Immune globulin
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Immune globulin Myocardial infarction in an elderly patient: case report A 65-year-old man with a history of coronary artery disease (CAD) developed a myocardial infarction during treatment with immune globulin infusion for common variable immunodeficiency. The man had been receiving monthly immune globulin (Polygam S/D 10%) for 6 years [dosage not clearly stated] without any complications. Polygam was removed from the market so he started receiving a different immune globulin, Gammagard (S/D 10%). His cardiac history included hypertension, hyperlipidaemia, diet-controlled type 2 diabetes mellitus, aortic and renal artery stenosis, exercise-induced chronic angina pectoris, which was stable, and previous CAD requiring bypass and percutaneous intervention; about 1 week previously, angina pectoris occurred whilst walking on a treadmill. He received his first infusion of Gammagard 40g (400 mg/kg), which contained 4% glucose and IgA (≤ 4.4 µg/mL); the infusion was administered at a rate of 1 mL/min for the initial 30 minutes then 2 mL/min for 30 minutes followed by 3 mL/min for 30 minutes. Near the end of the infusion cycle, he developed sudden onset of chest discomfort which radiated to both shoulders and arms. He rated his chest pain to be 8/10. Immune globulin was discontinued immediately. The man received two sublingual nitroglycerin [glyceryl trinitrate] tablets but angina pectoris persisted for about 1 hour. He was transferred to the emergency department. He had a BP of 112/70mm Hg and a heart rate of 57 beats/min. He received IV nitroglycerin and morphine, and his chest discomfort soon resolved. The immune globulin infusion (22g) was readministered at a rate of 3 mL/min and, during this, the man had recurrent chest discomfort. Immune globulin was stopped; his angina pectoris persisted for about 40 minutes. Increased creatine kinase MB fraction (15.9 ng/mL) and troponin T level (0.37 ng/mL) was revealed by inpatient evaluation; this indicated cardiac injury. He received aspirin, atenolol, atorvastatin, IV heparin, isosorbide dinitrate and morphine. High-grade left main and midcircumflex coronary artery disease was noted on left heart catheterisation imaging. After 2 weeks, repeat surgical revascularisation was performed and 3 weeks later, Gammagard (S/D 10%) 200 mg/kg was given; the dosage was increased to 300 mg/kg in 2 weeks. Immune globulin was infused at a rate of 1 mL/min for the initial 30 minutes followed by 2 mL/min for 30 minutes, 3 mL/min for 30 minutes and then 4 mL/min for 30 minutes. The goal was to reach an IgG trough level of 600 to 800 mg/dL; the final infusion rate was 2.4 mL/kg/h. He tolerated this protocol with IVIG 300 mg/kg and a final rate of 4 mL/min every 3 to 4 weeks for 12 months with no subsequent adverse thrombotic events. Author comment: "In conclusion, this case demonstrates angina and [myocardial infarction] associated with [immuno globulin] infusion in treatment doses far less than those used for idiopathic thrombocytopenia and neurologic disease." Dav´e S, et al. Myocardial infa
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