Abstract
Monoamine oxidase inhibitors (MAOIs) are known to cause hypertensive crisis when combined with intake of tyramine, classically found in cheese. We present a case of MAOI-induced hypertensive crisis leading to significant troponin release after soft cheese intake. A 51-year-old lady presented with left-sided chest pain, palpitations and headache in the context of significant hypertension after eating soft cheese. She had a similar episode 2 month prior to this presentation, which resulted in a diagnosis of non-ST elevation myocardial infarction after a troponin of 2768 ng/L (Ref < 17 ng/L) with normal cardiac investigations and CT pulmonary angiogram. She was known to be on tranylcypromine for bipolar depression. Subsequent cardiac investigations were normal, as were those for phaeochromocytoma and Conn’s disease. Tranylcypromine is a non-selective irreversible MAOI used in refractory depression and bipolar disorder. MAOIs are known to cause hypertensive crisis when combined with soft cheese due to unopposed release of catecholamines from reduced tyramine metabolisation, leading to injury and possible myonecrosis. Three previous case reports have demonstrated either creatinine kinase or troponin rise with myocardial infarction due to this hypertensive crisis and our case is the fourth with significant hypertension and cardiac biomarker rise related to MAOI, specifically tranylcypromine.
References
Smookler, S., & Bermudez, A. J. (1982). Hypertensive crisis resulting from an MAO inhibitor and an over-the-counter appetite suppressant. Annals of Emergency Medicine, 11(9), 482–484.
Linden, C. H., Rumack, B. H., & Strehlke, C. (1984). Monoamine oxidase inhibitor overdose. Annals of Emergency Medicine, 13(12), 1137–1144.
Ngo, A. S., Ho, R. Y., & Olson, K. R. (2010). Phenelzine-induced myocardial injury: A case report. Journal of Medical Toxicology, 6(4), 431–434.
Alkhouli, M., Mathur, M., & Patil, P. (2014). Revisiting the “cheese reaction”: More than just a hypertensive crisis? Journal of Clinical Psychopharmacology, 34(5), 665–667.
Liu, L. X., & Rustgi, A. K. (1987). Cardiac myonecrosis in hypertensive crisis associated with monoamine oxidase inhibitor therapy. The American Journal of Medicine, 82(5), 1060–1064.
Blackwell, B. (1963). Hypertensive crisis due to monoamine-oxidase inhibitors. The Lancet, 2(7313), 849–850.
Kokan, L., & Benowitz, N. L. (2007). Monoamine oxidase inhibitors. In K. Olsen (Eds.), Poisoning and drug overdose (pp. 269–272). New York: McGraw-Hill Lange.
Marley, E., BLAoKwELI, B., & Histamine, D. (1970). Interactions of monoamine oxidase inhibitors, amines, and foodstuffs. Advances in Pharmacology and Chemotherapy, 7, 185–239.
Sathyanarayana Rao, T. S., & Yeragani, V. K. (2009). Hypertensive crisis and cheese. Indian Journal of Psychiatry, 51(1), 65–66.
Horwitz, D., Lovenberg, W., Engelman, K., & Sjoerdsma, A. (1964). Monoamine oxidase inhibitors, tyramine, and cheese. JAMA, 188, 1108–1110.
Musuraca, G., Imperadore, F., Terraneo, C., Vaccarini, C., Prati, D., Centonze, M., et al. (2009). Pheochromocytoma mimicking a non-ST elevation acute myocardial infarction. Cardiology Journal, 16(4), 355–357.
Arnaldo, F. J., Pulido, M. A., & House, J. G. (2006). Cocaine induced non-ST-elevation myocardial infarction: An uncommon electrocardiographic presentation. Emergency Medicine Journal, 23(10), 816–817.
Acharji, S., Baber, U., Mehran, R., Fahy, M., Kirtane, A. J., Lansky, A. J., et al. (2012). Prognostic significance of elevated baseline troponin in patients with acute coronary syndromes and chronic kidney disease treated with different antithrombotic regimens: A substudy from the ACUITY trial. Circulation: Cardiovascular Interventions, 5(2), 157–165.
White, H. D. (2011). Pathobiology of troponin elevations: Do elevations occur with myocardial ischemia as well as necrosis? Journal of the American College of Cardiology, 57(24), 2406–2408.
Weil, B. R., Young, R. F., Shen, X., Suzuki, G., Qu, J., Malhotra, S., et al. (2017). Brief myocardial ischemia produces cardiac troponin I release and focal myocyte apoptosis in the absence of pathological infarction in swine. JACC: Basic to Translational Science, 2(2), 105–114.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
There are no conflicts of interest in this case report.
Ethical Approval
This case report was reviewed and accepted by the HREC Apollo Committee of Nepean Hospital.
Informed Consent
Informed consent was obtained from the patient involved in this case report.
Additional information
Communicated by John Allen Crow.
Rights and permissions
About this article
Cite this article
Salter, M., Kenney, A. Myocardial Injury from Tranylcypromine-Induced Hypertensive Crisis Secondary to Excessive Tyramine Intake. Cardiovasc Toxicol 18, 583–586 (2018). https://doi.org/10.1007/s12012-018-9476-9
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12012-018-9476-9