Case series on drug-induced anaphylactic shock

Kowsalya Devi. S

Clinical Pharmacist, Kauvery Hospital, Hosur

Background

Anaphylaxis is a clinical diagnosis, based on physical findings on presentation. with or without a history of exposure to an allergen ^[1]. Anaphylaxis is a rapid systemic and unpredictable disorder that is life-threatening, defined as a generalized, rapidly evolving, multi-systemic allergic reaction ^[2]Without treatment, anaphylaxis is often fatal due to its rapid progression to respiratory collapse. Anaphylactic reactions were classified as IgE-mediated responses, while anaphylactic reactions as IgE-independent events. ^[3]. Anaphylaxis causes the immune system to release a flood of chemicals that can cause shock. Blood pressure drops suddenly and the airways narrow, blocking breathing.

Case Presentation

1. NSAID’s Induced Anaphylactic Shock

A 54 year old male came to the Emergency with complaints of itching (both hands), difficulty in breathing and followed by syncope – 5 sec.

Patient had a history of neck pain and shoulder pain for one day. He was initially treated in outside hospital he took oral Tab. Intagesic MR (Chlorzoxazone 250mg, Diclofenac 50mg, Paracetamol 325mg) 1-0-1. After administration of Tab. Intagesic MR, patient had developed anaphylactic shock. He had no known allergy to drug or any other substances.

Vitals – Blood pressure (BP) was found to be 80/60 mmHg with a pulse rate of 86 bpm Oxygen Saturation by Pulse Oximeter (SPO2) was 99% in room air.

Management

Patient was stabilized with parenteral rehydration , and oxygen therapy via facemask along with Neb. Duolin + Budecort 12 hourly , Inj. Adrenaline 1ml IV stat ,Tab. Allegra M Oral HS, Tab. Delacort 24mg oral 1 ½ -0-0. Antiemetics (intravenous Ondansetron) PPI’s (intravenous Pantoprazole). The patient was discharged stable. On follow-up after a week, he was improving and there were no complaints.

2. Amoxicillin Induced Anaphylactic Shock

A 30-year-old male patient was admitted with C/O difficulty in retracting prepuce back. .He had h/o occasional pain.

Surgery plan was – Frenuloplasty + Stapler circumsion. Antibiotic was administered before surgery – Inj. Amoxicillin + Potassium Clavunate 1.2 g ID; test dose 1ml was given and patient had symptoms of giddiness, hypotension, and low pulse rate. He was found to be in Amoxicillin induced Anaphylactic Shock. Vitals – Blood pressure (BP) was found to be 90/60 mmHg with a pulse rate of 40 bpm, Oxygen Saturation by Pulse Oximeter (SPO2) was 95% in room air.

Management

Patient was stabilized with Inj. Hydrocortisone 100mg IV stat, Inj. Adrenaline 1ml IV stat, Inj. Ofloxacin 200mg IV stat given. He became stable and proceeded to undergo the procedure. He was discharged with stable vitals and following medications Tab. Ofloxacin 200mg oral twice a day for 5 days.

3. Ranitidine induced Anaphylactic Shock

A 67 years old female patient was brought to ER with c/o Itching all over the body, giddiness, headache, profuse sweating, generalized tiredness, palpitation and chest discomfort.

Patient was initially treated in outside hospital for Acute Gastritis ,She took oral Tab. Ranitidine 150 mg in morning .Patient had symptoms post ingestion of Ranitidine. After administration of Tab. Ranitidine 150 mg, patient had developed Anaphylactic shock. He had no previous history of allergies to any medication.

Vitals: Blood pressure (BP) was found to be 90/60 mmHg with a pulse rate of 86 bpm, Oxygen Saturation by Pulse Oximeter (SPO2) was 96% in room air.

Management

Patient was managed with Inj. Adrenaline 1ml IV stat, Inj. Avil 2ml IV Stat, Inj. Hydrocortisone 100mg IV Stat, Inj. Pan 40mg IV Stat, Inj. Emeset 4mg IV Stat .Patient was symptomatically better, hence she was discharged. Vital signs at the time were within normal limits .

Conclusion

Anaphylactic Shock is a severe ADR, This case report was prepared to highlight rare and unusual adverse reactions to widely used drugs. When the patient has a sharp drop in blood pressure, weak or rapid heart rate, and an increase in respiratory resistance within an extremely short period, and no other reason can explain, it should be taken into account that there was a serious allergic event to a drug. However, knowledge of these types of rare events should be disseminated to create awareness among the researchers and physicians. This ultimately ensures the approach for safe therapy. Adverse Drug Reaction Card was provided to the patient to avoid this type of reaction in the future.

Reference

Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M, Santos AF, Zolkipli ZQ, Bellou A, Beyer K, Bindslev‐Jensen C. Anaphylaxis: guidelines from the European Academy of Allergy and C linical Immunology. Allergy. 2014 Aug;69(8):1026-45.
Okubo Y, Nochioka K, Testa MA. Nationwide survey of hospitalization due to pediatric food-induced anaphylaxis in the United States. Pediatric Emergency Care. 2019 Nov 1;35(11):769-73.
Castilano A, Sternard B, Cummings ED, Shi R, Arnold T, Bahna SL. Pitfalls in anaphylaxis diagnosis and management at a university emergency department. InAllergy & Asthma Proceedings 2018 Jul 1 (Vol. 39, No. 4).

Kowsalya Devi. S
Clinical Pharmacist

Case series on drug-induced anaphylactic shock