Prolonged blue hives after intraoperative administration of isosulfan blue

Case description

A 77-year-old female with left breast atypical lobular hyperplasia and right breast invasive lobular carcinoma presented to our institution for left excisional biopsy and right lumpectomy with sentinel lymph node biopsy using dual-tracer (Technecium-99 and isosulfan blue dye). After completion of the left excisional biopsy, we injected 5 mL isosulfan blue dye throughout the right upper outer breast at a depth of 1–3 cm over approximately 20 seconds. Approximately 30 minutes after administration, the patient developed a blue maculopapular raised rash over the bilateral chest, right axilla, and right medial arm that rapidly progressed to confluent plaques (Figure 1A-1C). The patient was treated intraoperatively with diphenhydramine, prednisone, famotidine, and a 500 mL bolus of normal saline. She remained hemodynamically stable throughout with no evidence of anaphylaxis. Upon conclusion of the procedure 2 hours later, the blue hives had only mildly improved (Figure 1D-1E) and remained visible 14 hours later on postoperative day 1 (POD1). She was discharged to home in stable condition and returned on POD10 still exhibiting faint persistent blue discoloration over her right lateral chest wall (Figure 1F). The patient reported full resolution on POD15, with no evidence of discoloration at her POD20 visit (Figure 1G). Allergic and anaphylactoid reactions to isosulfan blue occur in approximately 0.5–1.6% of patients undergoing sentinel lymph node biopsy, with the majority of these manifesting as blue hives (1,2). Because these effects are predominantly self-limited, we prefer isosulfan blue over methylene blue due to the risk of local skin necrosis with methylene blue. In summary, bluish skin discoloration after isosulfan blue administration persisted for 15 days in this patient with no known allergies. This is one of the longest cases described.

Figure 1 Blue hives secondary to isosulfan blue administration. (A) Intraoperative, right upper arm and lateral chest wall. (B) Intraoperative, right breast. (C) Intraoperative, left breast. (D) Two hours post-treatment, right upper arm and breast. (E) Two hours post-treatment, bilateral chest. (F) POD10, persistent discoloration of right lateral chest wall. (G) POD20, right breast and axilla with complete resolution of discoloration. POD, postoperative day.

Acknowledgments

Funding: None.

Footnote

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Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-67/coif). I.L.W. serves as an unpaid editorial board member of Gland Surgery from August 2023 to July 2025. The other author has no conflicts of interest to declare.

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References

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2. Montgomery LL, Thorne AC, Van Zee KJ, et al. Isosulfan blue dye reactions during sentinel lymph node mapping for breast cancer. Anesth Analg 2002;95:385-8. [Crossref] [PubMed]