Abstract 17521: Esmolol-Associated Skin Necrosis: An Uncommon Adverse Reaction

Background: We report a case of a patient admitted to the cardiac care unit for evaluation of a non-ST-elevation myocardial infarction (NSTEMI) in the setting of atrial flutter (2:1) who developed a bullae and skin necrosis secondary to esmolol infusion.

Case presentation: A 48-year-old male with a past medical history of hypertension presented with exertional chest pain with associated shortness of breath and palpitations and was being evaluated for NSTEMI. Vitals were significant for blood pressure of 191/115 and heart rate of 125. Labs were significant for troponin I of 33.16 (<=0.15 ng/mL), which peaked at 38.24, and creatinine of 2.5. Electrocardiogram demonstrated atrial flutter 2:1 conduction with a rapid ventricular response. While in the cardiac critical unit, he was placed on an esmolol drip for rate control. Twenty-four hours after administration of the esmolol through a peripheral intravenous line (PIV), the patient began to feel pain with moderate edema around the site of the injection. The PIV was removed, and cold compresses were applied. Approximately 5-7 hours later, the patient developed multiple ring-like bullae around the injection site. Physical examination was noted for cold and tenderness to palpation with paresthesias. General surgery was consulted for compartment syndrome, which was ruled out. The cutaneous changes progressively worsened through admission, persisting in size and appearance with rupture and ulceration, and necrosis one week later (see image 1).

Conclusion: Although rare, esmolol can lead to skin necrosis and early identification is necessary for appropriate intervention including cessation of the culprit agent.