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Acute Fatal Allergic Myocarditis
Acute Fatal Allergic Myocarditis* Report of a Case PER
H.
LANGSJOEN, M.D. AND JAMES
C.
STINSON, M.D.
Temple, Texas
P
ARTICIPATION OF THE MYOCARDIUM IN
generalized allergic reactions, manifested by electrocardiographic changes, has been reported resulting from tetanus antitoxin,'·3 horse serum:" cincophen,· sulfonamides·· a and penicillin.··.. In these reports, the generalized reaction over-shadowed specific cardiac manifestations. A more recent report" suggests that on occasion, the myocardial reaction may be more prominent than the general systemic reaction. The ultimate degree of this disproportion would appear to be manifest in the following case of acute fatal allergic myocarditis with no other ('vidence of allergic reaction.
Hospital Course: He was found reactive to the tetallus antitoxin skin test and was therefore given 1,200,000 units of penicillin intramuscularly, and Y2 m\. of tetanus toxoid. An ice pack was applied to the wounded area after cleansing and minimal debridement. Only sips of water were permitted orally. At 5: 55 a.m., a physician was called to see the patient because of rapid development of shortness of breath and fall in blood pressure. His respirations were labored with blood-tinged saliva coming from his mouth. He was deeply cyanotic. Ten mg. of metaraminol bitartate (Aramine) was given intramuscularly. An emergency tracheostomy was performed without benefit. Heart sounds disappeart'd. He failed to respond to t'xternal cardiac massage
CASE REPORT
This 22-year-old white man was hrou~ht to the emergency room at 4-: 30 a.m. with a gunshot wound in the neck. allegedly inflicted in a hal' room altercation. There was no past history of remote or recent illness. Physical Examination: Blood pressure: 112/ 80; pulse: 94. He was alert and in no distress. Pupils were equal and reacted normally. Neurologic examination revealed no significant abnormality. No abnormality of the heart, lungs, ahdomen or extremities was noted. There were st'\"eral irregular superficial lacerations of the scalp and forehead. On the left side of tht' neck at the mid-lateral portion was a small penetrating wound with irregular edges surrounded by blackish areas be· lieved to be powder burns. Anotht'r larger irregular wound was present in the right posterior scapular area considered to be the wound of exit. A slight amount of subcutaneous emphysema was detected on the anterior surface of the neck. X-ray films of the skull, neck and chest were normal except for some small fragments of radiopaque material in the right posterior scapular region. -From the Cardiovascular Service and Department of Surgical Pathology, Scott and White Clinic. Presented at Fireside Conference, Southern Chapter, American College of Chest Physicians, November 16, 1964, Fouad A. Bashour, M.D., Moderator.
FIGVRE I: (upper) (X 450) Heart showing edema and eosinophilic leukocytes between myocardial fibers. FIGVRE 2. (lower) (X 450) Heart showing edema and eosinophilic leukocytes between myocardial fibers.
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Volume 48, No.4 October 1965
ACUTE FATAL ALLERGIC MYOCARDITIS
and he was pronounced dead at 6: 20 a.m., one hour and 50 minutes after admission. Pathologic Examination: This examination revealed that the path of the projectile had destroyed no vital structure and had caused minimal hemorrhage. There was no aspirated materia I in the air passages and no gross or Inicroscopic evidence of brain danlage. On microscopic examination of the heart, edema was apparent and there was infiltration between the fibers by eosinophils and occasional polymorphonuclear leukocytes (Fig. 1 and 2). Perivascular cuffing hy these cells was also observed. There was, in addition, congestion of the myocardial blood vessels and some lysis of the red ceIJs of the vessels of the right ventricle. The lungs had the histologic appearance of pulmonary congestion and edema, and eosinophils were not prominent in the sections studied. There were no other significant findings. The cause of death in this patient was not considered to be a direct result of his wound. From the clinical course and the microscopic changes in the heart and lungs, death probably was the result of an allergic reaction localized in the heart with acute and fatal cardiac decompensation.
ing needful administration of many potent and occasionally allergenic drugs, an awareness of the possibility of an acute allergic response of the myocardium is pertinent.
