Evaluation of myocardial injury through serum troponin I and echocardiography in anaphylaxis

Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock

Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.

Intraoperative Kounis Syndrome and Fixation Errors: A Case Report

Postinduction hypotension, though frequently due to anesthetic medications, has a variety of causes. We present a case of presumed intraoperative Kounis syndrome, or anaphylaxis-induced coronary vasospasm, in which the patient's perioperative course was initially attributed to anesthesia-induced hypotension and iatrogenic rebound hypertension leading to Takotsubo cardiomyopathy. A second anesthetic event with immediate recurrence of hypotension after the patient received levetiracetam appears to confirm the diagnosis of Kounis syndrome. In this report, we discuss the fixation error that led to this patient's original misdiagnosis.

Takotsubo cardiomyopathy following envenomation: An updated review

BACKGROUND

Takotsubo cardiomyopathy (TTC) can be diagnosed in patients presenting with clinical features of acute coronary syndrome (ACS) by using Mayo clinic criteria. Multiple precipitators have been attributed to causing TTC. Rarely it has been reported to occur following an acute envenomation.

AIM

This review describes the various patterns, mechanisms, and outcomes of envenomation induced TTC.

METHODS

In this review, we included all studies on “TTC” and “envenomation “published in the various databases before June 2022. To be included in the review articles had to have a distinct diagnosis of TTC and an envenomation

RESULTS

A total of 20 patients with envenomation induced TTC were identified. Most episodes of envenomation induced TTC were reported following a bee sting, scorpion sting, and snake envenomation. Fear and anxiety related to the sting, direct catecholamine toxicity and administration of exogenous beta-adrenergic agents have been commonly postulated to precipitate TTC in these patients. 95% of these patients presented with a clinical picture of ACS. Most of these patients also fulfill at least 3 out of 4 criteria of Mayo clinic criteria for TTC. Echocardiographic evidence of Apical TTC was noted in 72% of patients. 94% of these patients had clinical improvement following optimal management and 35% of these patients were treated with guideline directed medications for heart failure.

CONCLUSION

Envenomation following multiple insect stings and reptile bites can precipitate TTC. Most reported envenomation related TTC has been due to bee stings and scorpion bites. Common mechanisms causing TTC were fear, anxiety, and stress of envenomation. Most of these patients present with clinical presentation of ACS, ST elevation, and elevated troponin. The most common type of TTC in these patients is Apical, which improved following medical management.

Ondansetron-induced pseudoallergy with non-ischemic myocardial injury: A rare case report of Kounis syndrome

Ondansetron is an FDA-approved selective serotonin 5-HT3 receptor commonly indicated as an anti-emetic agent for nausea and vomiting. It is rare to observe fatal reactions from ondansetron despite having no allergies or previous exposure. We report a case of anaphylactoid reaction with spontaneous coronary vasospasms in response to intravenous ondansetron.

Impaired Myocardial Mitochondrial Function in an Experimental Model of Anaphylactic Shock

Anaphylactic shock (AS) is associated with a profound vasodilation and cardiac dysfunction. The cellular mechanisms underlying AS-related cardiac dysfunction are unknown. We hypothesized that myocardial mitochondrial dysfunction may be associated with AS cardiac dysfunction. In controls and sensitized Brown Norway rats, shock was induced by ovalbumin i.v bolus, and abdominal aortic blood flow (ABF), systemic mean arterial pressure (MAP), and lactatemia were measured for 15 min. Myocardial mitochondrial function was assessed with the evaluation of mitochondrial respiration, oxidative stress production by reactive oxygen species (ROS), reactive nitrogen species (RNS), and the measurement of superoxide dismutases (SODs) activity. Oxidative damage was assessed by lipid peroxidation. The mitochondrial ultrastructure was assessed using transmission electronic microscopy. AS was associated with a dramatic drop in ABF and MAP combined with a severe hyperlactatemia 15 min after shock induction. CI-linked substrate state (197 ± 21 vs. 144 ± 21 pmol/s/mg, p < 0.05), OXPHOS activity by complexes I and II (411 ± 47 vs. 246 ± 33 pmol/s/mg, p < 0.05), and OXPHOS activity through complex II (316 ± 40 vs. 203 ± 28 pmol/s/mg, p < 0.05) were significantly impaired. ROS and RNS production was not significantly increased, but SODs activity was significantly higher in the AS group (11.15 ± 1.02 vs. 15.50 ± 1.40 U/mL/mg protein, p = 0.02). Finally, cardiac lipid peroxidation was significantly increased in the AS group (8.50 ± 0.67 vs. 12.17 ± 1.44 µM/mg protein, p < 0.05). No obvious changes were observed in the mitochondrial ultrastructure between CON and AS groups. Our experimental model of AS results in rapid and deleterious hemodynamic effects and was associated with a myocardial mitochondrial dysfunction with oxidative damage and without mitochondrial ultrastructural injury.

