Allergy to gelatin

ON 27 March 1998, a 28-year-old man was admitted to the neurosurgery clinic of the University of Messina (Italy) for bilateral back pain with a left prevalence, which had begun about 2 months before. Therefore, before admission, he underwent conventional anti-in ̄ammatory and analgesic treatment without result, and acupuncture and physiokinesis therapy with moderate results. A month before admission, in view of the accentuation of symptoms, the patient underwent magnetic resonance imaging and computerized axial tomography. These methods detected a median posterior hernia at the L3±L4 level. The consultant neurosurgeon advised surgery. An operation by the L3±L4 left interlaminar approach was carried out on 7 April 1998. At 24 h after surgery, the patient References 1. ROMANO A, PIETRANTONIO F, DI FONSO M, et al. Positivity of patch tests in cutaneous reaction to diclofenac. Allergy 1994;49:57±59. 2. SCHAAD HJ, ZURCHER RM. Erythema and fever after diclofenac i.m. Ther Umsch 1998;55:586±588. 3. MACKOWIACK PA, LE MAISTRE CF. Drug fever: a critical appraisal of conventional concepts. Ann Intern Med 1987;106:728±733. 4. KUMAR KL, REULER JB. Drug fever. West J Med 1986;144:753±755. 5. GARCIÂA JM, GONZALO MA, ALCALDE MM. Successful desensitization of a fever induced by mesalazine. Allergy 1999;54 Suppl 52:201. ®rst complained of tingling of the lower limbs and, subsequently, paresis and complete bilateral de®cit of foot dorsi ̄exion. Therefore, he underwent repeated magnetic resonance imaging of the lumbosacral spine, and this showed dural sac L3±L4 compression because of the edematous reaction of the soft tissues. A subsequent allergy consultation led to the suspicion of an allergic reaction to a hemostatic gelatin sponge (Spongostan, Ferrosan, Denmark) placed at the end of surgery at the site of the wound. Therefore, the patient underwent disruption of the wound, cleansing of the phlogistic focus, removal of the Spongostan, and biopsy. The biopsy examination, carried out on a specimen obtained from the dural sac compression zone, showed the presence of phlogistic in®ltration, mainly by eosinophils, neutrophils, and histiocytes, together with chips of the gelatin sponge. After removal of the Spongostan, there was a gradual and rapid improvement of the neurologic objectiveness, supported by courses of daily rehabilitative physiokinesiotherapy. The patient was discharged on 2 May 1998. After 2 months, the patient returned for a checkup, during which patch tests were carried out with the International Contact Dermatitis Research Group (ICDRG) series (True Test, Pharmacia, Milan, Italy) and an extemporaneous preparation consisting of a dilution in vaseline of the gelatin sponge. The patch tests were scored at 48 and 72 h by the 1+ to 3+ system recommended by the ICDRG. They proved to be highly positive for gelatin (+++) at 48 h, and negative for the other substances. Absorbable gelatin sponges have been used for many years either as a wounddressing material (1) or for transcatheter arterial embolization in the treatment of various disorders (2). In recent years, cases of immediate-type allergic reaction caused by gelatin present in the vaccines (3) or in the recombinant human erythropoietin (4) have been reported in which speci®c IgE to gelatin was found in the sera of the patients. It has also been shown that there is a possibility of delayed-type hypersensitivity to gelatin, consisting of granulomatous arteritis with massive eosinophil leukocyte in®ltration subsequent to transarterial embolization therapy with a gelatin sponge (5). We describe here an adverse reaction subsequent to the application of a gelatin sponge, at the end of surgery for a disk hernia, at the site of the wound. The clinical course, the biopsy ®ndings, and the high positivity to the speci®c patch test suggest either a causative role of the gelatin or a pathogenic mechanism of delayed-type hypersensitivity. Our case represents the ®rst report of lower limb paresis by dural sac compression related to an allergic reaction to gelatin. Lastly, since the number of operations for disk hernia is very high and gelatin sponges are used frequently as hemostat, such an allergic reaction should always be taken into consideration.