الرحيم الرحمن الله الرحيم بسم الرحمن الله بسمElshaab Teaching HospitalElshaab Teaching HospitalUnit Of Dr .Nawal KordofaniUnit Of Dr .Nawal Kordofani

Case PresentationCase PresentationBy Ahmed HassanBy Ahmed Hassan

Personal Data:Personal Data:Name:Name:Age:75 yearAge:75 yearSex:MaleSex:MaleRes: TotiRes: TotiTribe: MahasTribe: MahasOcc:TailorOcc:TailorD.O.A: 23/10/2003D.O.A: 23/10/2003C/O : Chest pain /7 hrsC/O : Chest pain /7 hrs

H.P.I:H.P.I:This pt is a known case of HTN for This pt is a known case of HTN for the last 20 years but not on regular the last 20 years but not on regular treatment.Presented with treatment.Presented with retrosternal ,constricting chest pain retrosternal ,constricting chest pain , radiated to the Lt shoulder and Lt , radiated to the Lt shoulder and Lt arm associated with nausea and arm associated with nausea and vomiting ,also there was sweating vomiting ,also there was sweating and restlessness.There was no and restlessness.There was no cough,S.O.B,palpitations or cough,S.O.B,palpitations or syncopal attack.syncopal attack.

Systemic ReviewSystemic Review: : G.U.S:G.U.S:M.S.S: Un remarkable M.S.S: Un remarkable C.N.S:C.N.S:  P.M.H:P.M.H:No P.H of similar condition.No P.H of similar condition.The Pt is not known to be diabetic or The Pt is not known to be diabetic or asthmaticasthmaticNo PH of chronic coughNo PH of chronic cough

F.H:F.H: No FH of similar condition, HTN ,DM ,or No FH of similar condition, HTN ,DM ,or asthmaasthmaNo FH of sudden death.No FH of sudden death.S.HS.H:He is of moderate socioeconomic status, :He is of moderate socioeconomic status, married with 5 daughters .married with 5 daughters . Not smoker or alcohol consumer. Not smoker or alcohol consumer.D.HD.H : He was on diltiazem 60 mg b.d but : He was on diltiazem 60 mg b.d but not regularly.not regularly. Not known to be hypersensitive to Not known to be hypersensitive to any known drug. any known drug.

O/E:O/E:He looks unwell not P,J or CHe looks unwell not P,J or CJ.V.P not raised J.V.P not raised Thyroid not enlargedThyroid not enlargedL.N:not palpableL.N:not palpablePulse was 100 /b.p.m regular of small and Pulse was 100 /b.p.m regular of small and normal character, no R.F.D, peripheral normal character, no R.F.D, peripheral pulses were intact.pulses were intact.BP :110/75BP :110/75C.V.S:C.V.S:Chest:Chest:Abdomen: N.A.DAbdomen: N.A.DC.N.S:C.N.S:  

Investigations done at that time showed:Investigations done at that time showed:Hb:13.5 g/dlHb:13.5 g/dlT.W.B.C: 6800T.W.B.C: 6800E.S.R: 45mm/hE.S.R: 45mm/hB. urea:52mg/ dlB. urea:52mg/ dlS.k+: 3.6 meq/LS.k+: 3.6 meq/LS.Na+: 133 meq/LS.Na+: 133 meq/LR.B.S : 102 mg/dlR.B.S : 102 mg/dlC.X.R : not doneC.X.R : not doneE.C.G: showed extensive ant- M.I with E.C.G: showed extensive ant- M.I with unifocal P.V.Cs (SHOW) .unifocal P.V.Cs (SHOW) .

According to this presentation he was According to this presentation he was admitted to the CCU , admitted to the CCU , received :morphia ,nitrates , streptokinase received :morphia ,nitrates , streptokinase and lignocaine. On the 2and lignocaine. On the 2ndnd day his general day his general condition was improved and also his condition was improved and also his E.C.G (SHOW). In addition to nitrates he E.C.G (SHOW). In addition to nitrates he received,aspirin captopril ,and received,aspirin captopril ,and amiodarone amiodarone After one week he discharged in a good After one week he discharged in a good condition.(SHOW E.C.G on discharge):.condition.(SHOW E.C.G on discharge):.

