Blue Dye Leading to Blue Eyelids: Anaphylaxis after Sentinel Node Biopsy

Special Article - Surgical Case Reports

Austin J Surg. 2015;2(1): 1050.

Blue Dye Leading to Blue Eyelids: Anaphylaxis after Sentinel Node Biopsy

Vugts G1*, Den Ouden MM2, Koning TJJ2 and Maaskant-Braat AJG1

1Department of Surgery, Catharina Hospital, Eindhoven, Netherlands

2Department of Anesthesiology, Catharina Hospital, Eindhoven, Netherlands

*Corresponding author: Guusje Vugts, Catharina Hospital, Department of Surgery Postbus 13505602 ZA Eindhoven, Netherlands

Received: November 17, 2014; Accepted: January 05, 2015; Published: January 07, 2015


Blue dye is used to facilitate Sentinel Node Biopsy (SNB) in breast cancer patients. Hypersensitivity reactions to this blue dye are reported in up to 2.7% of patients. A very rare presentation is the occurrence of anaphylactic shock with blue palpebral angioedema after injection of blue dye. Anaphylaxis is a known cause for the development of angioedema, but blue coloring of the skin appears extraordinary. The blue palpebral angioedema appears to be explained by a systemic effect of the blue dye.

Keywords: Sentinel node biopsy; Breast cancer; Patent blue V; Anaphylactic shock


Anaphylactic reactions to Patent Blue V (PBV), a dye used to facilitate sentinel node biopsy (SNB) in breast cancer patients, are reported in 0.06-2.7% of the patients [1,2]. These reactions vary from cutaneous hypersensitivity manifestations (grade I hypersensitivity reactions) to anaphylaxis with hemodynamic instability (grade III hypersensitivity reactions) [2,3]. Rare presentations however do occur. We describe a case of blue palpebral angioedema after SNB with PBV.

Case Report

A 41-year-old woman presented at the surgical outpatient clinic with a right-sided nipple retraction. She did not report any other complaints of the breast and no palpable masses or clinically enlarged lymph nodes were detected at physical examination. Her medical history did not reveal any relevant comorbidities. Also, the patient had no known food or drug allergies. Mammography and ultrasound of the right breast showed multiple masses in the medial upper and lower quadrant, suspect for multifocal breast cancer. The 14G needle biopsy contained invasive ductal carcinoma. A Sentinel Node Biopsy (SNB) was performed, for definitive nodal staging prior to mastectomy and oncoplastic reconstruction. One day preoperative, 99m technetium-nanocolloid (Tc-99) was injected peritumoral and a sentinel node was visualized in the ipsilateral axilla. The SNB was performed under general anesthesia. Propofol, sufentanil, granisetron and dexamethasone were administered at induction of anesthesia. Dexamethasone was administered as prophylaxis for postoperative nausea. No antibiotics or muscle relaxants were administered. 1 cc of PBV was injected intradermal peri-areolar in the quadrant of the tumor. Then, the blue and radioactive sentinel node was removed.

Ten minutes after the injection of PBV, the patient developed hypotension of 75/40 mmHg and a bradycardia of 30 beats per minute. She also developed blue palpebralangioedema and blue hives on the skin of the neck (Figure 1 and Figure 2). The anaphylactic shock was treated with intravenous fluid resuscitation, hydrocortisone, epinephrine and clemastine and the vital parameters were monitored. The blood pressure recuperated to 120/70 mmHg with a heartbeat of 90 beats per minute, within a couple of minutes. The patient recovered without further complications and the blue coloring of the palpebral region disappeared in several hours. No other ophthalmic symptoms such as blue coloring of the bulbar conjunctiva were observed. In this case, anaphylaxis was a clinical diagnosis. No specific laboratory tests were carried out to confirm anaphylaxis. The sentinel node was assessed pathologically and contained a macro metastasis.

Citation: Vugts G, Den Ouden MM, Koning TJJ and Maaskant-Braat AJG. Blue Dye Leading to Blue Eyelids: Anaphylaxis after Sentinel Node Biopsy. Austin J Surg. 2015;2(1): 1050. ISSN: 2381-9030.