CASE
REPORT: MODIFIED DOSE OF EPINEPHRINE EFFECTIVE IN MANAGEMENT OF ANAPHYLACTIC DUE
TO STREPTOKINASE IN ELDERLY WITH ACUTE MYOCARDIAL INFARCTION
I Wayan Nariata, Cok Istri Anom S*, K. Suardamana*, K.
Suryana*
*Division
of Allergy Immunology Internal Medicine Udayana University/Sanglah Hospital,
Denpasar
Background:
Streptokinase is a thrombolytic agent used most commonly for the dissolution of
thrombi obstructing coronary arteries during acute myocardial infarction (AMI).
Anaphylactic reactions induced by streptokinase occur rarely and epinephrine is
an agent of choice for the management of anaphylaxis must carefully given in
the known heart desease and or elderly due to its sympatomimetic effect.
Case: A 65 years old woman with anteroseptal AMI
developed shortness of
breath all of a sudden accompanied by wheezing, angioedema and gradual decrease
of consciousness immediately after commencement of streptokinase
infusion. She had a history
of asthma since about 20 years, regularly controlled and also history of
allergy of amoxicillin, shrimp and marine fish. On physical examination we found
GCS E3V3M5, blood pressure 102/85 mmHg, pulse rate 120 bpm, respiratory rate 36
bpm, angioedema, wheezing and stridor. Baseline laboratory examination showed leukocytosis 15.7x103µL, CKMB
57.31 U/L, LDH 608.6 U/L, troponin T 0.37 ng/mL and ECG record showed ST segment elevation in the V1
to V5. Blood gas analysis obtained resulting hypoxia with ph 7.37, pCO2 44, pO2
72, O2 saturation 94.0%. There is no worsening of ECG record during anaphylaxis
from baseline. Data supports diagnose of Coronary Heart Disease/anteroseptal STEMI/Killip
I with anaphylactic reaction due to streptokinase. Low dose epinephrine 0.1 cc
administered by intramuscular route, methylprednisolone 62.5 mg bid i.v and dipenhydramine
10 mg tid iv in addition to therapy of enoxapharine 0.6 cc bid s.c, acetosal,
clopidogrel and simvastatin. Patients experienced clinical improvement 15 minutes
after receiving epinephrine and regain conscious in 1 hour. On the next day all
the symptoms improved as well as the ECG features. Echocardiography revealed mitral
regurgitation, LVH, LV dyskinesis, impaired LV function, EF 33%. Measurement of
total IgE was 445.5 kIU/L and she discharged on the eighth day.
Conclusion: Anaphylactic
reactions induced by streptokinase can occur rarely, but epinephrine that is an
agent of choice for the management of anaphylaxis can effectively given within
modified dose in elderly with AMI.
Keyword: anaphylaxis, modified
dose, epinephrine, AMI, elderly
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