.Two weeks later he presented to the .Two weeks later he presented to the casualty again C/O : S.O.B even at rest casualty again C/O : S.O.B even at rest and dry cough which was increased at and dry cough which was increased at night for 2 days.There was no chest night for 2 days.There was no chest pain , palpitations or syncopal attack . pain , palpitations or syncopal attack . No orthopnea ,P.N.D ,and no No orthopnea ,P.N.D ,and no haemoptysis, but the condition was haemoptysis, but the condition was associated with intermittent ,low grade associated with intermittent ,low grade fever not associated with sweating or fever not associated with sweating or rigor.rigor.  

O/E :O/E :The Pt looks unwell, dyspnoic,not P,J or C.The Pt looks unwell, dyspnoic,not P,J or C.J.V.P not raised.J.V.P not raised.Thyroid not enlarged.Thyroid not enlarged.L.N : not palpableL.N : not palpablePulse was 110 b.p m, irregular of small volume and Pulse was 110 b.p m, irregular of small volume and normal character ,no R.F.D ,peripheral pulses were normal character ,no R.F.D ,peripheral pulses were intact. intact. B .P 80/50. B .P 80/50. Hands :N.A.D.Hands :N.A.D.C.V.S :C.V.S :Apex at 6Apex at 6thth i.c.s , lateral to the m.c.l, normal in i.c.s , lateral to the m.c.l, normal in character .No palpable thrill, no L.P.H and no character .No palpable thrill, no L.P.H and no palpable 2palpable 2ndnd H.S .Muffled S1,and S2 ,no added H.S .Muffled S1,and S2 ,no added sound and no murmurs.sound and no murmurs.

Chest:Chest:There is pectus exacavatum deformity . R.R There is pectus exacavatum deformity . R.R 20/min.20/min.Chest moves equally . Trachea is central Chest moves equally . Trachea is central TVF : Decreased in the upper zones on both TVF : Decreased in the upper zones on both sides sides Impaired percussion note in the upper zones Impaired percussion note in the upper zones on both sides on both sides Decrease air entry on both upper and middle Decrease air entry on both upper and middle zones bilaterally zones bilaterally There is bilateral coarse crepitations There is bilateral coarse crepitations Abdomen Abdomen CNSCNS N.A.D. N.A.D.

SUMMARY:SUMMARY:75 Year-old Sudanese male presented to 75 Year-old Sudanese male presented to the casualty with acute MI,Received the the casualty with acute MI,Received the treatment accordingly plus amiodarone treatment accordingly plus amiodarone due to the presence of frequent P.V.Cs due to the presence of frequent P.V.Cs on E.C.G, and discharged after showing on E.C.G, and discharged after showing remarkable improvement.Two weeks remarkable improvement.Two weeks later he was readmitted again C/O S.O.B later he was readmitted again C/O S.O.B , dry cough and fever for with no P.H of , dry cough and fever for with no P.H of lung disease, with signs suggesting lung disease, with signs suggesting bilateral lung fibrosis bilateral lung fibrosis

∆∆/∆ :/∆ :1) 1) Amiodarone-induced Amiodarone-induced pulmonary toxicitypulmonary toxicity2)Cryptogenic F.A2)Cryptogenic F.A3)Extrinsic allergic alveolitis3)Extrinsic allergic alveolitis4) Sarcoidosis4) Sarcoidosis

Investigations:Investigations:*C.B.C:*C.B.C: Hb 14.1 g/dl Hb 14.1 g/dl E.S.R:55mm/hE.S.R:55mm/h T.W.B.C 8500 Neut: 53% T.W.B.C 8500 Neut: 53% Lymph: 42% Lymph: 42% Mono: 2% Mono: 2% Eos : 3% Eos : 3% Platelets : 300000 Platelets : 300000 R.B.Cs:Normochromic, normocytic. R.B.Cs:Normochromic, normocytic. W.B.C :Of normal morphology. W.B.C :Of normal morphology.