Dimethyl Fumarate-Induced Takotsubo Cardiomyopathy in a Patient With Relapsing-Remitting Multiple Sclerosis

Dimethyl fumarate (DMF) is an approved oral pharmacologic agent used in the treatment of relapsing-remitting multiple sclerosis (RRMS). Although commonly used in clinical practice, its mechanism of action remains largely unknown. Some frequent side effects associated with this drug are angioedema, hepatic injury, flushing, herpes zoster infection, and abdominal pain among others. A 47-year-old female presented with symptoms of an allergic reaction after initiating DMF therapy. She required intensive care unit admission due to an acute-hypoxic respiratory failure. A transthoracic echocardiogram (TTE) revealed apical ballooning and a left ventricular ejection fraction (LVEF) of 35%-40%. A coronary angiogram revealed no coronary artery disease. The diagnosis of takotsubo cardiomyopathy was made. The patient was managed with high-dose steroids and an epinephrine drip, in addition to a high-flow nasal cannula (HFNC) for respiratory support. At a three-month follow-up, a repeat TTE showed a resolution of the underlying takotsubo cardiomyopathy (CM) with no stunted myocardium and a normal ejection fraction (EF). Here, I highlight a life-threatening case of DMF-induced takotsubo CM and familiarize clinicians and patients with the need for close monitoring of symptoms when initiating disease-modifying drug (DMD) therapy.

Kounis Syndrome Secondary to Medicine-Induced Hypersensitivity

Introduction

Kounis syndrome is the concurrence of an acute coronary syndrome (ACS) caused by coronary vasospasms, acute myocardial infarctions, or stent thromboses in case of allergic or hypersensitivity reactions. Kounis syndrome is mediated by mast cells that interact with macrophages and T-lymphocytes, causing degranulation and inflammation with cytokine release. It is a life-threatening condition that has many trigger factors and is most commonly caused by medicines. Case Presentation. A 71-year-old male was admitted with a fever of five days' duration associated with cellulitis, for which he had been treated with clindamycin and flucloxacillin before admission. He was a diagnosed patient with hypertension and dyslipidemia five years ago. After taking the antibiotics, he had developed generalized itching followed by urticaria suggesting an allergic reaction. Therefore, he was admitted to the hospital. After admission, he developed an ischaemic-type chest pain associated with autonomic symptoms and shortness of breath. An immediate ECG was taken that showed ST-segment depressions in the chest leads V4–V6, confirmed by a repeat ECG. Troponin I was 8 ng/mL. Acute management of ACS was started, and prednisolone 10 mg daily dose was given. After complete recovery, the patient was discharged with aspirin, clopidogrel, atorvastatin, metoprolol, losartan, isosorbide mononitrate, and nicorandil. Prednisolone 10 mg daily dose was given for five days after discharge.

Conclusion

In immediate hypersensitivity, with persistent cardiovascular instability, Kounis syndrome should be considered, and an electrocardiogram and other appropriate assessments and treatments should be initiated. Prompt management of the allergic reaction and the ACS is vital for a better outcome of Kounis syndrome.

Remimazolam anaphylaxis during anesthesia induction

Anaphylactic shock is a potentially lethal complication during anesthesia and requires appropriate management to save the patient's life. We report a 32-year-old man who developed anaphylaxis during induction of general anesthesia with remimazolam for hand surgery. He received general anesthesia with midazolam 4 weeks before. This time facial flushing followed by a decrease of peripheral oxygen saturation (SpO₂) and blood pressure occurred 2 min after starting continuous remimazolam infusion at 6 mg/kg/h. Hypotension and SpO₂ were recovered by repeated administration of adrenaline. Despite no increase of serum tryptase levels, intradermal allergy tests 4 weeks postoperatively revealed that remimazolam and midazolam were positive, suggesting remimazolam as a causative agent for anaphylaxis. In the previous surgery, midazolam, which has a similar structure to remimazolam, may have caused sensitization. This is probably the first case report of anaphylaxis caused by remimazolam.

Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review

OBJECTIVES

Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications.

DATA SOURCES

A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane).

STUDY SELECTION

Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications.

DATA EXTRACTION

Data from the relevant publications were reviewed, summarized and the information synthesized.

DATA SYNTHESIS

This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions.

CONCLUSION

Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.

Hypersensitivity Myocarditis Due to Antitubercular Drugs in Children

BACKGROUND

Drug-related hypersensitivity myocarditis is a rare acute hypersensitivity reaction to therapeutic agents. Reports of antitubercular drugs causing hypersensitivity myocarditis are not described in literature.

