Angiœdème après thrombolyse intraveineuse par activateur tissulaire du plasminogène (altéplase)

Abstract

Case reportWe report the observation of an oro-facial angioedema during an intravenous alteplase injection, used as a thrombolytic treatment for an acute ischemic stroke. The allergy work up, comprising skin tests (prick test and intradermal reaction) and a drug challenge, was negative, ruling out an IgE (immunoglobulin E) mediated allergic hypersensitivity. DiscussionAngioedema is a known side effect of alteplase. It is often self-limiting, but can be life threatening. The risk factors are female gender, ischemic stroke of the insular cortex and treatment with ACE (angiotensin-converting enzyme) inhibitors. The three main pathophysiological hypotheses are: an IgE-mediated hypersensitivity, a non-specific mast cell degranulation or a bradykinin accumulation. Skin tests, followed by reintroduction of alteplase in case of negativity, are therefore of interest to rule out an IgE-mediated mechanism. Since alteplase is only activated in the presence of fibrin, its intravenous reintroduction is safe, without bleeding risk, in the absence of thrombosis. ConclusionA better knowledge of angioedema occurring with alteplase could improve their emergency and allergological management.