*B.urea:68 mg/dl *B.urea:68 mg/dl *S.K+ 2.5 meq/L*S.K+ 2.5 meq/L*S .Na+ 134meq/L*S .Na+ 134meq/L*S. creatinene 0.9 mg/dl*S. creatinene 0.9 mg/dl*S. Ca++9.3 mg/dl*S. Ca++9.3 mg/dl*R.B.S: 96 mg/dl*R.B.S: 96 mg/dl              E.C.GE.C.G:(:(SHOW)SHOW)C.X.R:C.X.R: showed diffuse reticulonodular showed diffuse reticulonodular shadowing mainly in the upper and mid zones. shadowing mainly in the upper and mid zones. Also there is enlarged cardiac shadow Also there is enlarged cardiac shadow (SHOW)(SHOW)*Old C.X.R (SHOW) *Old C.X.R (SHOW)

              Echo:Echo: Dilated poorly contracting LV with Dilated poorly contracting LV with aneurysm of the LV and amural thrombus.There aneurysm of the LV and amural thrombus.There is dyskinesia of the IVS (Ischaemic is dyskinesia of the IVS (Ischaemic cardiomyopathy)cardiomyopathy)              C.T scan of the chestC.T scan of the chest:There is reticular :There is reticular shadowing and peripheral honey combing shadowing and peripheral honey combing affecting mainly the mid and upper zone.affecting mainly the mid and upper zone.Also there is marked parenchymal distortion in Also there is marked parenchymal distortion in the upper zones.the upper zones.A few small lymph nodes seen in the aorto-A few small lymph nodes seen in the aorto-pulmonary pre-tracheal regions.pulmonary pre-tracheal regions.All these features are in favor of sarcoidosis .All these features are in favor of sarcoidosis .(SHOW)(SHOW)

Hospital course:Hospital course:The Pt was admitted to the I CC U.The Pt was admitted to the I CC U.Received oxygen, dopamine and dobutamine.Received oxygen, dopamine and dobutamine.Nitrates, captopril and amiodarone were Nitrates, captopril and amiodarone were stopped.stopped.Heparin and warfarin are givenHeparin and warfarin are givenHis general condition was improved: all His general condition was improved: all symptoms subsided, and BP became 100/70.symptoms subsided, and BP became 100/70.After 2 weeks C.X.R was repeated (SHOW).After 2 weeks C.X.R was repeated (SHOW).

Diagnosis:Diagnosis: Amiodarone-induced Amiodarone-induced

interstitial pneumonitis-interstitial pneumonitis-fibrosisfibrosis

So the Pt was discharged in a good condition.So the Pt was discharged in a good condition.On discharge he was on:On discharge he was on: Isosorbide dinitrate 10 Isosorbide dinitrate 10

mg b.dmg b.dCaptopril 12.5 mg /day and aspirin 100 mg/dayCaptopril 12.5 mg /day and aspirin 100 mg/day

Literature ReviewLiterature Review  

Amiodarone-induced Amiodarone-induced pulmonary toxicitypulmonary toxicity

Amiodarone hydrochloride is commonly Amiodarone hydrochloride is commonly administered due to its effectiveness against administered due to its effectiveness against both supraventricular and ventricular both supraventricular and ventricular tachyarrhythmias and its lack of association tachyarrhythmias and its lack of association with increased mortality. Amiodarone-induced with increased mortality. Amiodarone-induced pulmonary toxicity (AIPT) is one of the most pulmonary toxicity (AIPT) is one of the most serious adverse effects of amiodarone therapy serious adverse effects of amiodarone therapy and can be fatal. and can be fatal.

Estimates of AIPT vary widely in the literature, Estimates of AIPT vary widely in the literature, likely due to lack of standard diagnostic criteria likely due to lack of standard diagnostic criteria and administration of high dosages of and administration of high dosages of amiodarone in earlier studies .Recent estimates amiodarone in earlier studies .Recent estimates suggest a frequency of 3% or less. Several suggest a frequency of 3% or less. Several forms of pulmonary toxicity have been forms of pulmonary toxicity have been described with amiodarone,described with amiodarone, the most common of which isthe most common of which is (1)interstitial pneumonitis-fibrosis (1)interstitial pneumonitis-fibrosis(2)(2)    acute respiratory distress syndrome, acute respiratory distress syndrome,(3)(3)    BOOP, BOOP, (4) and a solitary pulmonary mass (4) and a solitary pulmonary mass

*Mechanisms ofAIPT*Mechanisms ofAIPT. . (1)(1) A A direct toxic reaction in which cell direct toxic reaction in which cell injury occurs due to accumulation of injury occurs due to accumulation of cellular phospholipids secondary to cellular phospholipids secondary to inhibition of lysosomal phospholipases by inhibition of lysosomal phospholipases by the drug.the drug.(2)(2) S Second is an indirect immunologic econd is an indirect immunologic mechanism with CD8 T cell mechanism with CD8 T cell lymphocytosislymphocytosis

