ACUTE CORONARY SYNDROME FOLLOWING THERAPEUTIC EPINEPHRINE FOR ANAPHYLAXIS. M. Okoronkwo MD, R. Jupiter. MD, S. Lim. MD Department of Medicine, LSU Health Sciences Center, New Orleans, Louisiana
INTRODUCTION: Vasospastic angina is caused by focal or diffuse spasm of an epicardial coronary artery and myocardial infarction may develop in some if the spasm is persistent. Here we present a case associated with treatment of anaphylaxis causing a myocardial infarction.
CASE: A 35-year old woman with a significant history of daily tobacco use presented to an urgent care clinic with an urticarial rash that developed 30 minutes after taking amoxicillin/clavulanic acid. She subsequently developed weakness and shortness of breath. Her blood pressure was 90/63, pulse was 57 beats/min, respiratory rate was 28 breaths per min and oxygen saturation was 98% on room air. She received an intramuscular injection of epinephrine and intravenous methylprednisolone, diphenhydramine, famotidine, and a 1500 cc bolus of normal saline. While awaiting transfer to an emergency department, she complained of chest pain. An emergent EKG revealed ST elevations through the anterior lateral leads with reciprocal depression in the inferior leads. Patient was transferred to a facility of higher level care for acute coronary syndrome. DISCUSSION: Two mechanisms have been elucidated to describe myocardial injury in the setting of anaphylaxis. Kounis Syndrome is defined as acute myocardial injury due to the anaphylactic response from mast cell and basophil mediated histamine release resulting in coronary vasospasm. Alpha receptor mediated vasospasm from therapeutic intermuscular epinephrine is suspected to result in myocardial injury as well. Our patient, having an allergic cutaneous manifestation along with respiratory and cardiovascular compromise, satisfied anaphylaxis criteria for epinephrine use. Case studies describe the temporal relationship of epinephrine treatment and chest pain with reported in as little as tenminutes after administration. Our patient developed chest pain shortly after epinephrine administration: This temporal relationship favors epinephrine induced vasospasmas the presumedmechanismof myocardial insult. Identification of patientsmost prone to this particular adverse effect of intramuscular epinephrine is a needed area of research and further exploration.
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