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AROUSED TO ATRIAL FIBRILLATION?
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AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 18, Number 5 • September 2000
diflunisal. Knowledge of this interference is important when salicylate toxicity or diflunisal overdose is suspected. PAULA. Szucs, MD
Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ RICHARD D. SHIH, MD
Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ New Jersey Poison Center Newark Beth Israel Medical Center Newark, NJ STEVEN M. MARCUS, MD
K. LEFF P.DELGADO
New Jersey Poison Center Newark Beth Israel Medical Center Newark, NJ
References 1. Litovitz TL, Smilkstein M, Felberg L, et al: 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1997;15:447-500 2. Almond G, Clark RF: Nonsteroidal Anti-inflammatory Agents, in Tintinalli JE, Ruiz E, Krome RL (eds): Emergency Medicine: A Comprehensive Study Guide. New York, NY McGraw-Hili, 1996, pp 792-796 3. Tocco DJ, Breault Go, Zacchei AG, et al: Physiological disposition and metabolism of 5-(2',4'-difluorophenyl) salicylic acid, a new salicylate. Drug Metab Dispos 1975;3:453-466 4. Sarma L, Wang SH, DeliaFera S: Diflunisal significantly interferes with salicylate measurements by FPIA-TDx® and UV-VIS aca method. Clin Chem 1985;31:1922-1923 5. Dalrymple RW, Stearns FM: Diflunisal interferes with determination of salicylate by the Trinder, Abbott TDx® and Dupont aca® method. Clin Chem 1986;32:230 6. Duffens KR, Smilkstein MJ, Bessen HA, et al: Falsely elevated salicylate levels due to diflunisal overdose. J Emerg Med 1987;5:499503V
Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1805-0021 $1 0.00/0 doi:1 0.1 053/ajem.2000.9277
AROUSED TO ATRIAL FIBRILLATION? To the Editor:-Viagra (sildenafil), a phosphodiesterase inhibitor used for erectile dysfunction,I,2 is associated with profound hypotension and myocardial ischemia when combined with nitrates. 3 Because affected patients tend to have cardiovascular disease and use multiple medications, it is difficult to define the exact cause for their adverse events. The sexual activity, sildenafil, drug interactions, or the patient's underlying cardiovascular disease can all be implicated. We describe a young healthy patient who developed atrial fibrillation while taking sildenafil for his impotence. A 35-year-old man presented to the hospital, complaining of persistent palpitations that began I hour after ingesting a single 100 mg tablet of sildenafil. The patient interrupted coitus because he felt lightheaded and had palpitations which were followed by a brief syncopal episode. He denied other symptoms or the use of ethanol, recreational drugs including inhaled nitrites, or prescription medicines. His medical history was only significant for erectile dysfunction, and he had used sildenafil previously without complication. Physical examination revealed an alert, anxious male whose vital
signs were normal except for an irregular heart rate ranging between 130 to 140 beats/minute. The cardiac examination revealed an irregularly irregular rhythm without any murmurs. The remainder of his physical examination was normal. An electrocardiogram showed atrial fibrillation at a rate of 114 beats/minute and was without ST segment or T wave abnormalities. Chest radiograph and routine laboratories including complete blood count, electrolytes, liver function tests, coagulation studies, urine toxicology, and cardiac enzymes revealed no abnormalities. Echocardiogram showed only mild tricuspid regurgitation. While in the emergency department, the patient was treated with diltiazem, 25 mg by intravenous bolus and was maintained on a continuous infusion for rate control. He failed chemical conversion twice with intravenous ibutilide, but converted spontaneously 2 days later. His follow-up examination was normal. The temporal relationship between the ingestion of sildenafil and new onset atrial fibrillation in a patient with no known risk factors for atrial fibrillation suggests that sildenafil was causally related to the arrhythmia. We can only assume that the atrial fibrillation occurred during intercourse when the patient developed palpitations and an eventual syncopal episode. We postulate that sildenafil may have caused profound hypotension leading to syncope and reflex tachycardia through catecholamine excess. There have been reports of sildenafil associated myocardial infarction4 and other cardiovascular events. However, we believe that this is the first documented report of sildenafil-associated atrial fibrillation. IN-HE! HAHN, MD ROBERT S. HOFFMAN, MD
