SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters
SESSION TYPE: Case Report Posters
PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm
INTRODUCTION: The most dangerous complication of amiodarone use is amiodarone-induced pulmonary toxicity (AIPT) (1). AIPT has no pathognomonic findings & is therefore diagnosed based on clinical suspicion & exclusion of other possible pulmonary diseases (2)
CASE PRESENTATION: A 91-year-old female with history of CHF & atrial fibrillation on amiodarone 200mg once daily for approximately 10 years, presented for worsening shortness of breath for 3 days. On admission vitals were stable & pulse oximetry revealed a SpO2 of 89% on room air which increased to 96% on 4 litres oxygen. Examination revealed decreased breath sounds at bases, bilateral rales right>left. No clinical signs of fluid overload. Chest x-ray (fig 1) showed increased bilateral airspace opacities and computed tomography (CT) of chest (fig 3) revealed diffuse airspace opacities, right > left. Initial lab work was within normal limits. She was admitted with a working diagnosis of acute hypoxemic respiratory failure due to community acquired pneumonia (CAP) versus COVID-19 pneumonia due to high suspicion based on her clinical picture. She received remdesvir, empiric antibiotics and amiodarone was discontinued. COVID-19 PCR was negative, patient did not spike fevers or had any leukocytosis & pneumonia workup was negative. Therefore we now considered AIPT. Gallium scan for AIPT revealed abnormal uptake involving lungs bilaterally consistent with AIPT. Patient was continued on dexamethasone, after which patient's oxygen requirement subsequently decreased & repeat chest x-ray (fig 2 ) showed a significant decrease in bilateral infiltrates on steroids. She was discharged home on 2 litres oxygen & prednisone taper for 4 months.
DISCUSSION: The advent of the highly contagious SARS-CoV-2 has made it further essential to diagnose AIPT correctly & to differentiate between these two entities. They have similar & non-specific features which makes this an even a greater challenge. Our elderly patient on long-term amiodarone use represents an at-risk group for AIPT (1). Her clinical picture was non-specific, initially suggesting CAP versus COVID-19 pneumonia. In our case, the consistent gallium scan findings confirmed the diagnosis of AIPT & enabled prompt anti-inflammatory treatment along with cessation of amiodarone which resulted in improved prognosis & outcome. AIPT should be suspected in patients taking amiodarone who have new or worsening symptoms with an insidious onset &/or new infiltrates on chest x-ray. Greater parenchymal activity on gallium scintigraphy scanning & the presence of lung biopsy findings can help further confirm the diagnosis (1)
CONCLUSIONS: In the era of the COVID-19 pandemic, it becomes even more challenging to diagnose and differentiate AIPT from SARS-CoV-2 pneumonia, which can have a similar presentation (3). Early recognition of AIPT is critical to prevent or minimize its potentially devastating pulmonary effects.
Reference #1: Martin, W. J., & Howard, D. M. (1985). Amiodarone-induced lung toxicity: In vitro evidence for the direct toxicity of the drug. American Journal of Pathology, 120(3), 344–350.
Reference #2: Benassi, F., Molardi, A., Righi, E. et al. ECMO for pulmonary rescue in an adult with amiodarone-induced toxicity. Heart Vessels 30, 410–415 (2015).
Reference #3: Macera M, De Angelis G, Sagnelli C, Coppola N, Vanvitelli Covid-Group. Clinical Presentation of COVID-19: Case Series and Review of the Literature. Int J Environ Res Public Health. 2020 Jul 14;17(14):5062.
DISCLOSURES: No relevant relationships by Nayaab Bakshi
No relevant relationships by Navjot Kaur Grewal
No relevant relationships by Talha Munir
No relevant relationships by Anusha Singhania