Nov 15, 2005 - with preexisting kidney disease and volume depletion.4. Although a relationship .... dermatomyositis. Lambert–Eaton myasthenic syndrome.
CASE REPORTS
Myocardial Infarction Associated with Intravenous Immune Globulin Sunita Bond Stenton, Dawn Dalen, and Kerry Wilbur
OBJECTIVE: To report a case of acute myocardial infarction (MI) experienced by a patient receiving intravenous immune globulin (IVIG) and review other published cases of MI associated with IVIG. CASE SUMMARY:
An 81-year-old Vietnamese man was prescribed IVIG for treatment of toxic epidermal necrolysis secondary to allopurinol. Thirty minutes following the start of the IVIG infusion, the patient developed crushing retrosternal chest pain and shortness of breath. The pain improved upon discontinuation of IVIG infusion but recurred when IVIG was restarted. The troponin level reached 140 µg/L, and a persantine sestamibi stress test (MIBI) indicated anterolateral ischemia. The patient was diagnosed with non–ST-elevation MI. An objective causality assessment using the Naranjo probability scale revealed a probable association between this adverse reaction and IVIG treatment.
DISCUSSION: Although an association between IVIG administration and MI has not been demonstrated in clinical trials, accumulating clinical experience suggests that a relationship between IVIG and myocardial ischemia exists. Twenty published case reports were identified. Risk of acute MI seems to be increased with use of high-dose IVIG and in older individuals, especially those with at least one cardiovascular risk factor, such as ischemic heart disease or hypertension. CONCLUSIONS: Case reports suggest a causal relationship between the use of IVIG and MI and other thrombotic events. While cardiovascular disease is not considered an absolute contraindication to therapy, expanding indications and subsequent use of IVIG merit that clinicians be aware of patient characteristics that may increase the risk for adverse reactions and recognize early signs of infarction. KEY WORDS: intravenous immune globulin, myocardial infarction.
Ann Pharmacother 2005;39:xxxx. Published Online, 15 Nov 2005, www.theannals.com, DOI 10.1345/aph.1G104
ntravenous immune globulin (IVIG) is a human plasmaImune derived immunoglobulin containing a broad range of imantibodies that protect against human pathogens and foreign antigens. Its ability to exert a variety of immunomodulating activities has led to increased use of IVIG to treat several immune-mediated disorders and autoimmune diseases (Table 1).1 High-dose IVIG (2 g/kg per treatment course) has been particularly efficacious in the treatment of skin diseases, including toxic epidermal necrolysis (TEN).2 Sudden and widespread apoptosis of epidermal cells in TEN is related to up-regulation of a protein called Fas ligand (Fas L). High-dose IVIG inhibits keratinocyte apoptosis triggered by Fas L interaction with the cell surface death receptor Fas and has been clinically associated with improved wound healing and, possibly, survival.3 Most adverse effects attributed to IVIG are mild, transient, self limited, and related to the speed of infusion. These effects include headache (50%), chills, myalgia (4%), low back pain (4–6%), cough (2%), fever (1%), or Author information provided at the end of the text.
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chest discomfort and do not generally require discontinuation of therapy. Serious reactions occur with an incidence of
