ANAPHILACTIC SHOCK DURING STREPTOKINASE THERAPY IN INFEROPOSTERIOR STEMI WITH

RIGHT VENTRICLE INVOLVEMENT PATIENT (IN ABSENCE OF PCI FACILITY): A CASE STUDY

INTRODUCTION

Despite the progress in the treatment of AMI, streptokinase is still being used in many countries. The
first largest thrombolytic trial evaluated that streptokinase therapy has a significant mortality benefit
when given as early as the onset of the symptom rather than later or not given at all. Streptokinase is a
non-human protein, and its presentation into the circulatory system can lead to severe anaphylactic
responses including death.

CASE DESCRIPTION

A 72 y o male referred from general clinic with specific chest pain that persisted from 4 hours ago. The
patient also complains about progressive fatigue and cold sweat. The patient is a heavy smoker, no
history of familial disease and no history of drugs allergy. From physical examination showed GCS of 456,
BP 100/60, RR 18, HR 84 x/mnt. ECG revealing St segment elevations at II, III, aVF, V7,V8,V9 and ST
elevation Right side of precordial Lead.

Lab result: Normal BGA, Lipid Profile, RFT, electrolyte, PT and PTT. Initial troponin I 0,09 ng/mL repeat
result after 6 hours elevate to 4,38 ng/mL. Random Blood Sugar of 139, slightly elevated SGOT of 54,
normal SGPT 34. Complete Blood count revealing initial Hb 12,6, WBC 8,9, Plt 155. Repeat CBC after 5
days revealed Hb lowering to 7,3; WBC of 13,9 and PLt lowering to 112. Chest X-Ray showed normal
cardiothoraxic ratio and aortic atherosclerosis. These findings were relayed to the coordinating ER, and a
STEMI protocol to allow for urgent fibrinolysis therapy

After loaded with ASA and CPG, we administered 1.5 million unit of streptokinase dissolved in 100cc NS
given within 1 hour. At the 44 th minute BP drop to 60/palp, HR of 99x/mnt, streptokinase was suspended
while 2 parts of 200 cc of NS loaded. The BP was maintained at 96/67 until the rest of the streptokinase
therapy and the patient has an adequate urine output.

One hour after the streptokinase administration, the patient started to feel itching sensation at head
back area and started to develop multiple urtica and angioedema meanwhile the chest pain is
diminishing. He also felt difficulty in breathing and cold sweat. The BP dropped to 50/palp, RR 29x/mnt,
HR 0f 101x/mnt. The patient received 0,3cc of epinephrine i.m., 125mg of methylprednisolone and
change the O2 delivered system to non-rebreathing mask with 12 lpm o2 flow. After 15 minute
evaluation BP still at 61/52 pulse at 105x/mint, later second course of epinephrine (0,5 i.m.)
administered while loading the patients with 500 cc of NS. One hour later the BP still at 71/42, HR of
92x/mint so dopamine drip of 5 cc/kg/hour added. The patient admitted to the ICCU with stable vital
sign for 2 days. The fibrinolysis therapy concluded as failed and the patient later referred to A type
hospital to consider rescue PCI option.
 DISCUSSION

The allergic reaction that happened to the patient assumed as immediate type of hypersensitivity
reaction. RVMI usually associated with inferior wall MI. Angiography often reveals occlusion of the right
coronary artery (RCA) proximal to the acute marginal branch while more proximal occlusion suggest
more extensive necrosis of the posterior and potentially the anterior RV myocardial wall. RV ischemia
may lead to systolic and diastolic dysfunction resulting in serious deficit in LV preload with subsequent
drop in cardiac output and consequent systemic hypotension. Adequate filling (preload) of the impair RV
is thus crucial to maintain sufficient RV output volume an LV function. In addition, patients with RV
involvement require continuous careful monitoring because they are at a significantly higher risk for
ventricular fibrillation, sustained ventricular tachycardia and high-degree AV blockade, any of which
would worsen the overall prognosis.

CONCLUSION

Early identification and risk stratification of patients with an accompanying RVMI is needed to manage an
appropriate treatment and detecting life-threatening arrhythmic complications.