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Weekly Chest CasesArchive of Old Cases

Case No : 593 Date 2009-03-09

  • Courtesy of Ju Won Lee, MD, Chin A Yi, MD / Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
  • Age/Sex 56 / M
  • Chief ComplaintDyspnea and cough for three weeks, S/P Mitral valve replacement six years ago
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Amiodarone-induced pulmonary toxicity
Radiologic Findings
Chest radiographs shows patchy ground-glass opacity and consolidation in the left lung with left pleural effusion. Non-contrast CT scans demostrate patch areas of consolidation in the left upper lobe, of which attenuation is higher than vascular attenuation in the mediastinum. The attenuation of the liver is unusually high on non-contrast CT, raising the suspicion of iodine deposition in patients with history of amiodarone medication.
Bronchioloaveolar lavage reveals non-specific findings with mainly macrophages with some lymphocytes and neutrophils, without malignant cells. Transbronchial lung biopsy at the left upper lobe reveals only foamy macrophage aggregates with fibrin.
In the patient's past medical history, he ingested amiodarone for arrhythmia for one years. Treatment was the cessation of amiodarone medication. In five days after discontinuation, patchy consolidations in the left upper lobe start to decrease in extent (arrow in figure 5). On two months follow up, the consolidation is markedly decreased in extent (arrow in figure 6), which confirms adiodarone-induced pulmonary toxicity and its improvement on cessation of amiodarone.

Brief Review
Amiodarone is one of the most frequently used medication for refractory ventricular tachyarrhythmias. Amiodarone pulmonary toxicity was recognized in 1980, and remains a significant cause of drug-induced interstitial lung disease (ILD). Pulmonary toxicity occurs in approximately 5-10% of patients, usually within months of starting therapy. Clinically, amiodarone-induced pulmonary toxicity manifests with dyspnea, a dry cough, weight loss, malaise, moderate fever and, sometimes, mild pleuritic chest pain.
NSIP is the most common manifestation of amiodarone-induced lung disease. Pleural inflammation is an accompanying feature and can manifest as pleural effusion. BOOP is less common and typically occurs in association with NSIP. A distinctive feature of amiodarone toxicity is the occurrence of focal, homogeneous pulmonary opacities. These opacities are typically peripheral in location and of high attenuation at CT due to incorporation of amiodarone into the type II pneumocytes. Amiodarone and its metabolite accumulate in many organs, achieving concentrations in lung tissue that are toxic to lung cells. Two iodines are present for each molecule of amiodarone or its metabolite. The combination of high-attenuation abnormalities within the lung, liver, or spleen are characteristic of amiodarone toxicity.
The prognosis is good, with most patients improving after discontinuation of therapy.
References
1. RadioGraphics 2000; 20:1245?259.
2. Respiration 2004;71:301?26.
Please refer to
Case 114 Case 176 Case 330
Keywords
Lung, Iatrogenic lung disease, Drug complication,

No. of Applicants : 92

▶ Correct Answer : 50/92,  54.3%
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - yashodha hospital , India pravin mahadevappa
  • - McGill University Health Centre , Canada Amr Ajlan
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - Changhua Christian Hospital , Taiwan Chia-Fu Tsai
  • - Osaka University , Japan Osamu Honda
  • - radiology , Korea (South) Lee Sanghee
  • - CH Sud Rnion , Reunion jean-baptiste Noel
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
  • - POPOVO HOSPITAL , Bulgaria VLADISLAV RUSINOV
  • - CH de la Ce Basque , France Paul ARDILOUZE
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - McGill University Health Center , Canada Faiza Al Kindi
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - hospital Sao Paulo , Brazil israel missrie
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - DCA, , India Rajesh Gothi
  • - Assam medical college , India Karunakaran M
  • - SMC , Korea (South) Jihoon Cha
  • - Bundang CHA hospital , Korea (South) Jung Jin Young
  • - SNUBH , Korea (South) Kyoung Jin Oh
  • - Shinchon Severance Hospital , Korea (South) Ho-Joon Lee
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) YOOKYUNG KIM
  • - Dongguk University International Hospital , Korea (South) Hee Seok Choi
  • - All India Institute of Medical Sciences , India Ashish Gupta
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Holy family hospital, College of Medicine, The Catholic University of Korea , Korea (South) Yoon Soo Kyung
  • - Ewha Womans University , Korea (South) Eun Ju Ha
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - Daegu Fatima Hospital , Korea (South) Tae-Hun Kim
  • - IRCCS S.Luca Hosp. , Italy filippo casolo
  • - Medical IT Consulting , Japan Kazumasa Nishimura
  • - MIR , United States Clint Jokerst
  • - CHRU lille , France manuel toledano
  • - Seoul National University Hospital , Korea (South) JUNG KIM
  • - Armed Force Capital Hospital , Korea (South) Dae Kun Oh
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - Consultant Radiologist, London , United Kingdom Shekhar Banavali
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - KASTURBA MEDICAL COLLEGE , India NAVEEN KULKARNI
  • - CHU Caen , France nicolas gautier
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - NASA SCANS , India RAKESH BHATIA
  • - govt royapettah hospital , India gopinathan kathirvelu
▶ Correct Answer as Differential Diagnosis : 2/92,  2.2%
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
▶ Semi-Correct Answer : 1/92,  1.1%
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
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