Medstar Georgetown University Hospital Washington DC, District of Columbia, United States
Background/Case Studies: A dialysis-dependent kidney transplant patient with no urine output, experienced chest pain and diaphoresis during a red blood cell (RBC) transfusion. Cardiology and transfusion medicine evaluation diagnosed a type II myocardial infarction (MI). This type of adverse reaction is not recognized in the CDC biovigilance diagnostic protocol for transfusions reactions prompting a literature review to investigate previous reports of a type II MI post-transfusion.
Study
Design/Methods: The case was separately investigated by cardiology as a suspected MI and by transfusion service as a suspected transfusion reaction. A literature search using search terms “transfusion reaction” and “myocardial infarction” was performed following the investigation.
Results/Findings: Initially the patient's hemoglobin (hgb) level was 6.5 g/dL. After 150mL of a second RBC unit was infused over 2 hours, the patient reported chest pain and diaphoresis. The systolic and diastolic blood pressure spiked during the chest pain to 180/86 mmHg compared to a baseline range of 116-141 mmHg systolic and 57-66 diastolic but no other significant vital sign changes were noted. Symptoms resolved after the transfusion was stopped and diphenhydramine was given.Cardiology observed rising and decreasing serial troponin levels (figure) supporting a diagnosis of type II MI. The transfusion service categorized the reaction under as “other” in the list of diagnoses available in the hospital information system and recommended timing future transfusions while undergoing dialysis or using a very low infusion rate. The literature review revealed multiple prior reports of MI associated with transfusion, but no cases definitively classifying the MIs as type II. Two possible relevant mechanisms for a type 2 MI from a transfusion were identified: Demand ischemia exasperated by the transfusion volume load and allergic angina or Kounis syndrome. Conclusions: Type II MIs may be underrecognized as a transfusion reaction because serial troponins measurements are not routine in transfusion reaction investigations. Some cases currently classified as “Transfusion Associated Dyspnea” could be type 2 MIs if serial troponins were part of the transfusion reaction evaluation. Allergic angina, also known as Kounis syndrome would be expected to respond to antihistamine treatment and because this treatment is generally benign, should be considered as a treatment for chest pain occurring during a transfusion in addition to stopping the transfusion. This presentation of fluid overload and chronic anemia resulting in increased cardiac load is not unique and may require increased awareness in the general transfusion setting.
