What are the pulmonary adverse effects of streptokinase and how should they be monitored and managed?

Pulmonary Adverse Effects of Streptokinase

When streptokinase is administered intravenously for systemic thrombolysis (e.g., pulmonary embolism), pulmonary hemorrhage is a rare but life-threatening complication that presents with massive hemoptysis, acute respiratory distress, and diffuse bilateral lung infiltrates; suspect this immediately in any patient developing sudden respiratory compromise after streptokinase administration. 1

Systemic (Intravenous) Administration for Pulmonary Embolism

Major Pulmonary Complications

• Pulmonary hemorrhage is the most serious pulmonary-specific adverse effect, manifesting as:

  • Massive hemoptysis 1
  • Acute-onset respiratory distress 1
  • Diffuse bilateral lung infiltrates on chest imaging 1
  • Severe anemia from blood loss 1
  • Potential progression to respiratory failure and death 1

• Adult respiratory distress syndrome (ARDS) has been reported, though this occurred in a patient receiving both streptokinase and urokinase 2

Monitoring Strategy for Systemic Use

• Monitor continuously for sudden respiratory compromise during and immediately after streptokinase infusion, as pulmonary hemorrhage can develop acutely 1

• Obtain urgent chest imaging (chest X-ray or CT) if new dyspnea, hemoptysis, or oxygen desaturation occurs 1

• Check serial hemoglobin levels to detect occult bleeding, particularly in patients with respiratory symptoms 1

• Assess oxygenation status with pulse oximetry and arterial blood gases if respiratory distress develops 1

Management of Pulmonary Hemorrhage

• Immediately discontinue streptokinase if pulmonary hemorrhage is suspected 1

• Provide supportive care including oxygen supplementation, mechanical ventilation if needed, and blood transfusion for severe anemia 1

• Conservative management with cessation of thrombolysis and supportive measures can lead to recovery in some patients 1

• Recognize that mortality is significant when pulmonary hemorrhage occurs, with death from respiratory failure reported 1

Intrapleural (Local) Administration for Pleural Infections

Common Adverse Effects

• Pleural pain (chest pain) occurs in approximately 7% of patients receiving intrapleural streptokinase versus 3% with placebo 2

• Fever is commonly noted with streptokinase, though distinguishing drug-induced fever from infection-related fever can be challenging 3, 2

• Immunological reactions occur most frequently with streptokinase due to its bacterial-derived antigenic properties 3, 2

Rare but Serious Complications

• Local pleural hemorrhage has been reported, including one pediatric case of significant bleeding after traumatic drain insertion 3, 2

• Systemic bleeding manifestations including epistaxis (nosebleeds) are rare 4, 2

• Transient disorientation without evidence of intracerebral bleeding has been documented 4, 2

Critical Safety Considerations for Intrapleural Use

• Streptokinase generates persistent neutralizing antibodies similar to systemic administration, even when given intrapleurally 3, 4

• Re-administration within 6 months is contraindicated due to risk of severe allergic reactions and loss of efficacy 4

• Provide patients with a streptokinase exposure card to document prior use 4, 2

• For any subsequent thrombolytic indication (myocardial infarction, pulmonary embolism), use urokinase or tissue plasminogen activator instead of streptokinase 4, 2

• No systemic fibrinolysis occurs at cumulative intrapleural doses up to 1.5 million IU, based on safety monitoring 4, 2

Common Pitfalls to Avoid

• Do not dismiss new respiratory symptoms as anxiety or underlying disease progression—always consider pulmonary hemorrhage in patients receiving systemic streptokinase 1

• Do not attribute all fever to the underlying infection when streptokinase is used intrapleurally; drug-induced fever is common 3, 2

• Do not exceed cumulative intrapleural doses of 1.5 million IU to avoid potential systemic fibrinolytic effects 4

• Do not use streptokinase for repeat thrombolysis within 6 months due to antibody formation 4

• Avoid intrapleural fibrinolytics within 24 hours of traumatic chest tube insertion due to increased bleeding risk 3

Alternative Agents with Lower Pulmonary Risk

• Urokinase is non-antigenic (derived from human urine) and carries lower immunological risk than streptokinase 3, 4, 2

• For intrapleural use, urokinase 100,000 IU once daily for 3 days is equally effective to streptokinase with fewer immunological reactions 4, 2

• For systemic pulmonary embolism, alteplase (rtPA) 100 mg over 2 hours provides similar efficacy to streptokinase with potentially lower antigenic risk 3, 5