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Amiodarone and Fluconazole: A Deadly Combination
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A6644 - Amiodarone and Fluconazole: A Deadly Combination
Author Block: A. Rai1, P. Soni2, W. Pascal1, N. Aggarwal2; 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY, United States, 2Maimonides Medical Center, Brooklyn, NY, United States.
Introduction:
The prevalence of systemic invasive fungal infections has been increasing in recent era with limited options for antifungal agents available in the market. Drug interactions have been the major limiting factor while choosing these agents. We present a rare case of a patient with very complicated hospital course who developed diffuse alveolar hemorrhage as a side effect of the amiodarone when administered with fluconazole.
Case Description:
A 62-year-old obese male with history of hypertension, CAD and diabetes presented to the ED with chest pain and dyspnea on exertion. He underwent cardiac catherization (CC) was found to have 90% LAD stenosis. CC was complicated by instent thrombosis. Patient developed severe cardiogenic shock for which he initially required V-A ECMO followed by LVAD implantation. Patient developed atrial fibrillation for which he was cardioverted multiple times and was started on amiodarone. His hospital course was further complicated by candida parapsilosis bacteremia which was initially treated with fluconazole. However, he developed diffuse alveolar hemorrhage (DAH) leading to ARDS requiring V-V ECMO. On detailed review to identify the etiology of sudden development of alveolar hemorrhage, we noted that patient was on amiodarone for rhythm control and then was later put on fluconazole for fugal bacteremia. Together these two medications are known to have synergistic effects1. Hence, fluconazole was stopped and micafungin was started. He responded very well to the treatment, ECMO was explanted 4 days later. For DAH, patient was started on high dose steroids which was tapered over 8 weeks. He was discharged home with outpatient follow up and is currently doing well.
Discussion:
DAH is a clinical syndrome resulting from pulmonary capillaritis or diffuse alveolar damage. DAH is usually associated with systemic disease, vasculitis or both. Few medications are known to cause DAH with amiodarone being one of them. To our knowledge this is the first case of DAH secondary to the combination these two medications. The exact mechanism for DAH when using this two agents is not clear but the generation of oxidative stress, mitochondrial dysfunction, and DNA damage are the few effects that has been described in the literature so far. Our case emphasizes that fluconazole when used in combination with amiodarone for fungal bacteremia can increases risk for life threatening DAH. Timely diagnoses and appropriately choosing alternative agent is crucial for positive outcome like in our patient.
References:
1.
http://aac.asm.org/content/57/4/1691.full
Author Block: A. Rai1, P. Soni2, W. Pascal1, N. Aggarwal2; 1Internal Medicine, Maimonides Medical Center, Brooklyn, NY, United States, 2Maimonides Medical Center, Brooklyn, NY, United States.
Introduction:
The prevalence of systemic invasive fungal infections has been increasing in recent era with limited options for antifungal agents available in the market. Drug interactions have been the major limiting factor while choosing these agents. We present a rare case of a patient with very complicated hospital course who developed diffuse alveolar hemorrhage as a side effect of the amiodarone when administered with fluconazole.
Case Description:
A 62-year-old obese male with history of hypertension, CAD and diabetes presented to the ED with chest pain and dyspnea on exertion. He underwent cardiac catherization (CC) was found to have 90% LAD stenosis. CC was complicated by instent thrombosis. Patient developed severe cardiogenic shock for which he initially required V-A ECMO followed by LVAD implantation. Patient developed atrial fibrillation for which he was cardioverted multiple times and was started on amiodarone. His hospital course was further complicated by candida parapsilosis bacteremia which was initially treated with fluconazole. However, he developed diffuse alveolar hemorrhage (DAH) leading to ARDS requiring V-V ECMO. On detailed review to identify the etiology of sudden development of alveolar hemorrhage, we noted that patient was on amiodarone for rhythm control and then was later put on fluconazole for fugal bacteremia. Together these two medications are known to have synergistic effects1. Hence, fluconazole was stopped and micafungin was started. He responded very well to the treatment, ECMO was explanted 4 days later. For DAH, patient was started on high dose steroids which was tapered over 8 weeks. He was discharged home with outpatient follow up and is currently doing well.
Discussion:
DAH is a clinical syndrome resulting from pulmonary capillaritis or diffuse alveolar damage. DAH is usually associated with systemic disease, vasculitis or both. Few medications are known to cause DAH with amiodarone being one of them. To our knowledge this is the first case of DAH secondary to the combination these two medications. The exact mechanism for DAH when using this two agents is not clear but the generation of oxidative stress, mitochondrial dysfunction, and DNA damage are the few effects that has been described in the literature so far. Our case emphasizes that fluconazole when used in combination with amiodarone for fungal bacteremia can increases risk for life threatening DAH. Timely diagnoses and appropriately choosing alternative agent is crucial for positive outcome like in our patient.
References:
1.
http://aac.asm.org/content/57/4/1691.full
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