C42-44 Recurrent Amiodarone-Induced Pulmonary Toxicity After Steroid Taper: A Cautionary Case

Introduction Amiodarone is widely prescribed, however, long-term use is associated with unfavorable side effects including pneumonitis. The incidence of amiodarone-induced pneumonitis is as high as 17%, with a mortality rate of around 10%. Prompt treatment with corticosteroids is essential, but after clinical improvement, guidance on how to taper steroids is sparse. Case Presentation An 80 year-old with a history of atrial fibrillation and quiescent seizure disorder presented with a 3-day history of dyspnea and cough and was admitted to the intensive care unit. Infectious work-up was negative and CTA chest showed diffuse bilateral ground glass opacities. He completed a course of antibiotics for possible pneumonia and was started on 60 mg of methylprednisolone. His hypoxia worsened and he required endotracheal intubation and lung protective mechanical ventilation. He underwent bronchoscopy with bronchoalveolar lavage, revealing a total cell count of 200 which was macrophage predominant; cytology described foamy macrophages. Sequential lavage was not consistent with diffuse alveolar hemorrhage. Microbiologic testing was negative. Serologic testing for connective tissue disease and hypersensitivity pneumonitis was unrevealing. On this basis, a working diagnosis of amiodarone-induced pneumonitis was made, and the patient’s methylprednisolone was intensified to 2 mg/kg/day. With increased steroid dosing and lung protective ventilation, his oxygenation and ventilation improved and he was extubated to high flow nasal cannula and subsequently weaned to low flow nasal cannula. His methylprednisolone was decreased to 1 mg/kg/day and he was transferred out of the ICU. The following day, he became increasingly hypoxic and was transferred back to the intensive care unit and re-intubated. His methylprednisolone was again increased to 2 mg/kg/day and his oxygenation and ventilation again improved, but his course was complicated by delirium and debility precluding extubation. After deliberation with his family providing substituted judgment that he would not wish for a tracheostomy or prolonged mechanical ventilation, life sustaining treatments were withdrawn and the patient died receiving comfort focused care. Discussion Treatment of amiodarone-induced pulmonary toxicity requires discontinuation of amiodarone and treatment with steroids. Steroids should be tapered once clinical improvement has been observed; however, given amiodarone’s long half-life and the possibility of symptom recurrence, steroids should be tapered cautiously. No definitive taper course has been proposed, but given the above, a slow taper should be considered to potentially prevent relapse of symptoms. Steroids are also associated with several untoward side effects, including delirium and weakness, which may also have complicated this case.