Acute Myocardial Injury Following Penicillin-Associated Anaphylactic Reaction in a Patient With Normal Coronary Arteries

An Unusual Presentation of Allergic Reactions: Kounis Syndrome

Kounis syndrome is a rare cause of angina pectoris and acute coronary syndrome associated with acute allergic reactions. We present a case of one middle-aged male with this syndrome presenting with ST elevation on electrocardiogram after amoxicillin intake. It is important that clinicians be aware of the possible link between allergic disorders and acute coronary syndromes. Therefore, an allergic insult should be considered during diagnostic and therapeutic steps in managing acute coronary syndromes in appropriate clinical context. Acute coronary syndromes associated with this syndrome should be managed per relevant guidelines and timely coronary angiography should be performed in majority of cases. (Hong Kong j.emerg.med. 2015;22: 371-375)

A rash decision. The hazards of the wrongful use of adrenaline

Anaphylaxis is life-threatening and should be addressed urgently. Its treatment is not without side effects and an accurate diagnosis must be made to prevent potential harm by the wrongful use of medication. A 46-year-old woman with hypertension treated with angiotensin converting enzyme inhibitor (ACEI) presented to the emergency department with non-pitting oedema of the face and limbs. A hasty diagnosis of anaphylaxis was made and intravenous adrenaline administered. The patient developed a myocardial infarction caused by coronary artery spasm that required invasive intervention. The initial clinical picture was resolved when the ACEI was discontinued unmasking a case of ACEI-induced angioedema. The correct differentiation of these two apparently similar clinical entities is of utmost importance in the management of emergency department patients.

Allergic angina following wasp sting: Kounis syndrome

Kounis syndrome is defined as an acute coronary syndrome triggered by the release of inflammatory mediators following an allergic insult characterized by acute onset of breathlessness, palpitations, diaphoresis and chest tightness (Gázquez V, Dalmau G, Gaig P, Gómez C, Navarro S, Mercé J. Kounis syndrome: report of 5 cases. J Investig Allergol Clin Immunol 2010;20:162–5). We report a 20-year-male patient who presented with acute myocardial infarction following a wasp sting at our institute. ECG showed non-ST-elevation myocardial infarction. Symptoms settled with hydrocortisone and adrenaline. Coronary angiogram revealed normal epicardial coronaries.

Apparent Epinephrine Toxicity in the Treatment of Anaphylaxis: A Patient Case of Prolonged Hypotension

Background

The emergent nature of anaphylaxis creates an environment of heightened risk for epinephrine medication misadventures that may occur in any health care setting. Literature to date has focused on the immediate adverse outcomes associated with epinephrine dosing and administration errors, with a lack of data available on prolonged consequences.

Objective

We present a unique case of refractory hypotension associated with the administration of high-dose epinephrine for the treatment of anaphylaxis that prompted a comprehensive safety evaluation and implementation of a process improvement plan for all patients experiencing an anaphylactic reaction in our institution.

Case Report

A 29-year-old female presented to an immediate care facility for treatment of anaphylaxis including 2 doses of epinephrine 1 mg (1:1000) intramuscularly. The patient was subsequently transported to our adult emergency department and developed isolated hypotension refractory to fluid resuscitation. The patient was then admitted to the medical intensive care unit with a diagnosis of epinephrine toxicity. The prolonged hypotensive response seen in this patient is believed to be a result of residual stimulation of the more sensitive beta receptors by high doses of epinephrine administered to the patient, resulting in a prolonged vasodilatory response.

Conclusion

Epinephrine is a high-alert medication used for the treatment of anaphylaxis. Proactive evaluation of current processes among institutions is recommended in order to minimize dosing and administration errors with epinephrine as these errors can lead to substantial harm to patients.

Stress-induced cardiomyopathy complicated by multiple organ failure following cephalosporin-induced anaphylaxis

Stress-induced cardiomyopathy, a reversible left ventricular dysfunction, has been reported following anaphylaxis; this clinical circumstance seems to be linked to elevated levels of circulating catecholamines. We present a 36-year-old woman diagnosed as stress-induced cardiomyopathy following ceftriaxone-induced anaphylaxis. After anaphylactic reaction, the patient initially presented with cardiogenic shock, and subsequently developed multiple organ failure. She recovered basically by multiple organ supportive therapies including intra-aortic balloon pump and continuous veno-venous hemofiltration. This case provides a unique opportunity to observe the triggering of stress-induced cardiomyopathy, and also it provides evidence to support the role of catecholamine in the pathogenesis of this disease.

Current understanding of Kounis syndrome

Inflammatory mediators, adhesion molecules of neutrophils and monocytes, have been shown to be increased in the plasma of patients presenting with acute coronary syndromes. Anaphylaxis is a systemic, immediate hypersensitivity reaction caused by rapid IgE-mediated release of mediators from mast cells and basophils. Kounis syndrome is the coincidental occurrence of these two distinct conditions accompanied by clinical and laboratory findings of angina pectoris caused by inflammatory mediators released during an allergic insult. Allergic angina can progress to acute myocardial infarction, which is termed 'allergic myocardial infarction'. There are several causes reported to be capable of inducing Kounis syndrome. These include a number of conditions, several drugs, foods and insect stings, among others. In this article, the clinical aspects, diagnosis, pathogenesis, incidence and epidemiology, related conditions and therapeutic management of this important syndrome are discussed.