An (b)(6) man presented with non-st elevation myocardial infarction (nstemi) and was treated for right coronary artery stenoses with atherectomy and 4 resolute dp-des, aspirin and clopidogrel (medtronic, (b)(4)).He sustained recurrent nstemi 43 days later.Angiography demonstrated in-stent thrombosis in a newly aneurysmal area which was treated with manual thrombectomy and balloon angioplasty.He was discharged on aspirin and ticagrelor.He presented with a diffuse macular pruritic rash accompanied by eosinophilia (2500/?l, reference: 100-300/?l) 74 days after initial stenting, though it had been present for several weeks before and he had failed topical over the counter treatments at home.The patient's only known allergy was "swelling" to penicillin; there were no changes to his longstanding medications, phenytoin, donepezil, metoprolol succinate and atorvastatin.Sequential elimination, each for >6 weeks, was used to determine if he was reacting to antiplatelets.First, clopidogrel was resumed in place of ticagrelor, but the rash persisted >6 weeks making an allergy to ticagrelor unlikely.Second, aspirin was eliminated for >6 weeks.The rash persisted; therefore, aspirin was restarted and clopidogrel was eliminated.The rash persisted after >6 weeks, shifting attention to the stent.Zotarolimus is 85% eluted after 60 days and is measurable in circulation for up to 180 days.One allergy to zotarolimus was considered unlikely since the reaction did not subside after 180 days.Daily oral prednisone (30 mg) diminished the rash, tapering worsened it.Skin testing 454 days after stenting revealed sensitivity to nickel, manganese, titanium, vanadium, and zinc.He was not a candidate for surgical explant, eosinophilia persisted long-term, and he stayed on steroids for approximately 3 years until his death.Fda safety report id # (b)(4).
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