Case Report
J Invest Allergol Clin Immunol 2004; Vol. 14(2): 162-164 © 2004 Esmon Publicidad
Myocardial ischemia due to severe amoxicillin allergy 163
Figure 1.
Figure 2.
© 2004 Esmon Publicidad J Invest Allergol Clin Immunol 2004; Vol. 14(2): 162-164
164 R. López-Abad et al.
serum specific IgE antibodies to amoxicillin, ampicillin, This case provided further evidence about how
penicillin and cefaclor by the CAP system (Pharmacia). anaphylaxis may cause myocardial injury and the
For safety and ethical reasons, we did not perform mechanism is likely to be vasospasm induced by mast
intradermal and challenge tests with amoxicillin and cells and basophil mediators, histamine being the most
other betalactamic antibiotics. The patient had a negative frequent one.
reaction to clavulanic acid but he showed an immediate
positive response to a highly diluted concentration of
amoxicillin. A pruriginous wheal with a mean diameter References
of 8 mm and associated surrounding erythema was found
at the side of the prick test. He also complained about 1. Vega JM, Blanca M, García JJ, Carmona MJ, Miranda A,
an immediate episode of generalized pruritus, which Pérez-Estrada M, Fernández S, Acebes JM, Terrados S.
rapidly subsided with antihistamine therapy. Immediate allergic reactions to amoxicillin. Allergy 1994;
49 (5): 317-322.
In clinical practice we do not test clavulanic acid due 2. Audicana M, Bernaola G, Urrutia I, Echechipía S, Gastamiza
to its great instability. In this case and with research G, Muñoz D, Fernández E, Fernández de Corres L. Allergic
purposes, we included this drug in our study, making the reactions to betalactams: studies in a group of patients
solution immediately before performing the cutaneous test. allergic to penicillin and evaluation of cross-reactivity with
Determinations of serum specific IgE antibodies to cephalosporin. Allergy 1994; 49 (2): 408-113.
amoxicillin, ampicillin, penicillin and cefaclor were all 3. Stein Isidore and Wecksell Irving. Cardiac disease
accompanying allergic drug
negative.
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A number of mechanisms have been proposed to and in vitro. Circulation Research 1975; 36: 520-528.
explain the phenomenon of anaphylaxis-induced 6. Sullivan TJ. Cardiac disorders in penicillin-induced
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anaphylatic shock; pharmacologic agents which may 7. Rich MW. Myocardial injury caused by an anaphylatic
cause vasospasm such as epinephrine (used to treat reaction to ampicillin/sulbactam in a patient with a normal
anaphylaxis) and, last but not least, the mediators of coronary arteries. Texas Heart Institute. Journal 1998; 25:
anaphylaxis [6, 7]. 194-197.
We present a patient with normal coronary arteries 8. Michelassi F, Landa L, Hill RD, Lowenstein E, Watkins WD,
who suffered a myocardial injury as a manifestation of Petkau AJ, Zapol WM. Leucotriene D4: a potent coronary
vasoconstrictor associated with impaired ventricular
anaphylatic reaction due to amoxicillin-clavulanic acid contraction. Science 1982; 217: 841-3.
administration. On the basis of the symptoms and allergy 9. Cistero A, Urias S, Guindo J, Lleonart R, García-Moll M,
study a diagnosis was made of severe allergic reaction Geli A, Bayes de Luna A. Coronary artery spasm and acute
caused by amoxicillin. myocardial infarction in naproxen-associated anaphylactic
To our knowledge, this is the first published report reaction. Allergy 1992; 47 (5): 576-8.
in which sensitization to the suspected antibiotic is 10. Ahmad S. Allopurinol and enalapril. Drug induced
anaphylactic coronary spasm and acute myocardial infarction
shown by the positive skin prick test to amoxicillin. The
(letter). Chest 1995; 108: 586.
negative result of the serum IgE determination could be 11. Stephen M Austin, Banajit Barooah, Chung S Kim.
explained if we knew that the CAP system determined Reversible Acute Cardiac Injury during Cefoxitin-Induced
only the presence of serum IgE antibodies against the anaphylaxis in a Patient with Normal Coronary Arteries. Am
amoxycilloil (major determinant). IgE-mediated J Med 1984; 77: 729-732.
reactions to betalactamics may be caused by major 12. Baldo BA. Penicillins and cephalosporins as allergens
determinants and in some cases by minor determinants, structural aspects of recognition and cross-reaction. Clin
Exp Allergy 1999; 29: 744-749.
particularly in anaphylatic reactions. It has been claimed
that inmediate reactions to penicillins are more often a
response to minor rather than to major determinants [12].
That is the reason why we think that our patient had a
hypersensitivity type I reaction to minor determinants.
Other reports only suggest it but we can confirm that
the allergic reaction was responsible for the coronary Dra. Raquel López Abad
involvement producing the angina and this can be
Allergy Section
confirmed through the positive result of a skin prick test Hospital Universitario Marqués de Valdecilla
with the drug involved. As previously mentioned before 39008 Santander (Spain)
we did not perform intradermal and challenge tests with Tel.: +34-942202543, +34-942202583
amoxicillin and other betalactamics antibiotics for safety Fax: +34-942202543
reasons. E-mail: mabadl@terra.es
J Invest Allergol Clin Immunol 2004; Vol. 14(2): 162-164 © 2004 Esmon Publicidad