Ashok Kumar Prashanth, Paulraj Shweta, Udekwu Adaora
Internal Medicine, Upstate Medical University, Syracuse, USA.
Medicine, Upstate Medical University, Syracuse, USA.
Cureus. 2020 Feb 18;12(2):e7028. doi: 10.7759/cureus.7028.
Therapeutic plasma exchange (TPE) is a procedure for removal of plasma and its components while leaving behind cellular elements via an apheresis device. It is used in multiple conditions one among which is systemic lupus erythematosus (SLE). Adverse reactions from TPE range from mild hypotension and fever to life-threatening cardiovascular compromise. We report the case of sudden hemodynamic collapse following TPE for a neuropsychiatric lupus flare in a patient on losartan. A 62-year-old Caucasian female with a history of drug-induced lupus presented to the hospital with symptoms of a neuropsychiatric lupus flare. She was initiated on TPE with 5% albumin based on recommendations by her rheumatologist. Shortly after TPE, she became hypotensive with poor response to fluid boluses, requiring pressor support and intubation. These symptoms resolved within 24 hours on supportive measures. This was believed to be due to losartan use on the day of TPE. The medication was discontinued and she had further sessions of TPE with no complications. Angiotensin-converting enzyme (ACE) inhibitors have previously been associated with flushing and hypotension in patients undergoing TPE. Patients undergoing TPE have an activation of the prekallikrein and bradykinin system on contact with the extracorporeal membranes. ACE inhibitors potentiate this reaction by inhibiting bradykinin catabolism. Angiotensin receptor blockers (ARBs) have also been postulated to cause elevated bradykinin levels although data pertaining to the use of ARBs in TPE is limited. We hope to highlight this rare interaction in our case and emphasize the need for further data with regard to the same.
治疗性血浆置换（TPE）是一种通过血液分离装置去除血浆及其成分而保留细胞成分的操作。它用于多种病症，其中之一是系统性红斑狼疮（SLE）。TPE的不良反应范围从轻度低血压和发热到危及生命的心血管功能障碍。我们报告了1例服用氯沙坦的患者在进行TPE治疗神经精神性狼疮发作后突然发生血流动力学崩溃的病例。一名有药物性狼疮病史的62岁白人女性因神经精神性狼疮发作症状入院。根据风湿病学家的建议，她开始接受基于5%白蛋白的TPE治疗。TPE后不久，她出现低血压，对补液反应不佳，需要使用升压药支持并进行插管。这些症状在采取支持措施后24小时内得到缓解。据信这是由于TPE当天使用了氯沙坦。停用该药物后，她进一步接受了TPE治疗，未出现并发症。血管紧张素转换酶（ACE）抑制剂此前已被证实与接受TPE治疗的患者出现潮红和低血压有关。接受TPE治疗的患者在与体外膜接触时会激活前激肽释放酶和缓激肽系统。ACE抑制剂通过抑制缓激肽分解来增强这种反应。血管紧张素受体阻滞剂（ARBs）也被推测会导致缓激肽水平升高，尽管关于ARBs在TPE中应用的数据有限。我们希望通过本病例突出这种罕见的相互作用，并强调需要进一步收集相关数据。
