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ST elevation in inferior derivation, coronary ectasia, and slow coronary flow following ceftriaxone use
American Journal of Emergency Medicine (2012) 30, 1657.e5–1657.e7
www.elsevier.com/locate/ajem
Case Report ST elevation in inferior derivation, coronary ectasia, and slow coronary flow following ceftriaxone use
low–molecular weight heparin, and diltiazem. In this case study, we presented acute coronary events following an allergic reaction to ceftriaxone.
Abstract A 24-year-old male patient presented with acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone. A coronary angiogram revealed ectasia and slow coronary flow in the right coronary artery, whereas the left coronary system was found to be normal. The patient was transferred to the coronary intensive care unit and given steroids, antihistamines, acetylsalicylic acid, clopidogrel,
Fig. 1
A ceftriaxone intramuscular injection was given to a 24year-old male patient who presented at the clinic with sore throat and coughing due to a lower respiratory tract infection. After receiving the ceftriaxone injection, the patient developed severe retrosternal chest pain, dyspnea, and redness in the face and eyes and was later diagnosed with an inferior myocardial infarction and transferred to the cardiology clinic of the Medikal Park Hospital after the first
Electrocardiogram shows ST elevation at inferior leads upon admission.
0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
1657.e6
Case Report
treatment was given (Fig. 1). The patient's eyesight was perturbed, there was redness in the skin and the face, and an arterial blood pressure of 90/60 mm Hg and a pulse of 75 beats per minute were noted upon admission to the cardiology clinic. The patient's new electrocardiogram in our hospital revealed an improved elevation of ST at the inferior derivations (Fig. 2). It was decided that the patient should receive an emergency coronary angiography because of the potential of spontaneous recanalization. The left coronary system was found to be normal using coronary angiography. There was clear ectasia in the right coronary artery, and opaque contrast agent was cleared very slowly (taking approximately 50-60 seconds) (Fig. 3). The patient was transferred to the coronary intensive care unit and given steroids, antihistamines (H1 and H2 blockers), acetylsalicylic acid, clopidogrel, low–molecular weight heparin, and diltiazem. There were borderline levels of troponin T both at the time of admission to the cardiology clinic and during follow-up. The patient was discharged with appropriate recommendations from the hospital. In this case study, we have described a young male who presented with acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone. Ceftriaxone is a third-generation cephalosporin antibacterial agent commonly used in Turkey. It is widely used to treat many infections, most commonly lower and upper respiratory tract infections caused by gram-positive pathogens. Cepha-
Fig. 2
losporin, like penicillin, may also cause an anaphylactic reaction. However, this is a rare adverse effect [1]. Coronary artery ectasia is rare coronary artery anomaly. It is defined as the abnormal dilatation of a segment of a coronary artery to a diameter that is 50% larger than the normal adjacent segments or 50% larger than the largest diameter of the coronary artery. The dilation can be regional or diffuse and can be seen with isolated or narrowing coronary artery disease [2]. Ischemia does not occur in the normal manner in patients with coronary artery ectasia. Gulec et al previously showed that patients with ectasia have decreased epicardial and microvascular perfusions [3]. Coronary flow was measured in another study; and it was determined that there was a decrease in flow rate in aneurysms, whereas the rate returned to normal in adjacent nondilated segments [4]. Slow coronary flow was first described by Tambe et al in 1972 [5]. They found that it is characterized by a delay in the flow of opaque contrast media in the coronary arteries in the absence of stenosis in the epicardial vessels. Slow coronary flow is diagnosed using angiograms and is measured by the number of images that need to be acquired to capture the movement of contrast agent from the start to the termination of a coronary vessel. The TIMI frame count method was suggested by Gibson et al [6]. The reference range of frames for the right coronary artery is 20.4 ± 3.0. The thrombolysis i myocardial
Electrocardiogram while patient was in our hospital.
Case Report
1657.e7 reflow phenomenon caused by microemboli during percutaneous coronary intervention. This case is interesting for 2 reasons. Firstly, acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone has never been reported. Secondly, it is interesting to note that coronary ectasia and slow coronary flow have never been shown to lead to acute coronary syndrome following an allergic reaction, due to presumably distal coronary spasm. T. Fikret İlgenli MD Department of Cardiology Gölcük Military Hospital 41650 Kocaeli, Turkey E-mail address: [email protected] Ayça Açıkalın MD Department of Emergency Medicine Gaziantep 25 Aralık Government Hospital Gaziantep, Turkey Serdar Türkmen MD Ahmet Avcı MD Onur Akpınar MD Department of Cardiology Medikal Park Hospital Gaziantep, Turkey doi:10.1016/j.ajem.2011.08.004
References Fig. 3 A and B, Coronary angiogram of the right coronary artery. Angiogram shows ectasia and slow flow.