2
3
4
5 6
7
8
DISCUSSION
There is no way of estimating the incidence of this condition. A search of the literature indicates that it is extremely rare. It is quite probable that it is overlooked more often than it is identified. In this case, the heart appeared grossly normal. The medico-legal implications demanded postmortem study, without which the diagnosis would have been missed. Allergic myocarditis has been reported responsive to steroid therapy.15 It is doubtful whether this fulminating case could have been successfully treated with steroids, but patients with lesser degrees of the disease might very well be saved. In all probability, the cause of the reaction was pencillin. The possibility that the tetanus toxoid or the tetanus antitoxin skin test was responsible is extremely remote. With the continu-
44 1
9
10
11 12 13 14
15
REFERENCES WADSWORTH, G. H. AND BROWN, C. H.: "Serum Reaction Complicated by Acute Carditis," I. Pediat., 117:801, 1940. Fox, T. T. AND MESSELHOFF, C. R.: "Electriocardiographic Changes in a Case of Serum Sickness due to Tetanus Antitoxin," New York I. M ed., 42: 152, 1942. McMANUS, J. F. AND LAWLOR, J. J.: "Myocardial Infarction following Administration of Tetanus Antitoxin," New Eng. I. Med., 242: 17, 1950. CRAWFORD, T. AND NASSIM, J. R.: "Cardiac Lesions in Rabbits following Injection of Horse Serum," I. Path. Bact., 63:619, 1951. MIKULICICH, G.: "Electrocardiographic Changes in Experimental Anaphylactic Reactions," I. Allergy, 22: 249, 1951. FOSTER, R. F. AND LAYMAN, J. D.: "Generalized Urticaria with Electrocardiographic Changes Simulating Myocardial Infarction," lAMA, 148:203, 1952. LILIENFELD, A., HOCHSTEIN, E. AND WEISS, W.: "Acute Myocarditis with Bundle Branch Block due to Sulfonamide Sensitivity," Circulation, 1: 1060, 1950. FRENCH, A. J. AND WELLER, C. V.: "Interstitial Myocarditis following Clinical and Experimental Use of Sulfonamide Drugs," Am. I. Path., 18: 109, 1942. BINDER, M. J., GUNDERSON, H. J., CANNON, J. AND ROSOVE, L.: "Electrocardiographic Changes Associated with Allergic Reactions to Penicillin," Am. Heart I., 40:940, 1950. PFISTER, C. W. AND PLICE, S. G.: "Acute. Myocardial Infarction during a Prolonged Allergic Reaction to Penicillin," Am. Heart I., 40: 945, 1950. FELDER, S. L. AND FELDER, L.: "Unusual Reactions to Penicillin," lAMA, 143: 361, 1950. GLOTZER, S. L.: "Electrocardiographic Changes During Sensitivity Reaction to Penicillin," Am. Heart I., 47: 300, 1954. BERNREITER, M.: "Electrocardiogram of Patient in Anaphylactic Shock," I AMA, 170 : 1628, 1959. WAUGH, D.: "Myocarditis, Arteritis, and Focal Hepatic, Splenic, and Renal Granuloma apparently due to Penicillin Sensitivity," Am. I. Path., 8:420, 1961 HADEN, R. F. AND LANGSJOEN, P. H.: "Manifestations of Myocardial Involvement in Acute Reactions to Penicillin," Am. I. Cardiol., 8: 420, 1961.
For reprints, please write Scott and White Memorial Hospital, Temple, Texas.
H.
LANGSJOEN, M.D. AND JAMES
C.
STINSON, M.D.
Temple, Texas
P
ARTICIPATION OF THE MYOCARDIUM IN
generalized allergic reactions, manifested by electrocardiographic changes, has been reported resulting from tetanus antitoxin,'·3 horse serum:" cincophen,· sulfonamides·· a and penicillin.··.. In these reports, the generalized reaction over-shadowed specific cardiac manifestations. A more recent report" suggests that on occasion, the myocardial reaction may be more prominent than the general systemic reaction. The ultimate degree of this disproportion would appear to be manifest in the following case of acute fatal allergic myocarditis with no other ('vidence of allergic reaction.
Hospital Course: He was found reactive to the tetallus antitoxin skin test and was therefore given 1,200,000 units of penicillin intramuscularly, and Y2 m\. of tetanus toxoid. An ice pack was applied to the wounded area after cleansing and minimal debridement. Only sips of water were permitted orally. At 5: 55 a.m., a physician was called to see the patient because of rapid development of shortness of breath and fall in blood pressure. His respirations were labored with blood-tinged saliva coming from his mouth. He was deeply cyanotic. Ten mg. of metaraminol bitartate (Aramine) was given intramuscularly. An emergency tracheostomy was performed without benefit. Heart sounds disappeart'd. He failed to respond to t'xternal cardiac massage
CASE REPORT
This 22-year-old white man was hrou~ht to the emergency room at 4-: 30 a.m. with a gunshot wound in the neck. allegedly inflicted in a hal' room altercation. There was no past history of remote or recent illness. Physical Examination: Blood pressure: 112/ 80; pulse: 94. He was alert and in no distress. Pupils were equal and reacted normally. Neurologic examination revealed no significant abnormality. No abnormality of the heart, lungs, ahdomen or extremities was noted. There were st'\"eral irregular superficial lacerations of the scalp and forehead. On the left side of tht' neck at the mid-lateral portion was a small penetrating wound with irregular edges surrounded by blackish areas be· lieved to be powder burns. Anotht'r larger irregular wound was present in the right posterior scapular area considered to be the wound of exit. A slight amount of subcutaneous emphysema was detected on the anterior surface of the neck. X-ray films of the skull, neck and chest were normal except for some small fragments of radiopaque material in the right posterior scapular region. -From the Cardiovascular Service and Department of Surgical Pathology, Scott and White Clinic. Presented at Fireside Conference, Southern Chapter, American College of Chest Physicians, November 16, 1964, Fouad A. Bashour, M.D., Moderator.
