Potential anaphylactoid reaction to nicardipine

Anaphylactic and anaphylactoid reactions are both acute allergic responses known to be potentially fatal if not treated emergently. Signs include bronchospasm, urticaria, nausea and vomiting, pharyngeal edema and cardiovascular collapse. Nicardipine hydrochloride is a dihydropyridine calcium channel blocker that has emerged as a first-line antihypertensive in which emergent blood pressure control is critical. The patient in this case is a 52-year-old male who arrived at the emergency department (ED) with right-sided hemineglect, severe dysarthria, and aphasia, and he was diagnosed with an acute left thalamic hemorrhage. His blood pressure readings were initially 252/135 mmHg despite multiple intermittent boluses of intravenous hydralazine. He was administered a nicardipine hydrochloride infusion at 2.5 mg/h. Due to poor blood pressure control, the rate was titrated up in increments of 2.5 mg/h in the span of 30 min. While up titrating the infusion rate, he developed diffuse swelling and erythema to his left upper extremity in which the medication was being infused, a body wide urticarial rash, tachycardia, diaphoresis, wheezing, and hypoxemia saturating 85% on room air.