Disulfiram ethanol reaction mimicking anaphylactic, cardioge
Published in the American Journal of Emergency Medicine, the authors report the case of a life-threatening shock mimicking successively anaphylactic, cardiogenic, and septic shock, which was finally related to disulfiram-ethanol reaction.

A 65-year-old man was referred ICU for shock. This patient reported no medical history except chronic alcohol abuse and was strictly asymptomatic until lunchtime, when he drunk 500 mL of wine. Half an hour later, he suddenly fainted and was transferred to the emergency department. Consciousness almost returned to normal, but blood pressure was 80/60 mm Hg, heart rate was 110 beats per minute, whereas respiratory rate was 25 breaths per minute and oxygen saturation 99% as he was breathing room air.

Temperature was 36°C. Medical examination was only remarkable for diffuse erythema on his chest and face, without mucosal swelling or pruritus. Anaphylaxis was nonetheless suspected, and the patient immediately received intravenous epinephrine (0.1 mg) and aggressive intravenous fluid resuscitation. Worsening circulatory failure required high-dose (0.8 μg/kg per minute) norepinephrine infusion.

ECG was suggestive of acute myocardial infarction on ECG (Fig..), but coronary angiography was strictly normal. Because of hypothermia (35.5°C) and intense shivering, a toxic shock syndrome was evoked, and intravenous broad-spectrum antibiotics combining ceftriaxone and clindamycin were started. The patient was then transferred to the ICU. Laboratory results revealed metabolic acidosis (pH 7.33; bicarbonates, 17.2 mmol/L; and arterial blood lactate, 8.7 mmol/L), but procalcitonin, high-sensitivity troponine, and other routine laboratory tests were strictly within normal ranges.

Blood ethanol concentration was 0.9 g/L 6 hours after ingestion. Whole-body computed tomographic scan was unremarkable. Transthoracic echocardiography revealed a hyperkinetic left ventricle without other abnormality. Further interrogation revealed that the patient erratically self-medicated with disulfiram and that he had ingested 500 mg of disulfiram 1 hour before alcohol intake.

His circulatory status dramatically improved, and norepinephrine was gradually weaned within 2 hours after ICU admission. Cutaneous manifestations, lactic acidosis, and ECG abnormalities also resolved within 6 hours. All bacteriological samples remained sterile, and antibiotics were discontinued. The patient was discharged home the day after, without any medication. The diagnosis of severe “disulfiram ethanol reaction” (DER) was retained.

Lessons learnt:-
- This case emphasizes the need to include drug interaction in the differential diagnosis of any shock, to avoid unnecessary and invasive procedures or therapeutics.

- Especially, DER should be suspected in an alcoholic patient presenting with miscellaneous manifestations mimicking anaphylaxis, complicated myocardial infarction, or toxinic shock.

- Emergency physicians and medical specialists should be aware of this life-threatening condition because of its misleading presentation.

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