Amiodarone-induced bronchiolitis obliterans organizing pneumonia in patient following percutaneous transluminal coronary angioplasty

doi:10.4236/crcm.2013.29136

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Vol.2, No.9, 521-524 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.29136

Amiodarone-induced bronchiolitis obliterans

organizing pneumonia in patient following

percutaneous transluminal coronary angioplasty

Massimo Bolognesi1*, Diletta Bolognesi2

1General Practice Medicine-Primary Care , C esena, Ita ly; *Corresponding Author: [email protected]

2Territorial Medicine-Primary Care, Cesena, Italy

Received 23 September 2013; revised 20 October 2013; accepted 18 November 2013

Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

a guardian.

ABSTRACT

Background: Many patients are affected by idio-

pathicbronchiolitis obliterans organizing pneu-

monia (BOOP). There are several know n causes

of BOOP, and several systemic disorders have

BOOP as an associated primary pulmonary le-

sion. Numerous agents including cytotoxic and

noncytotoxic drugs have the potential to cause

pulmonary toxicity. Descriptions of amiodarone-

related BOOP continue to be reported through-

out the world. Case Report: We reported a pa-

tient with original clinical presentation who de-

veloped recurrent sustained ventricular tachy-

cardia (SVT) despite the presence of implant able

cardioverter-defibrillator (ICD), hypoxaemia and

interstitial pneumonitis in both lung bases. After

percutaneous transluminal coro nary angioplasty,

he developed bronchiolitis obliterans organizing

pneumonia (BOOP). Conclusions: To our know-

ledge, such complications after percutaneous

coronary procedure in patients with amiodarone

therapy for arrhythmia prophylaxis, are not very

frequent in literature.

Keywords: Percutaneous Tr ansluminal Coronary

Angioplasty; Amiodarone; BOOP

1. INTRODUCTION

Bronchiolitis obliterans organizing pneumonia (BOOP)

is a distinct entity with various clinical, rad iographic and

histologic features [1]. The term Bronchiolitis obliterans

organizing pneumonia was first described in the early

1980s as a clinical pathologic syndrome characterized

symptomatically by subacute and chronic respiratory

illness, histopathologically by granulation tissue in the

bronchiolar lumen, alveolar ducts with some alveoli as-

sociated with a variable degree of interstitial and air

space infiltration by mononuclear cells with foamy

macrophages [2]. In most cases, the aetiology remains

unknown, although it has been associated with specific

diseases and causes including bacterial or viral infections,

diseases of the connective tissue, radiation therapy, mye-

lodysplastic syndrome, cocaine abuse, human immuno-

deficiency virus (HIV) infection, gastrointestinal disor-

ders, coronary artery bypassing grafting, and more vari-

ous pharmaceutical drugs [3]. Amiodarone is one of the

principal drugs involved in pulmonary toxicity, espe-

cially in patients undergoing cardiac surgery [4]. The

manifestations of pulmonary toxicity from amiodarone,

described in the literature include bronchiolitis obliter-

ans with or without sign s of organizing pneumonia, with

or without chronic interstitial fibrosis, pulmonary solitary

or multiple masses or respiratory distress syndrome [5-

11]. A tissue biopsy specimen is needed for a precise

diagnosis, but clinicoradiologic characteristics deter-

mined through biopsy-based studies may provide suffi-

cient diagnostic information. In fact, the ch est radiograph

showed the typical bilateral patchy (alveolar) infiltrate

and even more, the chest computed tomographic scan

showed the same findings, with bilateral areas of con-

solidation and ground glass opacities, usually with a pe-

ripheral location [6]. High-resolution chest computed

tomographic scans showed two types of linear opacities

that usually occurred in the lower lobes, frequently asso-

ciated with multifocal areas of consolidation, and usually

completely resolved with treatment [7]. We report here a

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522

case of a patient with classic clinical and radiological

description of amiodarone-induced BOOP seen immedi-

ately after percutaneous coronary intervention (PCI).

