American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Asystole after the first dose of lansoprazole Abstract Allergic reactions due to drug intake are responsible from an important amount of emergency admissions. Patients mostly complain of urticarial lesions. But clinical picture may sometimes include a large scale of signs and symptoms ranging from a simple confusion to serious conditions like coma and even cardiopulmonary arrest. In this article, a case of anaphylactic shock and respiratory arrest after lansoprazole intake is presented. Delays in reaching basic and advanced life support decrease chance of positive results of life support in anaphylactic shock victims. It is important to remember that any medication we usually prescribe in our daily practice for treatment of any disease has a potential to kill the patient. Lansoprazole is a proton pump inhibitory drug (PPI), which is frequently prescribed to patients with complaints related to stomach. In adults, its indications are gastroesophageal reflux disease, short-term treatment of duodenal ulcer, pathologic hypersecretory conditions including Zollinger-Ellison syndrome, gastric ulcers caused by nonsteroid antiinflammatory drugs, and shortterm treatment of benign gastric ulcer [1]. Lansoprazole inhibits gastric acid secretion at last level by inhibiting H +/K + adenosine triphosphatase enzyme, which is a proton pump located on gastric parietal cell wall [2]. It is reported that 1% or a little more of the lansoprazole-prescribed patients have some adverse reactions including abdominal pain, diarrhea, and gastric discomfort. Besides, some acute allergic intestinal nephritis [3] and allergic contact dermatitis [4] cases were reported. But, to the best of our knowledge, this is the first case of asystole after first dose of lansoprazole intake. In this case report, we want to emphasize that lansoprazole, which is thought to be a reliable and also a safe agent in oral treatment has a potential to cause serious anaphylaxis, which may lead to death. A 43-year-old woman with respiratory arrest was brought to our hospital by ambulance staff. We learned that the patient had dyspeptic complaints in the morning, and she took a capsule of 30 mg lansoprazole, which belongs to a relative of her 40 minutes before arrival. Suddenly, she had allergic symptoms in minutes and lost her consciousness. She waited for 20 minutes unconsciously and had hypoxia until first contact to emergency medical services. She had diabetes and a coronary angiography of mild stenosis in her medical history. An endotracheal tube was inserted. The patient was monitored, but the first rhythm we analyzed was asystole. Cardiopulmonary resuscitation (CPR) and advanced life support were initiated. She had widespread rashes on her body and a prominent periorbital edema. Metabolic acidosis was seen in arterial blood gas analysis. Rashes and periorbital edema decreased after injection of epinephrine 0.5 mg intramuscularly and methylprednisolone 2 mg per kg intravenously.
But no improvement in her consciousness level was seen. It was thought that long-lasting hypoxia might cause cerebral edema; thus, computed tomography of brain was performed. Computed tomographic scan revealed minimal cerebral edema. Afterward, oliguria, lactic acidosis, and an increase in liver enzymes were detected during her follow-up. And the patient took the diagnosis of multiorgan dysfunction syndrome (MODS), which was thought to be caused by long-lasting hypoxia after anaphylaxis. The patient was referred to intensive care unit, and advanced life support measures were continued. Unfortunately, no improvement was seen in her clinical condition, and she died. Anaphylaxis is a type of severe allergic reaction against allergenic substances entering human body [5]. This reaction may occur in minutes or hours depending on patient and allergenic agent. Cause of death is usually abrupt bronchospasm and bronchial obstruction. Delays in basic and advanced life support of anaphylactic shock patients affect morbidity and mortality negatively. Anaphylaxis may occur against any kind of allergens [5]. Early basic life support (BLS) is important in cardiopulmonary arrest conditions. Aim of CPR is supplying enough oxygen to especially vital organs like brain and heart with artificial circulation, which is achieved by a rescuer until spontaneous circulation and respiration returns. Hence, it is important to have an educated CPR team for achievement of enough oxygenation supply to vital organs like brain and heart after cardiac arrest [6]. Brain