FIGVRE I: (upper) (X 450) Heart showing edema and eosinophilic leukocytes between myocardial fibers. FIGVRE 2. (lower) (X 450) Heart showing edema and eosinophilic leukocytes between myocardial fibers.
440
Volume 48, No.4 October 1965
ACUTE FATAL ALLERGIC MYOCARDITIS
and he was pronounced dead at 6: 20 a.m., one hour and 50 minutes after admission. Pathologic Examination: This examination revealed that the path of the projectile had destroyed no vital structure and had caused minimal hemorrhage. There was no aspirated materia I in the air passages and no gross or Inicroscopic evidence of brain danlage. On microscopic examination of the heart, edema was apparent and there was infiltration between the fibers by eosinophils and occasional polymorphonuclear leukocytes (Fig. 1 and 2). Perivascular cuffing hy these cells was also observed. There was, in addition, congestion of the myocardial blood vessels and some lysis of the red ceIJs of the vessels of the right ventricle. The lungs had the histologic appearance of pulmonary congestion and edema, and eosinophils were not prominent in the sections studied. There were no other significant findings. The cause of death in this patient was not considered to be a direct result of his wound. From the clinical course and the microscopic changes in the heart and lungs, death probably was the result of an allergic reaction localized in the heart with acute and fatal cardiac decompensation.
ing needful administration of many potent and occasionally allergenic drugs, an awareness of the possibility of an acute allergic response of the myocardium is pertinent.
2
3
4
5 6
7
8
DISCUSSION
There is no way of estimating the incidence of this condition. A search of the literature indicates that it is extremely rare. It is quite probable that it is overlooked more often than it is identified. In this case, the heart appeared grossly normal. The medico-legal implications demanded postmortem study, without which the diagnosis would have been missed. Allergic myocarditis has been reported responsive to steroid therapy.15 It is doubtful whether this fulminating case could have been successfully treated with steroids, but patients with lesser degrees of the disease might very well be saved. In all probability, the cause of the reaction was pencillin. The possibility that the tetanus toxoid or the tetanus antitoxin skin test was responsible is extremely remote. With the continu-
44 1
9
10
11 12 13 14
15
REFERENCES WADSWORTH, G. H. AND BROWN, C. H.: "Serum Reaction Complicated by Acute Carditis," I. Pediat., 117:801, 1940. Fox, T. T. AND MESSELHOFF, C. R.: "Electriocardiographic Changes in a Case of Serum Sickness due to Tetanus Antitoxin," New York I. M ed., 42: 152, 1942. McMANUS, J. F. AND LAWLOR, J. J.: "Myocardial Infarction following Administration of Tetanus Antitoxin," New Eng. I. Med., 242: 17, 1950. CRAWFORD, T. AND NASSIM, J. R.: "Cardiac Lesions in Rabbits following Injection of Horse Serum," I. Path. Bact., 63:619, 1951. MIKULICICH, G.: "Electrocardiographic Changes in Experimental Anaphylactic Reactions," I. Allergy, 22: 249, 1951. FOSTER, R. F. AND LAYMAN, J. D.: "Generalized Urticaria with Electrocardiographic Changes Simulating Myocardial Infarction," lAMA, 148:203, 1952. LILIENFELD, A., HOCHSTEIN, E. AND WEISS, W.: "Acute Myocarditis with Bundle Branch Block due to Sulfonamide Sensitivity," Circulation, 1: 1060, 1950. FRENCH, A. J. AND WELLER, C. V.: "Interstitial Myocarditis following Clinical and Experimental Use of Sulfonamide Drugs," Am. I. Path., 18: 109, 1942. BINDER, M. J., GUNDERSON, H. J., CANNON, J. AND ROSOVE, L.: "Electrocardiographic Changes Associated with Allergic Reactions to Penicillin," Am. Heart I., 40:940, 1950. PFISTER, C. W. AND PLICE, S. G.: "Acute. Myocardial Infarction during a Prolonged Allergic Reaction to Penicillin," Am. Heart I., 40: 945, 1950. FELDER, S. L. AND FELDER, L.: "Unusual Reactions to Penicillin," lAMA, 143: 361, 1950. GLOTZER, S. L.: "Electrocardiographic Changes During Sensitivity Reaction to Penicillin," Am. Heart I., 47: 300, 1954. BERNREITER, M.: "Electrocardiogram of Patient in Anaphylactic Shock," I AMA, 170 : 1628, 1959. WAUGH, D.: "Myocarditis, Arteritis, and Focal Hepatic, Splenic, and Renal Granuloma apparently due to Penicillin Sensitivity," Am. I. Path., 8:420, 1961 HADEN, R. F. AND LANGSJOEN, P. H.: "Manifestations of Myocardial Involvement in Acute Reactions to Penicillin," Am. I. Cardiol., 8: 420, 1961.
For reprints, please write Scott and White Memorial Hospital, Temple, Texas.