2. CASE REPORT

This report concerns an 81-year-old man suffering from

ischemic dilated cardiomyopathy and permanent atrial

fibrillation. The patient had had previous myocardial

infarction and sustained ventricular tachycardia (SVT)

with impairment of theleft ventricular systolic function

that required multiple drugs, including amiodarone, and

implantable cardioverter-defibrillator (ICD). Significant

multivessel coronary artery disease with severe left ven-

tricular dysfunction, estimate by ejection fraction to 30%,

requireda percutaneous coronary intervention (PCI) by

dualangioplasty with drug-eluting stent. This procedure

was carried out under poor clinical conditions. This pa-

tient was in long term treatment with L-tiroxin a for jatro-

genic hypothyroidism. After discharge, at home, he de-

veloped symptoms of an upper respiratory infection,

worsened shortness of breath and cough and was again

admitted to hospital. Postero-anterior chest radiograph

recorded the first time in supine position (see Figure 1,

Panel B) and 2 days later in sitting positio n (see Figure 1,

Panel A), showed a worsening of infiltration of the bilat-

eral inferior lobe of the lungs with mild pleu ral effu sion.

Pneumonia was initially diagnosed and an antibiotic

therapy (Levofloxacina and Ceftriaxone) was started,

while a cardiac ablation was performed for recurrent

SVT (see Figure 2). After four days the patient remained

symptomatic despite antibiotics and symptomatic man-

agement. A subsequent chest high-resolution computed

tomography (HRCT) scan (see Figure 3) showed exten-

sive bilateral opacities which were more pronounced in

the lower lobes, particularly in the right lobe. In additio n

to the chest HRCT, which confirmed the bilateral pres-

ence of basal pulmonary infiltrates, the pulmonary func-

tion tests showed reduced. Then, amiodaronew as dis-

continued and the patient began an anti-inflammatory

treatment with steroids at high dose for presumed BO OP.

Other medications such ascarvedilol, furosemide, ACE

inhibitors, digoxin, ceftriaxone and nebulised broncho-

dilators were continued. There was a dramatic improve-

ment in the clinical as well as radiological status within

72 hours, and a chest x ray sh owed f airly good resolu tion

of infiltrates (see Figure 4). Thus, the presumptive di-

agnosis of acute amiodarone toxicity was confirmed.

3. CONCLUSIONS

Pulmonary drug toxicity is a common and possibly

underdiagnosed cause of acute and chronic lung disease

[8]. There are numerous drugs with potential toxic ef-

fects on the lungs: one of these is amiodarone. As Nacca

et al. describes in our case study [9], diagnosis of amio-

darone pulmonary toxicity is often one of exclusion as

there are no specific laboratory analyses to confirm this.

Therefore, the diagnosis is based on a combination of

clinical suspicion, history, radiographic and clinical evi-

dence, with the exclusion of alternative etiologies. Chest

X ray and subsequent chest HRCT show bilateral dif-

fuse or patchy infiltrates, more commonly in the right

lobe. Furthermore, pleural thickening and/or effusion has

been described. Pulmonary function tests typically reveal

either a restrictive or mixed obstructive/restrictive pat-

tern with a decreased diffusion lung capacity of 15% -

20% [10]. In fact, the earliest abnormality in amiodar-

one pulmonary toxicity is a decrease in the diffusion ca-

pacity for carbon monoxide. The aim of this report is to

emphasize the possibility of this dangerous disease in

patients undergoing cardiovascular surgery or other pro-

cedures such as percutaneous coronary angioplasty, es-

pecially when they are in long term therapy with amio-

darone, and when signs of iatrogenic effects such as hy-

pothyroidismare already present. The clinician must keep

Chest x ray findings

Sitting position Supine position

Figure 1. Chest x ray, in supine (Panel B) and sitting positions (Panel A), shows a progressive

worsening of bilateral patchy infiltrates in the lower lungs with mild pleural effusion.

M. Bolognesi, D. Bolognesi / Case Reports in Clinical Medicine 2 (2013) 521-524 523

Figure 2. ECG shows sustained ventricular tachycardia.

chest computed tomography (CT) scan

Figure 3. Chest HRCT scan shows findings similar to the chest radiograph, with bi-

lateral areas of consolidation and ground glass opacities with a peripheral location.

Figure 4. Chest x ray shows full resolution of infiltrates with

normal radiographic a pp ea ra nc es .

this in mind because medical decision depends on clini-

cal skills rather than any definitive diagnostic tests or

proven therapies. Pulmonary toxicity can be fatal. A high

index of suspicion is necessary in establishing the diag-

nosis of amiodarone-induced BOOP, since most cases are

reversible if detected early. In summary, the toxicity of

amiodarone should be considered in the differential di-

agnosis of all patients who are being treated with this

medication and presenting progressive or acute respira-

tory symptoms, especially those with a history of chronic

lung disease, supplemental oxygen therapy and after car-

diac surgery.

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