infarction (TIMI) frame count was 40 in the patient described in this case report. The etiopathogenesis is not clearly understood; but it has been suggested that high levels of serum uric acid, postprandial blood sugar, and platelets number/function are implicated [7,8]. Myocardial infarction with ST elevation was previously reported in patients with coronary ectasia [9]. Allergic coronary spasm (Kounis syndrome) is a wellknown disease that develops in response to various allergens [10]. Vasospasm of the coronary arteries has been suggested to be the main pathophysiologic mechanism. Local releases of vasoconstrictor substances cause macro- and microvascular constriction. However, in our patient, we saw coronary ectasia and slow coronary flow and, also, inadequate myocardial perfusion (myocardial blush) in the right coronary artery. We thought that distal (micro) coronary spasm was a pathophysiologic mechanism in our patient. This finding was similar to the coronary no-
[1] Kelkar PS, Li JTC. Cephalosporin allergy. N Engl J Med 2001;385: 804-9. [2] Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134-8. [3] Gulec S, Atmaca Y, Kilickap M, Akyurek O, Aras O, Oral D. Angiographic assessment of myocardial perfusion in patients with isolated coronary artery ectasia. Am J Cardiol 2003;91:996-9. [4] Hamaoka K, Onouchi Z, Kamiya Y, et al. Evaluation of coronary flow velocity dynamics and flow reserve in patients with Kawasaki disease by means of a Doppler guide wire. J Am Coll Cardiol 1998;31:833-40. [5] Tambe AA, Demany MA, Zimmerman HA. Angina pectoris and slow flow velocity of dye in coronary arteries—a new angiographic finding. Am Heart J 1972;84:66-71. [6] Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 1996;93:879-88. [7] Xia S, Deng SB, Wang Y, et al. Clinical analysis of the risk factors of slow coronary flow. Heart Vessels 2011 Jan 5. DOI:10.1007/s00380010-0081-5. [8] Gökçe M, Kaplan S, Tekelioğlu Y, et al. Platelet function disorder in patients with coronary slow flow. Clin Cardiol 2005;28:145-8. [9] Mrdović I, Jozić T, Ašanin M, et al. Myocardial Reinfarction in a patient with Coronary Ectasia. Cardiology 2004;102:32-4. [10] Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract 1991;45:121-8.
www.elsevier.com/locate/ajem
Case Report ST elevation in inferior derivation, coronary ectasia, and slow coronary flow following ceftriaxone use
low–molecular weight heparin, and diltiazem. In this case study, we presented acute coronary events following an allergic reaction to ceftriaxone.
Abstract A 24-year-old male patient presented with acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone. A coronary angiogram revealed ectasia and slow coronary flow in the right coronary artery, whereas the left coronary system was found to be normal. The patient was transferred to the coronary intensive care unit and given steroids, antihistamines, acetylsalicylic acid, clopidogrel,
Fig. 1
A ceftriaxone intramuscular injection was given to a 24year-old male patient who presented at the clinic with sore throat and coughing due to a lower respiratory tract infection. After receiving the ceftriaxone injection, the patient developed severe retrosternal chest pain, dyspnea, and redness in the face and eyes and was later diagnosed with an inferior myocardial infarction and transferred to the cardiology clinic of the Medikal Park Hospital after the first
Electrocardiogram shows ST elevation at inferior leads upon admission.
0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved.
1657.e6
Case Report
treatment was given (Fig. 1). The patient's eyesight was perturbed, there was redness in the skin and the face, and an arterial blood pressure of 90/60 mm Hg and a pulse of 75 beats per minute were noted upon admission to the cardiology clinic. The patient's new electrocardiogram in our hospital revealed an improved elevation of ST at the inferior derivations (Fig. 2). It was decided that the patient should receive an emergency coronary angiography because of the potential of spontaneous recanalization. The left coronary system was found to be normal using coronary angiography. There was clear ectasia in the right coronary artery, and opaque contrast agent was cleared very slowly (taking approximately 50-60 seconds) (Fig. 3). The patient was transferred to the coronary intensive care unit and given steroids, antihistamines (H1 and H2 blockers), acetylsalicylic acid, clopidogrel, low–molecular weight heparin, and diltiazem. There were borderline levels of troponin T both at the time of admission to the cardiology clinic and during follow-up. The patient was discharged with appropriate recommendations from the hospital. In this case study, we have described a young male who presented with acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone. Ceftriaxone is a third-generation cephalosporin antibacterial agent commonly used in Turkey. It is widely used to treat many infections, most commonly lower and upper respiratory tract infections caused by gram-positive pathogens. Cepha-
Fig. 2
losporin, like penicillin, may also cause an anaphylactic reaction. However, this is a rare adverse effect [1]. Coronary artery ectasia is rare coronary artery anomaly. It is defined as the abnormal dilatation of a segment of a coronary artery to a diameter that is 50% larger than the normal adjacent segments or 50% larger than the largest diameter of the coronary artery. The dilation can be regional or diffuse and can be seen with isolated or narrowing coronary artery disease [2]. Ischemia does not occur in the normal manner in patients with coronary artery ectasia. Gulec et al previously showed that patients with ectasia have decreased epicardial and microvascular perfusions [3]. Coronary flow was measured in another study; and it was determined that there was a decrease in flow rate in aneurysms, whereas the rate returned to normal in adjacent nondilated segments [4]. Slow coronary flow was first described by Tambe et al in 1972 [5]. They found that it is characterized by a delay in the flow of opaque contrast media in the coronary arteries in the absence of stenosis in the epicardial vessels. Slow coronary flow is diagnosed using angiograms and is measured by the number of images that need to be acquired to capture the movement of contrast agent from the start to the termination of a coronary vessel. The TIMI frame count method was suggested by Gibson et al [6]. The reference range of frames for the right coronary artery is 20.4 ± 3.0. The thrombolysis i myocardial
Electrocardiogram while patient was in our hospital.
