Pulmonary disease after amitriptyline overdosage.

A rapidly fatal diffuse pulmonary consolidation after ingestion of amitriptyline is reported.-Thedisease process was ac- companied by noticeable loss of lung compliance, and a gross diffusion defect at alveolar level.It seems unlikely that the course was that of an aspiration or bronchopneumonia, and clinically and pathologically it re- sembled the changes seen in surfactant deficiency.It is sug- gested that amitriptyline in overdosage may interfere with the production of surfactant.Case Report A 26-year-old housewife was admitted to an intensive care unit three hours after ingesting an unknown quantity of amitriptyline tablets.She was unconscious but responded to painful stimuli.Tendon reflexes were brisk and the plantar responses were extensor.An electrocardiogram showed a heart rate of 100 beats per minute in sinus rhythm, T-wave flattening in V5 and V6, but no bundle-branch block or ectopic beats.There were no abnormal respiratory signs and laryngeal reflexes were present.There was no history of previous chest disease.After 24 hours she was responding to all stimuli, and became agitated on tactile stimulation.She was still drowsy and irritable at 48 hours but was able to answer simple questions.At this time, however, her temperature rose to 101°F (38'3°C) and a few rales were audible at both lung bases.Routine chest physiotherapy was unproductive.Cloxacillin and ampicillin were started intramuscu- larly but during the third hospital day the rales became more ex- tensive and a chest x-ray picture showed patchy areas of consoli- dation in both lunz fields.The temperature varied between 990 and 103'F (37'2°-39 4°C).During the fourth hospital day she became dyspnoeic over a period of four hours.Her level of consciousness had not deterior- ated and all reflexes were now normal.Respiratory rate increased to 60 a minute.There was no evidence of bronchospasm.A chest x-ray picture showed diffuse consolidation throughout both lung fields (Fig. 1).In view of the deterioration and unproductive physio- therapy she was intubated, 30%/O humidified oxygen in air was given, and bronchial suction was performed.Very little secretion was aspirated and bacteriological culture grew no pathogens.She was attached to a Bennett ventilator which was patient triggered.The inspired oxygen was continued at 30%.The antibiotics were chang- ed to penicillin and streptomycin.On day six she became increasingly distressed and cyanosed while triggering the ventilator.Blood gases showed Pao, 42 mg Hg and Paco, 70 mm Hu (Fig. 2).Rales were audible throu-rhout the lungs, a chest radiograph confirmed generalized consolidation, and bronchial suction remained unproductive.Positive pressure respiration was started with a Barnet III ventilator using a high tidal volume and a minute volume of 15 litres.Intramuscular