BACKGROUND
Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s triad, is characterized by the presence of bronchial asthma, nasal polyps, and hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAID). The authors present a unique case of a 54-year-old female with a history of asthma and diabetes who developed life-threatening respiratory failure requiring intubation following the administration of acetaminophen. This case highlights the potential dangers of seemingly benign medications in patients with AERD and underscores the importance of obtaining a comprehensive medical history prior to drug administration.
CASE PRESENTATION
The patient underwent an elective hysterectomy and bilateral salpingo-oophorectomy without complications. However, on post-operative Day 1, they experienced acute respiratory failure with hypoxia and hypercapnia, necessitating intubation for airway protection. Despite administration of bronchodilators, the patient exhibited air trapping and high airway resistance, making mechanical ventilation challenging and requiring manual bag–mask ventilation.
The patient subsequently experienced asystole, requiring cardiopulmonary resuscitation and vasopressor support, with return of spontaneous circulation achieved within 1 minute. On Day 3, the patient was successfully extubated after weaning off pressors, sedatives, and paralytics. Acetaminophen was identified as the trigger for respiratory failure, and a diagnosis of AERD was established based on a CT sinus scan revealing significant mucosal thickening consistent with chronic inflammatory illness. The patient’s symptoms improved with appropriate management, and they were discharged on a steroid taper.
AERD is a non-IgE-mediated hypersensitivity reaction associated with aspirin or NSAIDs. The inhibition of the cyclooxygenase (COX) pathway by NSAIDs leads to reduced production of anti-inflammatory prostaglandin E2 and increased synthesis of pro-inflammatory leukotrienes. Acetaminophen, although not classified as an NSAID, exhibits weak COX-1 and COX-2 inhibition, potentially resulting in increased leukotriene production and decreased glutathione levels in alveolar macrophages. Reduced glutathione levels can trigger acute inflammatory processes in the lungs. Importantly, up to 34% of aspirin-sensitive patients may experience dose-dependent cross-reactivity with acetaminophen, particularly at doses of 1 g or higher. This case underscores the significance of obtaining a detailed medical history when prescribing apparently innocuous medications to patients with asthma.
CONCLUSION
In conclusion, this case highlights the severe respiratory complications that can arise from acetaminophen administration in patients with AERD. Healthcare providers should be vigilant in assessing patients’ medication history, particularly in those with asthma, to prevent potentially life-threatening reactions. Improved awareness and understanding of AERD and its associated risks will facilitate appropriate management strategies and optimize
patient outcomes.
