Acute myocardial infarction associated with high dose intravenous immunoglobulin infusion for autoimmune disorders. A study of four cases

Abstract

Objective-To report on four patients with autoimmune disorders who developed acute myocardial infarction (MI) during or soon after treatment with high dose intravenous immunoglobulins (IVIG) and to determine the clinical profile of patients prone to this complication. Methods-The clinical history of the four patients is reported with details concerning age, sex, indication for IVIG treatment, risk factors, timing of the MI and outcome. The relevant medical literature has been reviewed. Results-The patients, three men and one woman, aged 42-67, received IVIG treatment for diVerent autoimmune disorders. All had a history of atherosclerosis or previous risk factors such as hypertension, stroke, hyperlipidaemia and obesity. Two of the patients suVered a MI after the first infusion of IVIG while the others-after the 5th and 15th pulses. MI occurred during the infusion in two patients and after a few days in the others. All the patients recovered from the acute event. These observations are in concert with sporadic cases of IVIG related thrombosis reported in the medical literature. Conclusion-In patients with vascular risk factors such as old age, hypertension, history of stroke or coronary artery disease, the possibility of IVIG related vascular complications should be considered and IVIG prescribed with a cautious reweighted risk/benefit consideration. (Ann Rheum Dis 2000;59:77-80) High dose intravenous immunoglobulin (IVIG) treatment is being increasingly used in a wide range of autoimmune disorders such as Kawasaki, 1 neuroimmunological disorders, [2][3][4] dermatomyositis, 5 vasculitis 6 immune cytopenia and other conditions. 7 8 IVIG have been considered a safe medication, with minor adverse events such as headache, nausea and myalgias, occurring in less than 10% of patients.9 10 With the wider use of IVIG, the reported rate of side eVects has increased, 11 some of them being potentially fatal. 12We describe four patients with autoimmune disorders who developed acute myocardial infarction (MI) a few days after receiving IVIG. Case reports CASE 1The patient is a 60 year old man with relapsing polychondritis of three years duration manifesting as extreme fatigue, recurrent episodes of chondritis of the ears, hoarseness, livedo reticularis, migratory arthritis and myalgias, episcleritis and vestibular neuropathy with vertigo and sensorineural deafness. He had documented arterial hypertension for the past two years. Laboratory tests disclosed an increased erythrocyte sedimentation rate (ESR) (120 mm 1st h) and normocytic normochromic anaemia (Hb 10 g/dl). Immunological tests including anticardiolipin antibodies were negative. The patient was initially treated (at another centre) with prednisone (1 mg/kg) and monthly intravenous cyclophosphamide (800 mg/m 2 ), but repeated attempts to lower the prednisone dose below 25 mg/d resulted in acute exacerbations. Parenteral methotrexate 30 mg/week was prescribed. During this treatment he developed right hemiparesis with evidence of cerebral lacunar infarction on...

Safety and Adverse Events Profiles of Intravenous Gammaglobulin Products Used for Immunomodulation

“…The use of Polygam, which contains high concentrations of sodium at 10%, was associated with five cases of AMI. MI is a known complication of IVIg infusion (10,14). Our findings suggest that this may be due to the excipient (sodium chloride) and not incipient as evidenced by the lack of events with sucrose-based and isosmolar products.…”

“…Twenty-nine cases of thrombotic complications with the use of IVIg have been reported and include acute myocardial infarction (AMI), cerebral infarction, pulmonary embolism (PE), deep venous thrombosis (DVT), hepatic veno-occlusive disease, and spinal cord ischemia (7)(8)(9)(10)(11)(12). No correlation yet has been made between particular IVIg products and thrombotic complications.…”

Retinal vein occlusion following intravenous immunoglobulin treatment

“…Five cases of stroke, two cases of deep vein thrombosis, seven myocardial infarctions, one case each of RVO and pulmonary embolism have so far been described with IVIg [1][2][3][4][5][6][7]. The rate of thrombotic complications following IVIg may be as high as 3-5% though underreported and can involve both arterial and venous circulation [8].…”

Recurrent Acute Myocardial Infarction in Patients with Immune Thrombocytopenic Purpura

“…Thrombotic complications have been reported to occur during or after treatment when platelet counts begin to rise 4,5 and even during the severe to moderate thrombocytopenia phase. 6 However, the reported incidence of myocardial infarction in patients with chronic thrombocytopenia is low.…”