Progressive Pulmonary Hypertension and Lung Nodules Related to Intravenous Promethazine and Heparin Incompatibility.

Abstract

SESSION TITLE: Miscellaneous SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: This case describes a patient who had progressive embolic pulmonary hypertension and nodular lung disease related to intravenous heparin and promethazine drug incompatibility. CASE PRESENTATION: A 46-year-old woman with chronic relapsing pancreatitis under the supervision of a pain management specialist used self-administered promethazine injections through an implanted mediport at home. She presented to the hospital with abdominal pain, slowly progressive dyspnea on exertion, and a dry cough. Lab work demonstrated elevated liver function tests and CRP. Her chest x-ray showed borderline cardiomegaly and increased interstitial markings with reticular nodular opacities. CT angiography of the chest was negative for PE, but did confirm widespread poorly marginated small nodular densities as well as mild adenopathy. Bronchoscopy with BAL and wash was non-diagnostic. Her echo demonstrated an RVSP of 64 and a right heart catheter later confirmed moderate pulmonary HTN. Further lab workup for pulmonary HTN was negative. Pulmonary function testing showed restrictive disease with a reactive component. She required oxygen with exertion at discharge and was seen in close outpatient follow up for additional workup. Ten weeks later she was readmitted for symptom management of her severe abdominal pain. She denied any shortness of air or cough at that point in time. Repeat CT of the abdomen prompted chest imaging that demonstrated progressive widespread milliary nodular pattern of both lungs with progressive adenopathy. Echo demonstrated slight worsening of pulmonary hypertension. VATS was completed for surgical lung biopsy and pathology demonstrated an exuberant foreign body type reaction to polarizable amorphous foreign material associated with acute inflammation as well as focal microabscess formation. Cultures and stains for infectious organisms were negative. She denied illicit drug use and careful review of her outpatient medications revealed an in-line incompatibility of her IV heparin flushes and promethazine injections. MicroMedex IV compatibility listed the incompatibility as causing an increase in measured haze or turbidity, particulates and/or color change.1 Additional history was obtained and due to lack of readily available normal saline flushes, she had been using prefilled heparin syringes to flush her mediport after injecting promethazine. She was started on high dose prednisone that was slowly tapered over several months with normalization of her pulmonary hypertension on follow up echo. Follow up CT imaging demonstrated resolution of her adenopathy and improvement but incomplete resolution of her nodular airspace disease. DISCUSSION: The patient had been self-administering IV promethazine for nausea via an implanted port often several times per day. Her insurance company had only authorized a small allotment of prefilled saline syringes per month, but had provided a much larger allotment of prefilled heparin syringes for her to use for line maintenance. Due to this discrepancy, she would often use the more readily available heparin syringes as opposed to saline to flush her line after a promethazine dose. Incompatibility between IV promethazine and heparin led to precipitate formation that then embolized in the pulmonary circulation causing progressive pulmonary hypertension as well as diffuse micronodular airspace disease noted on CT. A progressive inflammatory reaction likely potentiated the progressive nodule growth. Treating the patient with steroids was successful in halting the inflammation and partial reversal of the disease process. Proper education about line maintenance and use of saline flushes prevented ongoing embolization. CONCLUSIONS: This case demonstrated the in-line incompatibility of IV promethazine and heparin had significant embolic effects on the pulmonary circulation. Obtaining a thorough history regarding utilization of home medications ultimately led to the diagnosis. Detailed attention as well as appropriate education and monitoring should be given to patients who self-administer IV medications via mediports. Reference #1: Truven Health Analytics MicroMedex IV compatability checker DISCLOSURE: The following authors have nothing to disclose: David Hasselbacher, Rebecca Parrish, Emma Coronel No Product/Research Disclosure Information