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A6941 - A Case of Ziprasidone-Induced Hypersensitivity Pneumonitis: A Previously Unreported Side Effect of an Atypical Antipsychotic
Author Block: S. Ashraf1, W. Graham2, H. Hayreh3; 1Kaiser Permanente Los Angeles, Los Angeles, CA, United States, 2Pulmonary Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States, 3Pulmonary Critical Care, Kaiser Permanente Los Angeles, Los Angeles, CA, United States.
A 59-year-old African American female with a 40-pack year tobacco history and bipolar disorder presented to the ED with fevers, dyspnea, and malaise for the last week. She had started Ziprasidone two weeks prior to the onset of symptoms. She otherwise denied any new medications, recent travel, sick contacts, or unusual environmental exposures.
On presentation, she was afebrile and mildly tachypnic, but spoke in complete sentences and maintaining a normal oxygen saturation on room air. Pulmonary auscultation found bilateral intermittent wheezes at end expiration. Laboratory studies showed a WBC count of 13,000 with neutrophil predominance. CT chest was obtained and showed diffuse bilateral ground glass opacities. Nasopharyngeal respiratory pathogen panel and bacterial blood and sputum cultures were negative for infectious etiologies. ANA, ANCA, SCL-70, and rheumatoid factor were also within normal limits.
On admission she was started on azithromycin and ceftriaxone for suspected community-acquired pneumonia. However, in the subsequent days she developed rapidly progressive hypoxic respiratory failure, requiring 100% oxygen via high-flow nasal cannula and transfer to the ICU. On hospital day 4, antibiotics and ziprasidone were discontinued and she was started on pulse dose IV solumedrol for suspected hypersensitivity pneumonitis. Within 24 hours, the patient’s respiratory status dramatically improved, and IV steroids were slowly tapered to oral prednisone and discharged one week after presentation. In clinic follow-up, she was tolerating a slow prednisone taper and was close to her baseline level of activity and functioning.
Ziprasidone is an atypical antipsychotic approved in 2001 for treatment in schizophrenia and bipolar disorder. It is an antagonist of dopamine and some serotonin receptors while being a partial agonist for other serotonin receptors, and is generally it is well tolerated (3). It is only rarely associated with drug reaction with eosinophilia and systemic symptoms (2).
Hypersensitivity pneumonitis, also known as extrinsic allergic alveolitis, is a syndrome which arises following a type III hypersensitivity response in the alveolar epithelium that is triggered by an allergen. It is usually the sequelae of repeated exposure to an allergen, whether it be environmental or medication-induced (1). Treatment is identification and removal of the offending allergen and steroids to minimize inflammation.
In our literature review, this is the first documented case of Ziprasidone-induced hypersensitivity pneumonitis. Our case demonstrates clinicians should have a high suspicion for hypersensitivity pneumonitis from atypical causes in patients with a negative infectious and autoimmune workup and consistent CT chest findings for hypersensitivity pneumonitis.