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Abstract: The patient presented to the hospital with cough and sputum and was admitted with a confirmed diagnosis of pulmonary infection. The patient had frequently used penicillin-based anti-inflammatory drugs, such as penicillin V potassium tablets, in the past and had no history of allergy, so after a negative penicillin skin test, he was treated with amoxicillin sodium for injection. However, the patient suddenly had chest tightness and dyspnea, and was diagnosed with anaphylaxis, so amoxicillin was immediately discontinued and the anaphylactic shock state was quickly corrected after the administration of volume expansion, rehydration, anti-allergic and anti-shock treatment.
[Basic information] Female, 60 years old
Type of disease】Anaphylaxis, pulmonary infection
Hospital】The Second Hospital of Harbin Medical University
Date of Consultation】February 2022
Treatment plan】Medication (sodium chloride injection + epinephrine hydrochloride injection + sodium methylprednisolone succinate for injection + aminophylline injection + loratadine capsule + dopamine hydrochloride injection + ertapenem for injection)
[Treatment period] Hospitalization for 10 days, review after 1 month
Treatment effect】The disease is under control and all indicators are improving
I. Initial consultation
Patient Auntie Cao, with cough and sputum for 1 week, was admitted to the hospital with lung infection. She was treated with amoxicillin sodium for injection. There was no allergy in the penicillin skin test before use, and there was a history of repeated use of amoxicillin in the past. However, this time, the patient suddenly developed chest tightness, dyspnea, peripheral skin redness, facial cyanosis dizziness, and blackness in front of the eyes when the drug was administered for about 5 minutes. Initially, we considered that the patient should be acutely allergic, so we immediately stopped the use of injectable amoxicillin sodium for static dosing, monitored blood pressure of 70/40 mmHg, heart rate of 120 beats/min and blood oxygen of 70%. Seeing such vital signs, we considered that the patient had anaphylactic shock and immediately pushed him into the resuscitation room, giving anti-allergy, rehydration and pressure-raising treatment, and perfecting blood routine, liver and kidney function and other laboratory tests. The results of routine blood tests: leukocytes 20.6×10^9/L, neutrophil percentage 88.2%, normal liver and kidney function, CT lung at admission: scattered infection in both lungs, more serious in the left lung.
II. Treatment history
Firstly, the family was informed that the patient had a severe penicillin allergic reaction and needed emergency treatment, and that the condition was dangerous, but most patients generally had a good prognosis as long as they were treated promptly. Considering that the patient’s allergy was related to amoxicillin this time, the drug was immediately discontinued. The patient was placed in a flat position, with lower extremities elevated, head lowered, and oxygen administered at high flow. Because the organism was in a state of hypovolemic shock, it needed to be corrected rapidly by opening intravenous access to infuse sodium chloride injection for volume expansion and rehydration to maintain tissue perfusion. Immediately inject epinephrine hydrochloride injection intramuscularly to constrict blood vessels, elevate blood pressure, reduce laryngeal and pulmonary exudation, relieve bronchospasm, and improve the symptoms of respiratory distress. Intravenous antiallergic drug sodium methylprednisolone succinate for injection, slow static push of airway antispasmodic drug aminophylline injection, and oral antihistamine loratadine capsules were administered. The patient’s blood pressure remained low after adequate rehydration, at around 80/50mmHg, and the vasoactive drug dopamine hydrochloride injection was given to promote blood pressure elevation. The anti-inflammatory drug was changed to ertapenem for injection.
III. Treatment effect
The patient’s blood pressure was still low at 80/50 mmHg after rapid volume expansion and rehydration of 1000 ml, and the vasoactive drug dopamine hydrochloride injection was given to assist in raising blood pressure, which was maintained at 90/60 mmHg. After the use of epinephrine hydrochloride injection, methylprednisolone sodium succinate for injection, aminophylline and loratadine capsule, the patient’s symptoms of dyspnea, lip cyanosis and skin redness were significantly relieved. . The heart rate gradually slowed down and was maintained at 90 beats/min, and the oxygen saturation was 96%. Blood pressure gradually rebounded, and then dobutamine hydrochloride injection was discontinued, and blood pressure was maintained at about 120/70 mmHg. Considering that the patient was allergic to penicillin and had anaphylaxis, the cephalosporins were also contraindicated in the choice of antibiotics, and the carbapenem antibiotic Ertapenem for Injection, which has a relatively low incidence of allergy, was given to the patient. Thereafter, the patient did not have any further allergic phenomena, and at 10 days of hospitalization, the lung CT lesion was significantly better than at the time of admission without obvious respiratory symptoms, so he was discharged, and was instructed to be reviewed after 1 month.
IV. Notes
We are glad that the patient recovered after undergoing active treatment. Advise the patient that the penicillin anaphylaxis that occurred in this patient will not leave sequelae because of the relatively timely resuscitation treatment, but that this class of drugs needs to be avoided in the future in the event of infectious lesions. Allergy may occur if used, and shock may be severe or even life-threatening. After discharge from the hospital, pay attention to rest, avoid getting cold, and exercise in moderation to strengthen the body’s resistance to disease. It is recommended to review the lung CT after 1 month to observe the repair of the infected person.
V. Personal insight
There are some clinical patients who usually use penicillin preparations frequently, such as oral penicillin V potassium tablets and amoxicillin capsules, etc. Due to frequent use of penicillin drugs, anti-penicillin antibodies may already exist in these patients’ bodies, and when used again, they may go into anaphylactic shock. Therefore, such people should be closely observed by their families and health care workers during the use of medication, and once the allergy occurs as in the case of the patient, it should be dealt with in a timely manner to avoid delaying the condition leading to serious consequences.