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Acute anaphylaxis: case report A 40-year-old man developed acute anaphylaxis following antivenom therapy with crotalidae-polyvalent-immune-Fab(ovine), and lisinopril for hypertension [routes not stated; not all dosages stated]. The man, presented approximately 6 hours after a bite by Crotalus oreganus abyssus on the lateral aspect of his right upper arm. His medical history was significant for chronic back pain and hypertension. He had been receiving lisinopril 2.5mg daily along with concomitant oxycodone. At presentation, he was mildly tachycardiac. However, no swelling, erythema or ecchymosis near the single puncture wound was seen. Of note, diffuse myalgias and myokymia involving the musculature of the back was observed. Comprehensive metabolic values and laboratory tests were normal except mild hypofibrinogenemia. The antivenom treatment was postponed. His vital signs were significant for heart rate of 95 beats/min. Mild myokymia of the back muscles was present, and swelling was noted in the forearm and hand, distal to the bite site on the lateral upper right arm. After 8 hours of the envenomation, he received four vials of polyvalent-immune-Fab(ovine) [Crofab, Boston Scientific] infusion. Approximately 1 hour following initiation of antivenom infusion, he developed a hypersensitivity reaction. His heart rate raised to 115 beats/min, and BP decreased to 80/40mm Hg. He developed acute anaphylaxis with symptoms of vomiting and angioedema of the lips and tongue, along with urticaria and wheezing. The man was treated with diphenhydramine, famotidine, methylprednisolone and epinephrine. Thereafter, his urticaria, vomiting, hypotension and bronchospasm resolved, and his angioedema stabilised within the next hour. Epinephrine was continued with gradual resolution of angioedema of the lips and tongue. The next day, his all other symptoms of anaphylaxis resolved. After 24 hours of initial presentation, he was discharged with a prescription of prednisone taper. Later, at the poison control follow-up, no further recurrence was observed. It was considered that lisinopril additionally led to progression of the acute anaphylaxis due to crotalidae-polyvalent-immune-Fab(ovine). Heise CW, et al. One Bite, Two Patients: Disparate Clinical Courses Following Simultaneous Crotalus oreganus abyssus Envenomation. Wilderness and Environmental 803520006 Medicine 31: 354-357, No. 3, Sep 2020. Available from: URL: http://doi.org/10.1016/j.wem.2020.05.004

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Reactions 12 Dec 2020 No. 1834