. Int Ophthalmol. 2008.

11. Andre P, Flechet ML. Angioedema after ovine hyaluronidase injection for treating hyaluronic acid overcorrection. J Cosmet Dermatol. 2008. 7:136–138.