may be protected from hypoxia with a good quality BLS. In this case, the patient unfortunately faced lack of BLS and oxygenation for 20 minutes. In adult population, PPIs may cause cutaneous reactions like drug eruptions. Its prevalence is 3 to 20 per 100 000 patients [4]. In the literature, allergic interstitial nephritis occurring in a renal transplant patient after lansoprazole intake [7] and an anaphylaxis case occurring after skin prick test and recovering after 4 hours [8] were reported. In this case, skin signs of anaphylaxis were detected like widespread rashes on her body and prominent periorbital edema on her face. Although there are some anaphylaxis cases after lansoprazole intake in the literature, [9] to the best of our knowledge, this is the first case of lansoprazole anaphylaxis leading to respiratory arrest, multiorgan failure, and finally, asystole. Reperfusion injury is an important subject after resuscitation of anaphylactic cases, and this is an important factor in morbidity and mortality of these patients. Rapid application of resuscitative measures and medical interventions will decrease morbidity and mortality rates in these cases. Multiorgan dysfunction syndrome is a severe clinical condition characterized by dysfunction of different vital organs like liver and kidneys, and homeostasis cannot be achieved without several interventions in this condition. Etiologic factors include infections,
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Candar M, et al, Asystole after the first dose of lansoprazole, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j. ajem.2014.03.051
2
M. Candar et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
trauma, hypoperfusion, and hypermetabolism. Although alkalosis, oliguria, hyperglycemia, and increased insulin requirement are seen in early stages, tachypnea, hypocapnia, hypoxia, azotemia, deterioration in liver function tests, alterations of coagulation tests, impairment in acid-base balance, anuria, ischemic colitis, and lactic acidosis may be seen in later stages [10]. This case took the diagnosis of MODS, which is thought to develop due to hypoperfusion. Increase in liver enzymes, oliguria, and lactic acidosis were detected in the patient during her follow-up. In conclusion, we should keep in mind that even frequently used and thought to be safe drugs like lansoprazole may cause anaphylaxis. Besides, witnesses of anaphylaxis victims should be able to activate emergency medical services as early as possible and do not hesitate to perform BLS until emergency team arrives.
Melik Candar, MD Harun Gunes, MD Behic Volkan Boz, MD Hayati Kandis, MD Department of Emergency Medicine Duzce University School of Medicine, Duzce, Turkey
Leyla Kutlucan, MD Department of Anesthesiology and Reanimation Duzce University School of Medicine, Duzce, Turkey
Ayhan Saritas MD Department of Emergency Medicine Duzce University School of Medicine, Duzce, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.051
References [1] Leufkens H, Claessens A, Heerdink E. A prospective follow-up study of 5669 users of lansoprazole in daily practice. Aliment Pharmacol Ther 1997;11(5):887–97. [2] Gerloff J, Mignot A, Barth H, Heintze K. Pharmacokinetics and absolute bioavailability of lansoprazole. Eur J Clin Pharmacol 1996;50(4):293–7. [3] Vilaplana J, Romaguera C. Allergic contact dermatitis due to lansoprazole, a proton pump inhibitor. Contact Dermatitis 2001;44(1):47–8. [4] Chularojanamontri L, Jiamton S, Manapajon A, Suvanasuthi S, Kulthanan K, Dhana N, et al. Cutaneous reactions to proton pump inhibitors: a case-control study. J Drugs Dermatol 2012;11(10):e43–7. [5] Saritas A, Erbas M, Gonen I, Candar M, Ozturk O, Kandis H, et al. Asystole after the first dose of ceftriaxone. Am J Emerg Med 2012;30(7):1321.e3–4. [6] Bilir O, Acemoglu H, Aslan S, Cakır Z, Kandis H, Türkyılmaz SE. Tıp doktorlarının temel yaşam desteği konusundaki bilgi düzeyleri ve etkileyen faktörler. Acil Tıp Dergisi 2007;7(1):18–24. [7] Yildirim T, Yilmaz R, Baydar DE, Kutlugun AA, Aki T, Turgan C. Lansoprazoleinduced acute allergic interstitial nephritis in a renal transplant recipient: a case report. Int Urol Nephrol 2012;44(6):1903–6. [8] Aksu K, Kurt E. Anaphylaxis to lansoprazole with tolerance to omeprazole. Allergol Immunopathol (Madr) 2012;40(6):393–4. [9] Choi SW, Han JM, Bae YJ, Lee YS, Cho YS, Moon HB, et al. Lessons from two cases of anaphylaxis to proton pump inhibitors. J Clin Pharm Ther 2012;37(5):614–6. [10] Tulunay M. Yoğun bakım infeksiyonlarına genel bakış. Turkiye Klinikleri J Surg 2002;7(3):149–59.