Onset of AIPTOnset of AIPT May be rapid, occurring within days, or, more May be rapid, occurring within days, or, more commonly, insidious, occurring after several commonly, insidious, occurring after several months of therapymonths of therapy.. Risk factors Risk factors for AIPT include dose and, for AIPT include dose and, potentially, duration of treatment with the drug, potentially, duration of treatment with the drug, and abnormal baseline pulmonary function. and abnormal baseline pulmonary function. Dosages of 400 mg/day or less are believed to Dosages of 400 mg/day or less are believed to be associated with a lower frequency of AIPTbe associated with a lower frequency of AIPT ]] Duration of therapy is thought to pose a risk Duration of therapy is thought to pose a risk due to the high cumulative amount of due to the high cumulative amount of amiodarone to which the person is exposedamiodarone to which the person is exposed

Symptoms of AIPTSymptoms of AIPT include fever, include fever, nonproductive cough, pleuritic chest pain, and nonproductive cough, pleuritic chest pain, and dyspneadyspnea.. Physical findings Physical findings may include diffuse rales may include diffuse rales and a pleural rub Since the signs and and a pleural rub Since the signs and symptoms are nonspecific and often similar to symptoms are nonspecific and often similar to those in patients with heart failure, pulmonary those in patients with heart failure, pulmonary emboli, and pneumonia, the diagnosis is one emboli, and pneumonia, the diagnosis is one of exclusion of exclusion

Management of AIPTManagement of AIPT ideally involves(1)discontinuation of ideally involves(1)discontinuation of amiodarone.amiodarone.(2)corticosteroids were documented to be (2)corticosteroids were documented to be effective in case reports and should be effective in case reports and should be considered.Although specific steroid considered.Although specific steroid regimens often are not reported, regimens often are not reported, prednisone 40-60 mg/day with tapering prednisone 40-60 mg/day with tapering over 2-6 months was suggested . over 2-6 months was suggested .

If the patient's presentation is not life If the patient's presentation is not life threatening and amiodarone cannot be threatening and amiodarone cannot be withdrawn because it is the only or optimal withdrawn because it is the only or optimal therapy available for a patient, lowering the therapy available for a patient, lowering the dosage and administering concurrent low-dose dosage and administering concurrent low-dose steroids may be effective.steroids may be effective.Supportive therapy to manage respiratory Supportive therapy to manage respiratory distress should be started as necessary. distress should be started as necessary.

The prognosisThe prognosis of patients with AIPT is of patients with AIPT is generally good as pulmonary toxicity is often generally good as pulmonary toxicity is often reversible. Mortality rates vary widely because reversible. Mortality rates vary widely because death may be due to the underlying cardiac death may be due to the underlying cardiac disease, amiodarone toxicity, or both. In disease, amiodarone toxicity, or both. In patients who develop acute respiratory failure patients who develop acute respiratory failure and require mechanical ventilation, mortality and require mechanical ventilation, mortality ranges from 50-100%. However, death due to ranges from 50-100%. However, death due to AIPT itself was 5-10% in earlier studies that AIPT itself was 5-10% in earlier studies that gave dosages of more than 400 mg/day . gave dosages of more than 400 mg/day .

The lowest effective dosage of amiodarone The lowest effective dosage of amiodarone should be given. A simple and important should be given. A simple and important screening method for AIPT involves patient self-screening method for AIPT involves patient self-reporting of pulmonary symptoms such as reporting of pulmonary symptoms such as nonproductive cough, dyspnea, and pleuritic nonproductive cough, dyspnea, and pleuritic chest pain. Patients should be instructed to chest pain. Patients should be instructed to report development of such symptoms report development of such symptoms promptly, as this is often the earliest indication promptly, as this is often the earliest indication of AIPT and early detection is vital. of AIPT and early detection is vital.

. In addition, baseline chest radiograph and . In addition, baseline chest radiograph and pulmonary function tests, with repeat chest films pulmonary function tests, with repeat chest films every 3 months, are suggested for monitoring. every 3 months, are suggested for monitoring. However, as AIPTcan present rapidly, the value However, as AIPTcan present rapidly, the value of serial chest radiograph monitoring is of serial chest radiograph monitoring is questionable .questionable .

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