Myocardial Infarction Induced by Intravenous Iron Dextran Infusion in Absence of Coronary Artery Disease.

A 37-year-old-female presented with history of fatigue for 2–3 months and excessive vaginal bleeding. Further evaluation of the patient revealed iron deficiency anemia secondary to blood loss because of dysfunctional uterine bleeding. She was scheduled for intravenous (IV) iron dextran infusion because of her inability to tolerate oral iron. The possible risks were explained to the patient who decided to proceed with the infusion. Immediately after the infusion the patient developed anaphylactic type reaction and complained of severe chest pain and shortness of breath. Electrocardiogram (EKG) done did not show any evidence of ST changes suggestive of ischemia. However her troponin was elevated at 2.7 (0–0.25). Patient underwent a cardiac catheterization that did not show any evidence of coronary artery disease (CAD). There was however mild impairment of left ventricular systolic function with severe hypokinesis of the apex and distal anterior and anterolateral wall with ejection fraction of around 45 %. Patient most likely developed a non-ST elevation myocardial infarction (MI) secondary to IV iron-dextran induced anaphylactic reaction and hypotension. She was treated with steroids and anti histaminics. She was discharged home second day after catheterization.

Discussion: IV iron infusion is often given to iron deficient patient intolerant to oral iron. Patients report number of adverse events from IV iron dextran infusion that can range from injection site reactions to nausea, diarrhea, allergic type reactions including rash, uticaria, dyspnea, hypotension and in most severe cases, shock and death. Severe anaphylactic reaction may be seen in approximately 0.6% of patients. This risk of anaphylactic reactions appears to be probably secondary to dextran that is known to be antigenic. The exact mechanism is not well understood although cross reactivity to antibodies formed in response to polysaccharides generated by gastrointestinal organisms has been offered as an explanation. Although cases of anaphylactic reactions secondary to IV iron have been reported in literature this is the first case to the best of our knowledge in which patient was documented to have MI in absence of CAD. MI was most likely induced by coronary vasospasm and hypotension secondary to anaphylactic reaction. Hence caution must be exercised when adminstering IV iron-dextran infusion. This should only be given when appropriate resuscitative equipment is immediately available. Alternative IV iron preparations should be considered when possible.