Please cite this article as: Candar M, et al, Asystole after the first dose of lansoprazole, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j. ajem.2014.03.051
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Asystole after the first dose of lansoprazole Abstract Allergic reactions due to drug intake are responsible from an important amount of emergency admissions. Patients mostly complain of urticarial lesions. But clinical picture may sometimes include a large scale of signs and symptoms ranging from a simple confusion to serious conditions like coma and even cardiopulmonary arrest. In this article, a case of anaphylactic shock and respiratory arrest after lansoprazole intake is presented. Delays in reaching basic and advanced life support decrease chance of positive results of life support in anaphylactic shock victims. It is important to remember that any medication we usually prescribe in our daily practice for treatment of any disease has a potential to kill the patient. Lansoprazole is a proton pump inhibitory drug (PPI), which is frequently prescribed to patients with complaints related to stomach. In adults, its indications are gastroesophageal reflux disease, short-term treatment of duodenal ulcer, pathologic hypersecretory conditions including Zollinger-Ellison syndrome, gastric ulcers caused by nonsteroid antiinflammatory drugs, and shortterm treatment of benign gastric ulcer [1]. Lansoprazole inhibits gastric acid secretion at last level by inhibiting H +/K + adenosine triphosphatase enzyme, which is a proton pump located on gastric parietal cell wall [2]. It is reported that 1% or a little more of the lansoprazole-prescribed patients have some adverse reactions including abdominal pain, diarrhea, and gastric discomfort. Besides, some acute allergic intestinal nephritis [3] and allergic contact dermatitis [4] cases were reported. But, to the best of our knowledge, this is the first case of asystole after first dose of lansoprazole intake. In this case report, we want to emphasize that lansoprazole, which is thought to be a reliable and also a safe agent in oral treatment has a potential to cause serious anaphylaxis, which may lead to death. A 43-year-old woman with respiratory arrest was brought to our hospital by ambulance staff. We learned that the patient had dyspeptic complaints in the morning, and she took a capsule of 30 mg lansoprazole, which belongs to a relative of her 40 minutes before arrival. Suddenly, she had allergic symptoms in minutes and lost her consciousness. She waited for 20 minutes unconsciously and had hypoxia until first contact to emergency medical services. She had diabetes and a coronary angiography of mild stenosis in her medical history. An endotracheal tube was inserted. The patient was monitored, but the first rhythm we analyzed was asystole. Cardiopulmonary resuscitation (CPR) and advanced life support were initiated. She had widespread rashes on her body and a prominent periorbital edema. Metabolic acidosis was seen in arterial blood gas analysis. Rashes and periorbital edema decreased after injection of epinephrine 0.5 mg intramuscularly and methylprednisolone 2 mg per kg intravenously.
But no improvement in her consciousness level was seen. It was thought that long-lasting hypoxia might cause cerebral edema; thus, computed tomography of brain was performed. Computed tomographic scan revealed minimal cerebral edema. Afterward, oliguria, lactic acidosis, and an increase in liver enzymes were detected during her follow-up. And the patient took the diagnosis of multiorgan dysfunction syndrome (MODS), which was thought to be caused by long-lasting hypoxia after anaphylaxis. The patient was referred to intensive care unit, and advanced life support measures were continued. Unfortunately, no improvement was seen in her clinical condition, and she died. Anaphylaxis is a type of severe allergic reaction against allergenic substances entering human body [5]. This reaction may occur in minutes or hours depending on patient and allergenic agent. Cause of death is usually abrupt bronchospasm and bronchial obstruction. Delays in basic and advanced life support of anaphylactic shock patients affect morbidity and mortality negatively. Anaphylaxis may occur against any kind of allergens [5]. Early basic life support (BLS) is important in cardiopulmonary arrest conditions. Aim of CPR is supplying enough oxygen to especially vital organs like brain and heart with artificial circulation, which is achieved by a rescuer until spontaneous circulation and respiration returns. Hence, it is important to have an educated CPR team for achievement of enough oxygenation supply to vital organs like brain and heart after cardiac arrest [6]. Brain may