Case Report
1657.e7 reflow phenomenon caused by microemboli during percutaneous coronary intervention. This case is interesting for 2 reasons. Firstly, acute coronary syndrome with ST elevation following an allergic reaction to ceftriaxone has never been reported. Secondly, it is interesting to note that coronary ectasia and slow coronary flow have never been shown to lead to acute coronary syndrome following an allergic reaction, due to presumably distal coronary spasm. T. Fikret İlgenli MD Department of Cardiology Gölcük Military Hospital 41650 Kocaeli, Turkey E-mail address: [email protected] Ayça Açıkalın MD Department of Emergency Medicine Gaziantep 25 Aralık Government Hospital Gaziantep, Turkey Serdar Türkmen MD Ahmet Avcı MD Onur Akpınar MD Department of Cardiology Medikal Park Hospital Gaziantep, Turkey doi:10.1016/j.ajem.2011.08.004
References Fig. 3 A and B, Coronary angiogram of the right coronary artery. Angiogram shows ectasia and slow flow.
infarction (TIMI) frame count was 40 in the patient described in this case report. The etiopathogenesis is not clearly understood; but it has been suggested that high levels of serum uric acid, postprandial blood sugar, and platelets number/function are implicated [7,8]. Myocardial infarction with ST elevation was previously reported in patients with coronary ectasia [9]. Allergic coronary spasm (Kounis syndrome) is a wellknown disease that develops in response to various allergens [10]. Vasospasm of the coronary arteries has been suggested to be the main pathophysiologic mechanism. Local releases of vasoconstrictor substances cause macro- and microvascular constriction. However, in our patient, we saw coronary ectasia and slow coronary flow and, also, inadequate myocardial perfusion (myocardial blush) in the right coronary artery. We thought that distal (micro) coronary spasm was a pathophysiologic mechanism in our patient. This finding was similar to the coronary no-
[1] Kelkar PS, Li JTC. Cephalosporin allergy. N Engl J Med 2001;385: 804-9. [2] Swaye PS, Fisher LD, Litwin P, et al. Aneurysmal coronary artery disease. Circulation 1983;67:134-8. [3] Gulec S, Atmaca Y, Kilickap M, Akyurek O, Aras O, Oral D. Angiographic assessment of myocardial perfusion in patients with isolated coronary artery ectasia. Am J Cardiol 2003;91:996-9. [4] Hamaoka K, Onouchi Z, Kamiya Y, et al. Evaluation of coronary flow velocity dynamics and flow reserve in patients with Kawasaki disease by means of a Doppler guide wire. J Am Coll Cardiol 1998;31:833-40. [5] Tambe AA, Demany MA, Zimmerman HA. Angina pectoris and slow flow velocity of dye in coronary arteries—a new angiographic finding. Am Heart J 1972;84:66-71. [6] Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count: a quantitative method of assessing coronary artery flow. Circulation 1996;93:879-88. [7] Xia S, Deng SB, Wang Y, et al. Clinical analysis of the risk factors of slow coronary flow. Heart Vessels 2011 Jan 5. DOI:10.1007/s00380010-0081-5. [8] Gökçe M, Kaplan S, Tekelioğlu Y, et al. Platelet function disorder in patients with coronary slow flow. Clin Cardiol 2005;28:145-8. [9] Mrdović I, Jozić T, Ašanin M, et al. Myocardial Reinfarction in a patient with Coronary Ectasia. Cardiology 2004;102:32-4. [10] Kounis NG, Zavras GM. Histamine-induced coronary artery spasm: the concept of allergic angina. Br J Clin Pract 1991;45:121-8.