New York City Poison Center New York, NY
References 1, Pfizer, Viagra (sildenafil citrate) drug insert, 1998 revised 2, Goldstein I, Lue TF, Padma-Nathan H, et al: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397-404 3. Summary of Reports of Death in Viagra Users Received from Marketing (late March) through mid-November 1998, accessed November 1998, http:www.fda.gov/cder/foi/labeI/1998/ViagralabeI2.pdf 4. Feenstra J, van Drie-Pierik RJHM, Lacle CF, et al: Acute myocardial infarction associated with sildenafil. Lancet 1998;352:957958
Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1805-0022$10.0010 doi:1 0, 1053/ajem.2000,9273
ANAPHYLAXIS FROM INTRAVENOUS THIAMINE-LONG FORGOTTEN? To the Editor:-Anaphylactic reactions to administration of thiamine hydrochloride, although very uncommon can be life threatening. Routine administration of thiamine is commonly practiced by emergency physicians and internists alike while dealing with chronic alcoholics, malnourished and other patients at risk for thiamine deficiency. 1 We present this case of anaphylaxis to intravenous administration of thiamine, a reminder that despite its enormous safety profile, an assumption that thiamine is completely innocuous cannot be made. A 51-year-old woman with history of diabetes mellitus, chronic alcoholism and anxiety disorder was found by the EMS in an acute confusional state. Her home medications included insulin and lorazepam. The family mentioned an allergy to penicillin. Vital signs were: pulse rate 100 beats/min, blood pressure 118/70 mmHg, respiratory rate 20 breaths/min. Twenty-five g of 50% dextrose and 100 mg of thiamine hydrochloride were administered by the EMS intravenously. On arrival at the hospital 20 minutes
AMERICAN JOURNAL OF EMERGENCY MEDICINE. Volume 18, Number 5 • September 2000
diflunisal. Knowledge of this interference is important when salicylate toxicity or diflunisal overdose is suspected. PAULA. Szucs, MD
Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ RICHARD D. SHIH, MD
Department of Emergency Medicine Morristown Memorial Hospital Morristown, NJ New Jersey Poison Center Newark Beth Israel Medical Center Newark, NJ STEVEN M. MARCUS, MD
K. LEFF P.DELGADO
New Jersey Poison Center Newark Beth Israel Medical Center Newark, NJ
References 1. Litovitz TL, Smilkstein M, Felberg L, et al: 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1997;15:447-500 2. Almond G, Clark RF: Nonsteroidal Anti-inflammatory Agents, in Tintinalli JE, Ruiz E, Krome RL (eds): Emergency Medicine: A Comprehensive Study Guide. New York, NY McGraw-Hili, 1996, pp 792-796 3. Tocco DJ, Breault Go, Zacchei AG, et al: Physiological disposition and metabolism of 5-(2',4'-difluorophenyl) salicylic acid, a new salicylate. Drug Metab Dispos 1975;3:453-466 4. Sarma L, Wang SH, DeliaFera S: Diflunisal significantly interferes with salicylate measurements by FPIA-TDx® and UV-VIS aca method. Clin Chem 1985;31:1922-1923 5. Dalrymple RW, Stearns FM: Diflunisal interferes with determination of salicylate by the Trinder, Abbott TDx® and Dupont aca® method. Clin Chem 1986;32:230 6. Duffens KR, Smilkstein MJ, Bessen HA, et al: Falsely elevated salicylate levels due to diflunisal overdose. J Emerg Med 1987;5:499503V
Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1805-0021 $1 0.00/0 doi:1 0.1 053/ajem.2000.9277
