We read with interest your letter "Anaphylaxis to dye during breast surgery" [1]. You report a high incidence of anaphylaxis to Patent Blue V dye in a small number of patients over a 21-month-period, compared with the reported incidence of 0.86% allergic reactions to Patent Blue V dye from the combined datasets of the ALMANAC trial and NEW START training programme (n=7,917) [2]. These patients were given either 2mls of 2.5% aqueous solution of Patent Blue V diluted to 5mls with normal saline or 2 mls undiluted patent blue V dye. It has been shown that there is a trend towards fewer allergic reactions with smaller volumes of blue dye, with no difference in the success of sentinel lymph node identification with dye volumes from 1-5mls [3]. Considering the high incidence of allergic reactions, is it possible that your figures relate to higher volume of blue dye usage?

A. Hegarty

A. Merrigan

S. O Riain

Limerick University Hospital

Dooradoyle, Limerick, Ireland

E-mail: aoifehegarty1@gmail.com 

No external funding and no competing interests declared. 

References.

1. Robinson L. Anaphylaxis to dye during breast surgery. Anaesthesia 2011; 66: 841-842

2. Barthelmes L, Goyal A, Newcombe RG, McNeill F, Mansel RE. Adverse reactions to patent blue V dye - the NEW START and ALMANAC experience.

    European Journal of Surgical Oncology 2010;36:399-403  

3. King TA et al. A prospective analysis of the effect of blue-dye volume on sentinel lymph node mapping success and incidence of allergic reactions in  

    patients with breast cancer. Ann Surg Oncol 2004;11(5):535-41

Thank you for your interest in the issue of blue dye allergy and the antigenic load required to precipitate an anaphylactic reaction.

The dose used at our institution is 2ml of neat 2.5% Patent Blue V dye injected around the breast areola as per the protocol in the NEW START and ALMANAC programmes [1]. Iosulphan blue was used in the paper by King TA et al [2] and their conclusion stated  'a non significant trend towards fewer allergic reactions with smaller volumes of the blue dye.'

If Patent Blue Dye anaphylaxis is Ig E mediated then even smaller volumes of the dye could  trigger an allergic reaction in a susceptible individual.

L. Robinson

South Devon Foundation Healthcare Trust

Torquay . U.K.

e-mail: louise.robinson@nhs.net

No external funding and no competing interests declared.

References 

1. Barthelmes L, Goyal A, Newcombe RG, McNeill F, Mansel RE. Adverse reactions to patent blue V dye - the NEW START and ALMANAC experience. European Journal of Surgical Oncology 2010; 36: 399-403  

2. King TA et al. A prospective analysis of the effect of blue-dye volume on sentinel lymph node mapping success and incidence of allergic reactions in patients with breast cancer. Annals of Surgical Oncology 2004;11: 535-41