Heart attack induced by sulfa drug allergic reaction

[Burritomedic1127]

Had a call a couple days ago for the rollover on a local highway that had me guessing. 4 car MVA one rolled multiple times and everyone, somehow, was ok and ambulatory. One pt was pregnant and wanted to be seen at the hospital just to check on the baby (22 weeks, not the car that rolled, hasn't felt the baby kick after accident). While en route to the hospital, the baby was kicking, vitals were golden on monitor, everyone was thankful no one got hurt. While obtaining past medical hx, the pt states she had a heart attack at 26. Interested, I wanted to peel the onion more and asked the cause of the MI. Sulfonaminde allergic reaction causing the heart attack. Had a guess at a possible understanding the physiology in my head but needed to do some homework.

Found a couple articles/studies stating that potentially cardiac mast cells in an allergic reaction can negatively effect the coronary arteries, I'm assuming vasoconstriction. People with any coronary vessel disease are more predisposed to damaging cardiac events from allergic reactions.

Anybody seen/hear this before? The information I found isn't too satisfying as an answer.

Here's the articles:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2515352/#!po=13.8889

http://www.ncbi.nlm.nih.gov/pubmed/17620826

 

[Carlos Danger]

Anytime tissue oxygen demand is greater than oxygen supply, infarction is a possibility.

With anaphylaxis you have both increased myocardial O2 demand and reduced O2 delivery. Coronary vasoconstriction from chemical mediators may play a role as well, I'm not sure.

 

[Burritomedic1127]

Anytime tissue oxygen demand is greater than oxygen supply, infarction is a possibility.

With anaphylaxis you have both increased myocardial O2 demand and reduced O2 delivery. Coronary vasoconstriction from chemical mediators may play a role as well, I'm not sure.

Figured it was due to some mismatch in demand but was hoping for some type of white rhino cytokine Ive never heard of haha

 

[Ewok Jerky]

What Remi said (as usual)

 

[zzyzx]

Poor historian.

 

[Burritomedic1127]

Poor historian.

?

 

[zzyzx]

Anaphylaxis does not cause a "heart attack." The patient is a poor historian. She misunderstood something that somebody told her, or someone did not educate her properly on whatever happened when she got a sulfa drug.

 

[NomadicMedic]

The term heart attack is often misused and is fairly ambiguous. How many times have you seen or heard the phrase, "he died of a massive heart attack"?

The patient really died from cardiac arrest secondary to an MI, cardiac arrhythmia or hypoxia. My guess is this patient suffered anaphylaxis and required some amount of resuscitation.

I might have peeled the onion a little more and gotten specifics about the "heart attack"... or I might have just said "that's nice" and kept writing my PCR.

 

[Ewok Jerky]

Anaphylaxis does not cause a "heart attack." The patient is a poor historian. She misunderstood something that somebody told her, or someone did not educate her properly on whatever happened when she got a sulfa drug.

You may me be right about her being a poor historian, although discounting a patients history because you don't believe it or it sounds unlikely is not good practice.

Also, if PCN allergy can lead to MI so can any other antigen.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC553970/

 

[NomadicMedic]

Certainly not discounting her history, but it does sound like a case of poor understanding of the past events.

At any rate, if the PT wasn't suffering any cardiac complaints and since you weren't planning to administer a sulfa drug during transport, it's a possible allergy notation and a line in the narrative.

 

[zzyzx]

Good lord, this is a SINGLE case report. I don't doubt that you could find someone with toe pain who developed an acute MI if you Googled hard enough.
I've only looked at this briefly, but there are lots of problems that I see. So, you have an obese guy who is in anaphylactic shock and is given epi twice. An initial 12-lead is not done, but after the second round of epi he starts having chest pain, so they decide to do a 12 lead. This shows elevated ST segments and then they test for troponin and see that it is elevated as well. None of this is surprising, but they freak out and give the poor guy thrombolytics!!!
I just got off a night shift so I'll just let someone else point out all the problems with this scenario. Going back to the original poster, the patient was told something wrong or didn't understand what she was told, big surprise, enough said.

 

[Carlos Danger]

I've never seen it or read about it, but in theory anaphylactic shock (due to sulfa or a bee sting or anything else) could absolutely result in a myocardial infarction. That whole supply:demand thing that I referred to earlier.

I wouldn't automatically assume that someone reporting that as part of their history has no idea what they are talking about.

 

[Ewok Jerky]

This shows elevated ST segments and then they test for troponin and see that it is elevated as well.

You are aware of the definition of "myocardial infarction" right? Where do you think those troponins came from?

anaphylactic SHOCK can certainly lead to poor coronary perfusion and demand ischemia leading to MI, just like any other kind of shock.

The case report I referenced includes a bibliography of 8 other case reports of MI associated with anaphylaxis, unfortunately I do not have full access to review them. Just because there hasn't been a case-control doesn't mean its never happened.

 

[Burritomedic1127]

Good lord, this is a SINGLE case report. I don't doubt that you could find someone with toe pain who developed an acute MI if you Googled hard enough.
I've only looked at this briefly, but there are lots of problems that I see. So, you have an obese guy who is in anaphylactic shock and is given epi twice. An initial 12-lead is not done, but after the second round of epi he starts having chest pain, so they decide to do a 12 lead. This shows elevated ST segments and then they test for troponin and see that it is elevated as well. None of this is surprising, but they freak out and give the poor guy thrombolytics!!!
I just got off a night shift so I'll just let someone else point out all the problems with this scenario. Going back to the original poster, the patient was told something wrong or didn't understand what she was told, big surprise, enough said.

Just a word of advice, they day you downplay pt's as poor historians because of an presumed assumption that they don't understand, is the day you get burned as a provider. With anything, just because there are only a few cases of something rare, doesn't mean they can't happen again or to your patient your downplaying. I'd step down from the pedestal, and never assume. Was my lady from the orginal post in some sort of cardiac distress, No, but that doesn't stop me from researching something that I've never heard of. White rhinos do show up occasionally, and I'm not going to be the *** hat that downplayed one because of my assumption of people or my own misunderstanding of said white rhino.

 

[Christopher]

Anaphylaxis does not cause a "heart attack." The patient is a poor historian. She misunderstood something that somebody told her, or someone did not educate her properly on whatever happened when she got a sulfa drug.

Good lord, this is a SINGLE case report. I don't doubt that you could find someone with toe pain who developed an acute MI if you Googled hard enough.
I've only looked at this briefly, but there are lots of problems that I see. So, you have an obese guy who is in anaphylactic shock and is given epi twice. An initial 12-lead is not done, but after the second round of epi he starts having chest pain, so they decide to do a 12 lead. This shows elevated ST segments and then they test for troponin and see that it is elevated as well. None of this is surprising, but they freak out and give the poor guy thrombolytics!!!
I just got off a night shift so I'll just let someone else point out all the problems with this scenario. Going back to the original poster, the patient was told something wrong or didn't understand what she was told, big surprise, enough said.

The term you're missing, which caused your confusion, is Kounis Syndrome. This is a type of myocardial infarction brought on by an allergen. (As you note, you can also have a Type II MI from vasoconstriction related to epinephrine administration.)