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Fatal anaphylactic reaction to oral diclofenac sodium

Chandigarh, India

To the Editor:

Diclofenac sodium is commonly used in pain clinic and peri-operatively. We report a fatal anaphylactic reaction to oral diclofenac in a nine-year-old girl hospitalised for "transient synovitis". She had no history of atopy or cardio-respiratory illness and her clinical investigations were unremarkable. After symptomatic improvement on oral nimsulide and limb traction, oral diclofenac 25 mg twice daily was prescribed at discharge. At home, after a first dose of diclofenac, she complained of body aches, itching, showed cutaneous flushing and became febrile (38.9°C). Attributing her symptoms to fever, a second dose was given within two hours. Soon, the girl became restless, developed a generalised body rash and choking sensation. Within 35 min, she was brought to the ICU gasping, cyanosed, pulseless, with mid-dilated weakly reactive pupils and was intubated. Aggressive hemodynamic and respiratory support was provided but failed to resuscitate the child.

The second dose of diclofenac probably lead to a fulminant allergic reaction while delayed hospitalisation likely proved fatal. Should routine sensitivity tests be performed with diclofenac sodium? This drug is considered safe with a worldwide experience of 7.6 million patients per year.¹ Van der Klauw et al. found 30 cases² of probable anaphylaxis to diclofenac in 992 reports on drug reaction. A fatal drug reaction following im diclofenac has been reported,³ but sodium metabisulphite preservative as a cause was not ruled out. In a singular report of reaction to oral diclofenac, the patient survived due to prompt resuscitation.⁴. It is therefore essential to remain aware of the toxic profile of all drugs. Prompt recognition and treatment of serious complications can help avert such untoward outcomes.

References

1 O'Brien WM. Adverse reactions to nonsteroidal anti-inflammatory drugs. Diclofenac compared with other nonsteroidal anti-inflammatory drugs. Am J Med 1986; 80: 70–80.

2 Van der Klauw MM, Wilson JHP, Stricker BHCH. Drug-associated anaphylaxis: 20 years of reporting in the Netherland (1974–1994) and review of literature. Clin Exp Allergy 1996; 26: 1355–63.[Medline]

3 Alkawajah AM, Eifawal M, Mahmoud SF. Fatal anaphylactic reaction to diclofenac. Forensic Sci Int 1993; 60: 107–10.[Medline]

4 Milman U, Hermani D. Anaphylactic reaction to oral diclofenac sodium sustained release tablet. Isr J Med Sci 1994; 30: 909–10.[Medline]

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