Inflammation from Eutectic Mixture of Local Anesthetics during Neonatal Male Circumcision: A Case Report

Background: We report an unusual case of inflammation following the application of eutectic mixture of local anesthetic (EMLA) cream, a topical lidocaine-prilocaine anesthetic, resulting in an aborted neonatal male circumcision (NMC). Inflammation from EMLA cream are rare adverse events; the only pictured instance of this reaction occurred in two neonates from Botswana dating back to 2013. However, we observed inflammation in a neonate of Haitian descent. This report is important for two primary reasons: firstly, to inform clinicians about the appearance and duration of inflammation to help manage similar neonates; and secondly, to discuss the etiology and incidence of this reaction, particularly if the reaction occurs in diverse neonates. Case presentation The neonate displayed normal male genitalia on examination prior to planned circumcision using a Gomco clamp on day two of life. We applied EMLA cream on the prepuce and placed an occlusive dressing. After one hour, we examined the penis and then aborted the procedure due to edema and erythema of the prepuce resulting in difficulty visualizing the glans. We did not observe any distress in the neonate nor any systemic sequelae from this reaction. Although the neonate voided successfully in the interim, inflammation had not fully decreased by day three of life. We discharged the neonate on day three of life without incident and counseled the mother on expectations for reduction in swelling. During the neonate’s well-baby visit five days later, the pediatrician did not note any irregularities during the physical exam. Conclusions: Inflammation may be a result of vasodilation induced by lidocaine-prilocaine blockage of sympathetic nerves of vasoconstriction. Management of this reaction is supportive, and if the parent still desires circumcision, evidence-based alternatives for neonatal anesthesia or analgesia exist. As this reaction to EMLA cream is harmless, many cases of inflammation during NMC may go unreported. Furthermore, adverse reactions in diverse patients have historically been underexplored. With this report, three neonates of sub-Saharan African ancestry have experienced this reaction. Increased reporting and further research are needed to understand which neonates are most susceptible to EMLA-induced inflammation.