Jayamali W D, Herath H M M T B, Kulathunga Aruna
National Hospital, Colombo, Sri Lanka.
BMC Cardiovasc Disord. 2017 Sep 4;17(1):237. doi: 10.1186/s12872-017-0670-7.
Anaphylaxis 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.
A 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.
Here 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.
过敏反应是一种急性、可能致命的医疗紧急情况。在过敏反应中发生的心肌损伤或梗死，可能是由于过敏反应本身（即所谓的库尼斯综合征），也可能是由于肾上腺素治疗的影响。肾上腺素被认为是过敏反应治疗的基石。治疗剂量的肾上腺素继发心肌梗死是一种罕见情况，文献中仅报道了少数病例。心肌损伤的机制被认为是由于肾上腺素继发冠状动脉痉挛，因为这些病例的冠状动脉造影显示正常。
一名21岁既往健康的男性，在食用已知过敏的虾类一小时后，因出现荨麻疹皮疹和呼吸困难入住当地医院。他接受了0.5毫升肌肉注射肾上腺素（1:1000），注射于大腿外侧，随后出现心悸和紧缩样的中央胸痛。心电图显示Ⅲ、aVF及V1至V5导联ST段压低，随后他被转至三级医疗机构。两小时后进行的第二次心电图显示ST段压低消失，但Ⅰ及aVL导联出现新的T波倒置。肌钙蛋白I升高，水平为2.15纳克/毫升。他在急诊治疗单元接受了舌下硝酸甘油治疗，症状缓解。经胸二维超声心动图及平板运动负荷试验正常，CT冠状动脉造影显示冠状动脉正常。
在此，我们报告一例年轻健康的成年人，其无冠状动脉疾病的显著危险因素，在因过敏反应接受治疗剂量的肾上腺素肌肉注射后发生心肌梗死。推测的机制很可能是α受体介导的冠状动脉血管痉挛。然而，在危及生命的过敏反应情况下使用肾上腺素可挽救生命，其益处远大于不良反应的风险。因此，报告本病例的目的不是劝阻在过敏反应中使用肾上腺素，而是让大家意识到在急性情况下可能出现的这种潜在不良反应。
