Title: AMIODARONE-INDUCED PULMONARY TOXICITY LEADING TO ACUTE RESPIRATORY DISTRESS SYNDROME
Abstract: SESSION TITLE: Toxicology SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Although widely used for multiple arrhythmias, amiodarone is known for its side effect profile. Among the most severe adverse events include a spectrum of amiodarone-induced pulmonary toxicity (AIPT). Its presentation can vary from a dose-related chronic and subacute form, including interstitial pneumonitis, organizing pneumonia, and eosinophilic pneumonia, to a more aggressive acute expression, such as ARDS. We present a case of rapidly progressive acute pulmonary toxicity manifesting as ARDS that improved with steroid treatment. CASE PRESENTATION: A 61-year-old with COPD, biventricular heart failure with EF of 10%, and paroxysmal atrial fibrillation presents to the hospital with dyspnea and severe hypoxia at rest. He was admitted to the Critical-Care Unit with a diagnosis of cardiogenic shock requiring milrinone infusion. Initial CT was consistent with diffuse centrilobular emphysema, ground-glass opacities with interlobular septal thickening, and pleural effusions consistent with pulmonary edema. Swann Ganz catheter was deployed, revealing mPAP of 44 with PCWP of 33; therefore, aggressive diuresis was started with symptomatic improvement. His course was complicated with rapid atrial fibrillation requiring amiodarone infusion continued with oral formulation. During the following days, his hypoxia worsened, requiring high-flow nasal cannula despite a PCWP of 10, with repeat CT revealing worsening ground-glass opacities with prominent interlobar septal thickening with upper lobe predominance. Infectious work-up was negative, and bronchoscopy ruled out DAH. After excluding other causes for ARDS, he was started empirically on steroids with a working diagnosis of amiodarone-induced pulmonary toxicity. He was eventually discharged on a prednisone taper with significant improvement noted on CT chest on follow-up. DISCUSSION: The diagnosis of acute AIPT is rare and one of exclusion after considering other common causes of ARDS and entities such as diffuse alveolar hemorrhage, acute interstitial pneumonia, and cardiogenic pulmonary edema, among others. In its subacute to chronic form, AIPT presents more often as Interstitial pneumonitis, with an incidence of 1-5% and dose-dependent relation. True incidence for amiodarone-related ARDS is challenging to ascertain; however, it has been described to represent around 2% of total cases of AIPT with a mortality rate of approximately 50%. An association has been noted with male gender, advanced age, and those with pulmonary and renal disease. ARDS has also been reported in patients receiving amiodarone during the periprocedural period after thoracic surgery and pulmonary vascular interventions though this relationship is debated. Although not diagnostic, bronchoscopy with bronchoalveolar lavage can be considered to rule out infection, bleeding, and other causes of interstitial disease. Upon clinical suspicion, amiodarone should be promptly suspended, and while supportive treatment ensues, empiric therapy with corticosteroids can be considered with observed favorable results. CONCLUSIONS: Amiodarone is an effective and frequently used antiarrhythmic medication in hospitalized patients. Though more often seen after two months of continuous use, acute presentation is also possible and is related to worse outcomes. In our reported case, after suspension of amiodarone and initiation of steroids, the patient had substantial clinical improvement with a resolution of radiographic findings and improvement in oxygen requirement. REFERENCE #1: Donaldson L, Grant IS, Naysmith MR, Thomas JS. Acute amiodarone-induced lung toxicity. Intensive Care Med. 1998;24(6):626-630. REFERENCE #2: Jackevicius CA, Tom A, Essebag V, et al. Population-level incidence and risk factors for pulmonary toxicity associated with amiodarone. Am J Cardiol. 2011;108(5):705-710. REFERENCE #3: Feduska ET, Thoma BN, Torjman MC, Goldhammer JE. Acute Amiodarone Pulmonary Toxicity. Journal of cardiothoracic and vascular anesthesia. 2021;35(5):1485-1494. DISCLOSURES: No relevant relationships by Dorys Chavez Melendez No relevant relationships by Aakash Goyal No relevant relationships by Arnaldo Rodriguez-Rivera No relevant relationships by Bhavna Sharma No relevant relationships by Sahar Sultan
Publication Year: 2023
Publication Date: 2023-10-01
Language: en
Type: article
Indexed In: ['crossref']
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Cited By Count: 2
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