Coma resulting from a grade IV anaphylactic reaction to atracurium

We report a grade IV anaphylactic reaction to atracurium. A 51-year-old woman was scheduled for an elective laparoscopic fibroidectomy. Her past medical history was negative for allergies, previous anaphylactic or anaphylactoid reactions, and acute or chronic diseases and she had no current symptoms. Atracurium injection evoked an immediate respiratory arrest and neck edema, hindering intubation. An emergency tracheotomy was performed, resulting in significant hemorrhage, shock and hypoxic coma. The diagnosis of anaphylaxis to atracurium was confirmed by an allergy investigation. This case report stresses the fact that acutely severe anaphylactic reactions can occur without typical skin or cardiac symptoms. Furthermore, low risk patients with a bland medical history are never exempt from the risk of anaphylactic shock, even with a designated low-risk agent of sensitization.