Fatal injection of ranitidine: a case report

Journal of Medical Case Reports Fatal injection of ranitidine: a case report Antonio Oliva 2 Sara Partemi 2 Vincenzo Arena 1 Fabio De Giorgio 2 Catia Colecchi 2 Nadia Fucci 0 Vincenzo L Pascali 2 0 Forensic Toxicology Laboratories, Catholic University, School of Medicine , Rome , Italy 1 Institute of Pathology, Catholic University, School of Medicine , Rome , Italy 2 Institute of Legal Medicine, Catholic University, School of Medicine , Rome , Italy Introduction: Ranitidine hydrochloride (Zantac®), a histamine-2-receptor antagonist, is a widely used medication with an excellent safety record. Anaphylactic reaction to ranitidine is an extremely rare event and a related death has never been described in the literature. Case presentation: We present the clinical history, histological and toxicological data of a 51year-old man with negative anamnesis for allergic events, who died suddenly after the intravenous administration of one phial of Zantac® 50 mg prescribed as a routine post-surgical prophylaxis for stress ulcer. Conclusion: Although the incidence of anaphylactic reactions related to ranitidine is low, caution needs to be exercised on administration of this drug. In addition, further study is needed to define strategies for the prevention of adverse drug reactions in hospitalized patients. - Introduction Ranitidine hydrochloride (Zantac®) is a histamine-2receptor antagonist (H2RA) medication used in peptic ulcer disease therapy, acute stress ulcers, gastroesophageal reflux and related disorders (indications and dosages are summarized in Tables 1 and 2). This medication is often used intravenously in the operating room and during recovery in surgical departments or intensive care units, and orally in medical departments [1]. Ranitidine has an excellent safety record [2,3] and we found no reports of fatalities related to this drug in the literature, although the incidence of anaphylactic reaction to H2RAs and proton pump inhibitors together has been reported as 0.3% to 0.7% (see [4]). Several other adverse events are reported in clinical trials or in the routine management of patients treated with ranitidine [5]. Central nervous system symptoms such as malaise, dizziness, somnolence, insomnia and vertigo have been reported. Rare events of reversible mental confusion, agitation, depression and hallucinations have also been described, predominantly in severely ill elderly patients. Effects on the cardiovascular system have included rare cases of arrhythmias such as tachycardia, bradycardia, atrioventricular block and premature ventricular beats [6]. There have been occasional reports of hepatocellular, cholestatic or mixed hepatitis, with or without jaundice. These events are usually reversible, but in rare circumstances death has occurred. Cases of agranulocytosis, pancytopenia, sometimes with marrow hypoplasia, and aplastic anemia, and exceedingly rare events of acquired immune hemolytic anemia have been reported. 150 mg or 10 ml of syrup 150 mg or 10 ml of syrup 50 mg or 10 ml of syrup 50 mg or 10 ml of syrup 150 mg or 10 ml of syrup 150 mg or 10 ml of syrup 150 mg or 10 ml of syrup 150 mg or 10 ml of syrup A large epidemiological study suggested an increased risk of developing pneumonia in current users of H2RAs compared with patients who had stopped H2RA treatment. However, a causal relationship between the use of H2RAs and pneumonia has not been established. Case presentation A 51-year-old man was admitted to the hospital for treatment of benign prostatic hyperplasia (BPH). The patient's anamnesis was negative for allergic events. Before hospitalization he was being treated with alfuzosin, which belongs to a group of medications known as alpha-1Areceptor antagonists used to treat the symptoms of enlarged prostate and BPH. On admission to the hospital alfuzosin treatment was suspended and the patient underwent transurethral resection of the prostate under epidural anesthesia, followed by post-surgical administration of antibiotics (modivid) and lactated Ringer's solution. Twenty-four hours after surgery, routine prophylaxis for stress ulcer (one phial of Zantac® 50 mg, intravenous, in normal saline solution) was prescribed. Within minutes of the injection of ranitidine, the patient developed a combination of wheezing, dyspnea and hypotension followed by loss of consciousness. Despite intensive resuscitation attempts, no cardiac activity reappeared and death was certified 30 minutes later. As the circumstances of death appeared suspicious to the treating emergency physician, a forensic investigation was initiated and the public prosecutor ordered a forensic necropsy. The autopsy revealed pulmonary congestion with widespread upper airway edema, the presence of petechial hemorrhages and brain swelling with diffuse petechial hemorrhages. There was no evidence of recent myocardial Treatment and maintenance for duodenal ulcer, hypersecretory conditions, gastroesophageal reflux. infarction or ot (...truncated)