Myocardial infarction during anaphylaxis in a young healthy male with normal coronary arteries- is epinephrine the culprit?

Abstract

BackgroundAnaphylaxis is an acute, potentially fatal medical emergency. Myocardial injury or infarction in the setting of an anaphylaxis can be due the anaphylaxis itself, when it is known as Kounis syndrome or it can also be due to the effect of epinephrine treatment. Epinephrine is considered as the cornerstone in management of anaphylaxis. Myocardial infarction secondary to therapeutic doses of adrenaline is a rare occurrence and only a few cases have been reported in literature. The mechanism of myocardial injury was considered to be due to coronary vasospasm secondary to epinephrine as the coronary angiograms were normal on these occasions.Case presentationA 21-year- old previously healthy male got admitted to the local hospital with an urticarial rash and difficulty in breathing, one hour after ingestion of prawns for which he was known to be allergic. He was treated with 0.5 ml of intramuscular adrenaline (1:1000) which was administered to the lateral side of the thigh, following which he developed palpitations and tightening type central chest pain. Electrocardiogram showed ST segment depressions in leads III, aVF and V1 to V5 and he was transferred to a tertiary care hospital. The second electrocardiogram, done 2 h later, showed resolution of ST segment depressions but new T inversions in leads I and aVL. Troponin I was elevated with a titer of 2.15 ng/ml. He was treated with sublingual GTN in the emergency treatment unit and the symptoms resolved. Transthoracic 2D echocardiogram and stress testing with treadmill was normal and CT coronary angiogram revealed normal coronary arteries.ConclusionHere we present a case of a young healthy adult with no significant risk factors for coronary artery disease who developed myocardial infarction following intramuscular administration of therapeutic dose of adrenalin for an anaphylactic reaction. The postulated mechanism is most likely an alpha receptor mediated coronary vascular spasm. However the use of adrenaline in the setting of life threatening anaphylaxis is life saving and the benefits far outweigh the risks of adverse effects. Therefore the purpose of reporting this case is not to discourage the use of adrenaline in anaphylaxis but to make aware of this potential adverse effect which can occur in the acute setting.

Intramuscular Epinephrine-Induced Transient ST-Elevation Myocardial Infarction

“…Acute MI during anaphylactic reaction has been previously reported and may result from the anaphylaxis itself or from the epinephrine used to treat the anaphylaxis. 1 - 4 Kounis syndrome is the nonthrombogenic cause of myocardial ischemia or infarction triggered by the release of inflammatory mediators during an allergic or anaphylactic reaction. 11 The main pathophysiological pathway is thought to be the activation and degranulation of mast cells within the coronary arteries during these allergic reactions with release of chemical mediators like histamine and tryptase resulting in coronary vasospasm.…”

“… 1 , 2 It may result from the anaphylaxis itself or from the epinephrine used to treat the anaphylaxis. 1 - 6 While cases of MI due to large doses of intravenous epinephrine have previously been reported, MI after therapeutic doses of intramuscular epinephrine is rarely reported. 7 - 10 In this article, we present a case of acute MI in a young healthy patient after the use of intramuscular epinephrine for presumed anaphylaxis and review the literature for similar cases.…”

Myocardial Infarction in Children

“…Although this treatment has been used safely for many years, there is a need for heart rate and ECG monitorisation in cases administered epinephrine consecutively [55]. It has been reported that MI has developed associated with epinephrine not only in cases with racemic epinephrine but also in cases where epinephrine has been used when applying cardiopulmonary resuscitation [56]. The coronary vasospasm of epinephrine is made over alpha 1 and alpha 2 receptors.…”

“…While low-dose adrenaline shows a beta mimetic effect, at high doses the effect is seen by vasoconstriction, primarily over the alpha 1 and alpha 2 receptors. As there is a relationship between epinephrine used intravenously and a higher complication rate, the selection of intramuscular or subcutaneous routes could contribute greatly to reducing the cardiovascular risks [56] Vasodilators such as nitrate and calcium channel blockers are selected in MI cases related to epinephrine [57,58].…”

Kounis Syndrome: A simple MRI with contrast turned into a life threatening condition

“…1 Anaphylaxis is an immediate allergic reaction that has the propensity to cause severe coronary vasospasms. 2,3 Anaphylaxis virtually affects all major systems of the body including the cardiovascular system making the heart a target organ. 4 Kounis syndrome is a hypersensitivity coronary disorder induced by various allergens.…”