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Anaphylaxis in an elderly patient: case report A 73-year-old woman receiving perindopril for hypertension developed anaphylaxis following treatment with alteplase for an acute ischaemic stroke. The woman, who had atrial fibrillation, and known hypertension treated with perindopril [dosage, route and duration of treatment to reaction onset not stated], presented with vascular occlusion of the right middle cerebral artery (MCA). A bolus dose of IV alteplase (5.9mg bolus plus infusion of 52.7 mg/hour) was initiated. Due to a finding of major infarction in the MCA territory, the alteplase infusion was withheld and she was transferred for consideration of intra-arterial mechanical clot extraction. Upon arrival, she was noted to have an audible wheeze and mild tachypnoea. Due to persistent occlusion of the right MCA second division, IV alteplase (59.4mg over 60 minutes) was recommended 3 hours following the initial bolus. After completing the alteplase infusion (4 hours after the initial bolus), she developed angioedema of the lips and tongue, with increased respiratory distress. The woman was treated with hydrocortisone, ranitidine, prochlorperazine, and epinephrine [adrenaline]. She was transferred to the ICU following intubation. Her serum tryptase levels were 2 and 4 µg/L at the end of the alteplase infusion and 1.5 hours following the start of anaphylaxis, respectively. A CT brain scan, performed 24 hours after the alteplase infusion, revealed a small haemorrhage in the right internal capsule. She was extubated the following day, but required transfer to a nursing home upon eventual discharge. Author comment: "There is a suggestion that concurrent use of an angiotensin converting enzyme (ACE) inhibitor and alteplase is associated with an increased risk of hemiorolingual angioedema." Cheng JN, et al. A patient with anaphylaxis after alteplase infusion. Journal of Clinical Neuroscience 19: 314-315, No. 2, Feb 2012. Available from: URL: http:// 803069057 dx.doi.org/10.1016/j.jocn.2011.07.018 - Australia

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Reactions 14 Apr 2012 No. 1397