AROUSED TO ATRIAL FIBRILLATION? To the Editor:-Viagra (sildenafil), a phosphodiesterase inhibitor used for erectile dysfunction,I,2 is associated with profound hypotension and myocardial ischemia when combined with nitrates. 3 Because affected patients tend to have cardiovascular disease and use multiple medications, it is difficult to define the exact cause for their adverse events. The sexual activity, sildenafil, drug interactions, or the patient's underlying cardiovascular disease can all be implicated. We describe a young healthy patient who developed atrial fibrillation while taking sildenafil for his impotence. A 35-year-old man presented to the hospital, complaining of persistent palpitations that began I hour after ingesting a single 100 mg tablet of sildenafil. The patient interrupted coitus because he felt lightheaded and had palpitations which were followed by a brief syncopal episode. He denied other symptoms or the use of ethanol, recreational drugs including inhaled nitrites, or prescription medicines. His medical history was only significant for erectile dysfunction, and he had used sildenafil previously without complication. Physical examination revealed an alert, anxious male whose vital
signs were normal except for an irregular heart rate ranging between 130 to 140 beats/minute. The cardiac examination revealed an irregularly irregular rhythm without any murmurs. The remainder of his physical examination was normal. An electrocardiogram showed atrial fibrillation at a rate of 114 beats/minute and was without ST segment or T wave abnormalities. Chest radiograph and routine laboratories including complete blood count, electrolytes, liver function tests, coagulation studies, urine toxicology, and cardiac enzymes revealed no abnormalities. Echocardiogram showed only mild tricuspid regurgitation. While in the emergency department, the patient was treated with diltiazem, 25 mg by intravenous bolus and was maintained on a continuous infusion for rate control. He failed chemical conversion twice with intravenous ibutilide, but converted spontaneously 2 days later. His follow-up examination was normal. The temporal relationship between the ingestion of sildenafil and new onset atrial fibrillation in a patient with no known risk factors for atrial fibrillation suggests that sildenafil was causally related to the arrhythmia. We can only assume that the atrial fibrillation occurred during intercourse when the patient developed palpitations and an eventual syncopal episode. We postulate that sildenafil may have caused profound hypotension leading to syncope and reflex tachycardia through catecholamine excess. There have been reports of sildenafil associated myocardial infarction4 and other cardiovascular events. However, we believe that this is the first documented report of sildenafil-associated atrial fibrillation. IN-HE! HAHN, MD ROBERT S. HOFFMAN, MD
New York City Poison Center New York, NY
References 1, Pfizer, Viagra (sildenafil citrate) drug insert, 1998 revised 2, Goldstein I, Lue TF, Padma-Nathan H, et al: Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397-404 3. Summary of Reports of Death in Viagra Users Received from Marketing (late March) through mid-November 1998, accessed November 1998, http:www.fda.gov/cder/foi/labeI/1998/ViagralabeI2.pdf 4. Feenstra J, van Drie-Pierik RJHM, Lacle CF, et al: Acute myocardial infarction associated with sildenafil. Lancet 1998;352:957958
Copyright © 2000 by W.B. Saunders Company 0735-6757/00/1805-0022$10.0010 doi:1 0, 1053/ajem.2000,9273
ANAPHYLAXIS FROM INTRAVENOUS THIAMINE-LONG FORGOTTEN? To the Editor:-Anaphylactic reactions to administration of thiamine hydrochloride, although very uncommon can be life threatening. Routine administration of thiamine is commonly practiced by emergency physicians and internists alike while dealing with chronic alcoholics, malnourished and other patients at risk for thiamine deficiency. 1 We present this case of anaphylaxis to intravenous administration of thiamine, a reminder that despite its enormous safety profile, an assumption that thiamine is completely innocuous cannot be made. A 51-year-old woman with history of diabetes mellitus, chronic alcoholism and anxiety disorder was found by the EMS in an acute confusional state. Her home medications included insulin and lorazepam. The family mentioned an allergy to penicillin. Vital signs were: pulse rate 100 beats/min, blood pressure 118/70 mmHg, respiratory rate 20 breaths/min. Twenty-five g of 50% dextrose and 100 mg of thiamine hydrochloride were administered by the EMS intravenously. On arrival at the hospital 20 minutes