Acute myocardial injury after administration of intravenous epinephrine for allergic reaction

Abstract

Myocardial injury or infarction in the setting of anaphylaxis can be due to anaphylaxis itself, known as Kounis syndrome, or as a result of treatment with epinephrine. Myocardial ischemia caused by therapeutic doses of epinephrine in the setting of anaphylaxis is a rare event attributed to coronary artery vasospasm. A 41-year-old female with past medical history of recurrent costochondritis, chronic thrombocytopenia, and nonspecific palindromic rheumatism presented to the emergency department with perioral numbness, flushing and throat tightness after a meal containing fish and almonds. Intramuscular epinephrine was ordered but inadvertently administered intravenously, after which she developed sharp, substernal chest pain and palpitations. Electrocardiogram showed normal sinus rhythm with QT interval prolongation. Troponin peaked at 1.41 ng/mL. She was given 324 mg of aspirin in the emergency department. Transthoracic echocardiogram showed normal ejection fraction with lateral wall motion abnormality. We present a case of a patient with no significant risk factors for coronary artery disease who developed myocardial injury following inadvertent IV administration of a therapeutic dose of epinephrine for an anaphylactic-like reaction. The development of myocardial injury after epinephrine is rare, with only six reported cases in literature and just one after intravenous administration. This is the first described case of known myocardial injury without ST-T wave changes on electrocardiogram . The proposed mechanism is an alpha-1 receptor-mediated coronary vascular spasm resulting in myocardial ischemia. The aim of this case is to raise awareness of the potential for acute myocardial injury after inadvertent intravenous administration of epinephrine for anaphylaxis, even in patients with no known risk factors for coronary artery disease, as well as to demonstrate that this clinical scenario can present regardless of troponin elevation and without ST-T wave ECG changes.

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis

“…Other side effects described included decreased ejection fraction, diagnosis of cardiomyopathy, and coronary artery thrombus that was diagnosed on cardiac catheterization 19–22 . The other case reports described 34 patients in total who received an intravenous bolus dose of epinephrine inadvertently, or an inappropriately high IM dose 23–52 . This led to a wide array of side effects including arrhythmias, cardiomyopathy, thrombus, and cardiac arrest.…”

Management of Food Allergies and Food-Related Anaphylaxis

“…97 Arrhythmia and acute coronary syndrome after intramuscular epinephrine are rare with only 7 case reports described in the literature. 98 Antihistamines, corticosteroids, and mast cell stabilizers such as cromolyn are commonly prescribed in the acute setting because they may mitigate certain symptoms of allergic reactions (eg, pruritus, urticaria, abdominal discomfort), and patients and clinicians express more comfort and familiarity with these medications than with epinephrine. 75 However, unlike epinephrine, these medications do not interrupt acute mast cell degranulation and do not stop anaphylaxis.…”

“…A 2021 meta-analysis of 86 studies, comprising datasets from 20 prospective and 68 retrospective observational studies (36 557 anaphylaxis events), showed that although 1 in 10 anaphylactic events were associated with the need for more than 1 epinephrine dose, only 2.2% (95% CI, 1.1%-4.1%) of reactions were associated with failure to respond to 2 doses of epinephrine . Arrhythmia and acute coronary syndrome after intramuscular epinephrine are rare with only 7 case reports described in the literature . Antihistamines, corticosteroids, and mast cell stabilizers such as cromolyn are commonly prescribed in the acute setting because they may mitigate certain symptoms of allergic reactions (eg, pruritus, urticaria, abdominal discomfort), and patients and clinicians express more comfort and familiarity with these medications than with epinephrine .…”

Exploring Variations in Etiology and Clinical Presentations of Kounis Syndrome Across Pediatric and Adult Populations: A Comprehensive Review

“…Furthermore, elevated levels of cardiac enzymes, tryptase, and eosinophilia can also serve as indications of Kounis syndrome. In all reported cases involving pediatric patients, ischemic changes (ST elevation and ST depression) were observed on the ECG, except for one case where a 15-year-old patient with Kounis syndrome, due to a wasp sting, displayed normal findings on the ECG [ 34 , 40 , 64 - 66 , 72 , 83 - 90 ]. Similarly, in the case of the adult case reports, it was also observed that ischemic changes were noted on the electrocardiogram (ECG).…”