Disclosures: Elana Hartman, MD: No financial relationships or conflicts of interest

Case Description: Patient presented to primary stroke center hospital with complaint of left sided weakness and facial droop. CT head was negative for acute hemorrhage but MRI revealed right MCA infarction. Initial NIHSS was 5 and cardiopulmonary status was stable. Given these findings, patient was deemed candidate for tPA. However, following bolus of tPA patient was noted to have respiratory distress, stomach upset and hypotension which was believed to be secondary to anaphylaxis to tpA. She was emergently intubated and treated with methylprednisolone, epinephrine and diphenhydramine. She was transferred to Neuro ICU for closer monitoring. She did not require further treatment for anaphylaxis given short half-life of tPA (approximately 6 minutes).

Setting: Primary Stroke Center Hospital

Patient: 87-year-old female with right MCA infarction. Assessment/

Results: Patient was successfully extubated after 24 hours. Her overall NIHSS improved but left upper limb weakness persisted along with balance deficits. Following extubation she underwent formal swallow evaluation and initially placed on mechanical chopped diet with thin liquids but overtime returned to a regular consistency diet. She was discharged to acute care rehabilitation and successfully completed her rehabilitation course without any further pulmonary complications.

Discussion: tPA is frequently used in stroke centers to treat acute ischemic infarctions. Like any other medication allergic reactions and anaphylaxis are possible. Further, it is not uncommon for someone who suffered an ischemic infarct to show signs of respiratory distress. It can be seen commonly in setting of aspiration, herniation, infarction extension or hemorrhagic conversion. However, as shown in this case, acute change in respiratory status with associated hypotension and gastroenterological symptoms one should also add anaphylaxis to tPA to the differential diagnosis.

Conclusion: Although routinely used to treat ischemic infarction, we rarely see anaphylaxis and severe allergic reactions to tPA. This case demonstrates importance of a broad differential when treating stroke patients with acute cardiopulmonary instability.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/anaphylaxis-secondary-to-tpa-a-case-report/