METHODS

Retrospective chart review of children admitted between January 1, 2016, and March 31, 2019, was conducted to identify children receiving antitubercular drugs who were diagnosed with hypersensitivity myocarditis.

RESULTS

Three children (2 girls), who had hypersensitivity myocarditis due to antitubercular therapy, were identified. Cases 1 and 2 developed hypersensitivity myocarditis due to rifampicin, and isoniazid-rifampicin combination, respectively, on reintroduction of drugs, while case 3 developed hypersensitivity to streptomycin on first exposure. All children developed symptoms within minutes to hours of starting the offending drugs. Severe myocardial dysfunction leading to shock and pulmonary edema was seen in cases 1 and 3, while case 2 presented with wide QRS complex ventricular rhythm with bradycardia and hypotensive shock. Cases 1 and 2 were treated with steroids. Cases 1 and 3 received intravenous immunoglobulin therapy. First 2 children survived while third died of refractory shock. Total serum IgE levels were elevated in all children (range: 161-3053 kU/L).

CONCLUSION

Hypersensitivity myocarditis is a rare but life-threatening adverse effect of antitubercular drugs. Prompt diagnosis of hypersensitivity myocarditis and timely steroid therapy can be lifesaving.

Anaphylactic cardiovascular collapse and Kounis syndrome: systemic vasodilation or coronary vasoconstriction?

The first reported human anaphylactic death is considered to be the Pharaoh Menes death, caused by a wasp sting. Currently, anaphylactic cardiovascular events represent one of most frequent medical emergencies. Rapid diagnosis, prompt and appropriate treatment can be life saving. The main concept beyond anaphylaxis lies to myocardial damage and ventricular dysfunction, thus resulting in cardiovascular collapse. Cardiac output depression due to coronary hypoperfusion from systemic vasodilation, leakage of plasma and volume loss due to increased vascular permeability, as well as reduced venous return, are regarded as the main causes of cardiovascular collapse. Clinical reports and experiments indicate that the human heart, in general, and the coronary arteries, in particular, could be the primary target of the released anaphylactic mediators. Coronary vasoconstriction and thrombosis induced by the released mediators namely histamine, chymase, tryptase, cathepsin D, leukotrienes, thromboxane and platelet activating factor (PAF) can result to further myocardial damage and anaphylaxis associated acute coronary syndrome, the so-called Kounis syndrome. Kounis syndrome with increase of cardiac troponin and other cardiac biomarkers, can progress to heart failure and cardiovascular collapse. In experimental anaphylaxis, cardiac reactions caused by the intracardiac histamine and release of other anaphylactic mediators are followed by secondary cardiovascular reactions, such as cardiac arrhythmias, atrioventricular block, acute myocardial ischemia, decrease in coronary blood flow and cardiac output, cerebral blood flow, left ventricular developed pressure (LVdp/dtmax) as well as increase in portal venous and coronary vascular resistance denoting vascular spasm. Clinically, some patients with anaphylactic myocardial infarction respond satisfactorily to appropriate interventional and medical therapy, while anti-allergic treatment with antihistamines, corticosteroids and fluid replacement might be ineffective. Therefore, differentiating the decrease of cardiac output due to myocardial tissue hypoperfusion from systemic vasodilation and leakage of plasma, from myocardial tissue due to coronary vasoconstriction and thrombosis might be challenging during anaphylactic cardiac collapse. Combined antiallergic, anti-ischemic and antithrombotic treatment seems currently beneficial. Simultaneous measurements of peripheral arterial resistance and coronary blood flow with newer diagnostic techniques including cardiac magnetic resonance imaging (MRI) and myocardial scintigraphy may help elucidating the pathophysiology of anaphylactic cardiovascular collapse, thus rendering treatment more rapid and effective.

Cefuroxime-associated Kounis syndrome with unique peculiarity in perioperative prophylaxis

Cefuroxime is a broad spectrum antibacterial agent administered in cases of perioperative prophylaxis. Kounis syndrome is defined as the concurrence of anaphylactic events with acute coronary syndromes. Limited data is available for cefuroxime-associated Kounis syndrome in perioperative prophylaxis. We report the case of a 37-year-old woman undergoing bilateral sweat gland resection who presented with Kounis syndrome following cefuroxime infusion for perioperative prophylaxis. The patient had severe symptoms and unique manifestations that never been reported before: pink frothy sputum indicating heart failure, due to severe systolic dysfunction requiring invasive ventilation and intra-aortic balloon counter-pulsation. Cefuroxime-associated Kounis syndrome has several unique and life-threatening peculiarities which broaden our understanding of clinical and laboratory characteristics. It is important for physicians to be aware of possible cardiovascular complications in perioperative cefuroxime prophylaxis.