Ajitkumar Jadhav, Digvijay Nalawade, Raj Sachde, Sridevi Chigulapalli

Department of Cardiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Abstract

Objective: Ticagrelor is a potent oral P2Y12 receptor inhibitor widely used as part of dual antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI). Although generally well tolerated, hypersensitivity reactions to ticagrelor are rarely reported.

Case presentation: We describe a case of a 56-year-old male with acute coronary syndrome who developed generalized pruritus, urticarial rash, and angioedema following initiation of ticagrelor after intravascular ultrasound–guided PCI. Prompt recognition, exclusion of infective causes, and substitution with prasugrel led to complete symptom resolution without ischemic complications.

Conclusion: This case highlights the importance of early identification of ticagrelor-induced cutaneous hypersensitivity and demonstrates the safety of switching to an alternative P2Y12 inhibitor in the post-PCI setting.

Key words: Ticagrelor, acute coronary syndrome, drug-induced rash, hypersensitivity, percutaneous coronary intervention

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor forms the cornerstone of management in patients with acute coronary syndrome (ACS), particularly following percutaneous coronary intervention (PCI) (1). Ticagrelor, a reversible oral P2Y12 inhibitor, has demonstrated superior ischemic outcomes compared with clopidogrel in ACS but is associated with adverse effects such as dyspnea, bradyarrhythmias, and bleeding (2). Cutaneous hypersensitivity reactions to ticagrelor are uncommon and sparsely reported in literature (3, 4). Early recognition is essential, as continued exposure may lead to progression of symptoms, while abrupt cessation without an alternative antiplatelet agent carries a risk of stent thrombosis.

We report a rare case of ticagrelor-induced cutaneous hypersensitivity presenting with urticarial rash and angioedema shortly after PCI.

Graphical abstract

Case report

A 56-year-old male with a known history of hypothyroidism on regular treatment presented with complaints of sudden-onset rest angina for seven days, associated with dyspnea on exertion (New York Heart Association class II). There was no prior history of coronary artery disease, drug allergy, or recent infection. Written informed consent was obtained from the patient for examinations, coronary intervention, the medical management, and the publication of this case report and associated images.

On admission, the patient was hemodynamically stable. Vital parameters were within normal limits. Cardiovascular, respiratory, abdominal, and neurological examinations were unremarkable.

Electrocardiography (ECG) revealed changes suggestive of an evolved inferior wall myocardial infarction. Baseline laboratory investigations, including renal and hepatic function tests, were within normal limits.

Coronary angiography demonstrated critical stenotic lesions in the left anterior descending artery and a major obtuse marginal branch. The patient underwent intravascular ultrasound (IVUS)–guided PCI to both vessels with optimal angiographic and IVUS results. Post-procedure, the patient received a loading dose of ticagrelor and was initiated on standard DAPT with ticagrelor and aspirin. The post-procedural course was uneventful, and the patient was discharged the following day in stable condition.

Three days after discharge, the patient presented to the emergency department with complaints of generalized itching for two days, followed by urticarial rash over the extremities (forearm), neck and anterior abdominal wall region for one day (Fig. 1-3), and subsequent generalized swelling for one day. There was no associated fever, respiratory distress, chest pain, or recurrence of anginal symptoms.

On examination, the patient was vitally stable. Dermatological examination revealed urticarial wheals over the limbs and neck with mild generalized edema. There were no mucosal lesions or features suggestive of anaphylaxis. Systemic examination was otherwise unremarkable. Repeat ECG showed no new ischemic changes.

A dermatology consultation was sought. Differential diagnoses included drug-induced hypersensitivity reaction versus infective etiology. Laboratory markers of infection and inflammation, including complete blood count and inflammatory markers were within normal limits. The platelet count remained stable at 210,000/ µL and coagulation tests were within normal limits, ruling out thrombocytopenia or systemic coagulopathy. There were no clinical signs of bleeding.

 A multidisciplinary team (MDT) consisting of cardiologists and dermatologists was convened to determine the optimal management strategy.

Figure 1. Cutaneous hypersensitivity reaction affecting the upper limb. (A) Rash over the proximal arm.

(B) Extension of lesions along the forearm after ticagrelor initiation post–percutaneous coronary intervention.

Figure 2. Clinical photograph showing a diffuse erythematous maculopapular rash involving the neck

Figure 3. Clinical photograph showing a diffuse erythematous maculopapular rash involving the anterior abdominal wall