be protected from hypoxia with a good quality BLS. In this case, the patient unfortunately faced lack of BLS and oxygenation for 20 minutes. In adult population, PPIs may cause cutaneous reactions like drug eruptions. Its prevalence is 3 to 20 per 100 000 patients [4]. In the literature, allergic interstitial nephritis occurring in a renal transplant patient after lansoprazole intake [7] and an anaphylaxis case occurring after skin prick test and recovering after 4 hours [8] were reported. In this case, skin signs of anaphylaxis were detected like widespread rashes on her body and prominent periorbital edema on her face. Although there are some anaphylaxis cases after lansoprazole intake in the literature, [9] to the best of our knowledge, this is the first case of lansoprazole anaphylaxis leading to respiratory arrest, multiorgan failure, and finally, asystole. Reperfusion injury is an important subject after resuscitation of anaphylactic cases, and this is an important factor in morbidity and mortality of these patients. Rapid application of resuscitative measures and medical interventions will decrease morbidity and mortality rates in these cases. Multiorgan dysfunction syndrome is a severe clinical condition characterized by dysfunction of different vital organs like liver and kidneys, and homeostasis cannot be achieved without several interventions in this condition. Etiologic factors include infections,
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Candar M, et al, Asystole after the first dose of lansoprazole, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j. ajem.2014.03.051
2
M. Candar et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
trauma, hypoperfusion, and hypermetabolism. Although alkalosis, oliguria, hyperglycemia, and increased insulin requirement are seen in early stages, tachypnea, hypocapnia, hypoxia, azotemia, deterioration in liver function tests, alterations of coagulation tests, impairment in acid-base balance, anuria, ischemic colitis, and lactic acidosis may be seen in later stages [10]. This case took the diagnosis of MODS, which is thought to develop due to hypoperfusion. Increase in liver enzymes, oliguria, and lactic acidosis were detected in the patient during her follow-up. In conclusion, we should keep in mind that even frequently used and thought to be safe drugs like lansoprazole may cause anaphylaxis. Besides, witnesses of anaphylaxis victims should be able to activate emergency medical services as early as possible and do not hesitate to perform BLS until emergency team arrives.
Melik Candar, MD Harun Gunes, MD Behic Volkan Boz, MD Hayati Kandis, MD Department of Emergency Medicine Duzce University School of Medicine, Duzce, Turkey
Leyla Kutlucan, MD Department of Anesthesiology and Reanimation Duzce University School of Medicine, Duzce, Turkey
Ayhan Saritas MD Department of Emergency Medicine Duzce University School of Medicine, Duzce, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.051
References [1] Leufkens H, Claessens A, Heerdink E. A prospective follow-up study of 5669 users of lansoprazole in daily practice. Aliment Pharmacol Ther 1997;11(5):887–97. [2] Gerloff J, Mignot A, Barth H, Heintze K. Pharmacokinetics and absolute bioavailability of lansoprazole. Eur J Clin Pharmacol 1996;50(4):293–7. [3] Vilaplana J, Romaguera C. Allergic contact dermatitis due to lansoprazole, a proton pump inhibitor. Contact Dermatitis 2001;44(1):47–8. [4] Chularojanamontri L, Jiamton S, Manapajon A, Suvanasuthi S, Kulthanan K, Dhana N, et al. Cutaneous reactions to proton pump inhibitors: a case-control study. J Drugs Dermatol 2012;11(10):e43–7. [5] Saritas A, Erbas M, Gonen I, Candar M, Ozturk O, Kandis H, et al. Asystole after the first dose of ceftriaxone. Am J Emerg Med 2012;30(7):1321.e3–4. [6] Bilir O, Acemoglu H, Aslan S, Cakır Z, Kandis H, Türkyılmaz SE. Tıp doktorlarının temel yaşam desteği konusundaki bilgi düzeyleri ve etkileyen faktörler. Acil Tıp Dergisi 2007;7(1):18–24. [7] Yildirim T, Yilmaz R, Baydar DE, Kutlugun AA, Aki T, Turgan C. Lansoprazoleinduced acute allergic interstitial nephritis in a renal transplant recipient: a case report. Int Urol Nephrol 2012;44(6):1903–6. [8] Aksu K, Kurt E. Anaphylaxis to lansoprazole with tolerance to omeprazole. Allergol Immunopathol (Madr) 2012;40(6):393–4. [9] Choi SW, Han JM, Bae YJ, Lee YS, Cho YS, Moon HB, et al. Lessons from two cases of anaphylaxis to proton pump inhibitors. J Clin Pharm Ther 2012;37(5):614–6. [10] Tulunay M. Yoğun bakım infeksiyonlarına genel bakış. Turkiye Klinikleri J Surg 2002;7(3):149–59.
Please cite this article as: Candar M, et al, Asystole after the first dose of lansoprazole, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j. ajem.2014.03.051
