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Weekly Chest CasesCases by Disease Category

Case No : 1340 Date 2023-06-26

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  • Courtesy of Hyungin Park, Woo Hyeon Lim, Jong Hyuk Lee, Eui Jin Hwang, Soon Ho Yoon / Seoul National University Hospital
  • Age/Sex 51 / M
  • Chief ComplaintDyspnea PHx: Lung cancer s/p LUL upper division segmentectomy, Mitral stenosis, Atrial fibrillation
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5

Diagnosis With Brief Discussion

Diagnosis
Amiodarone pulmonary toxicity
Radiologic Findings
(Fig. 1-2) Chest computed tomography (CT) scans with lung window show interstitial thickening, subpleural ground-glass opacities and partial consolidation in both lower lobes.
(Fig. 3) Noncontrast CT scan with mediastinal window shows slightly increased attenuation of the liver relative to the spleen.
(Fig. 4-5) Follow up chest CT images show improved interstitial thickening and GGOs in both lungs.
Brief Review
The patient had a history of atrial fibrillation treated with amiodarone. After discontinuation of amiodarone, interstitial thickening, and GGOs improved on CT scan.
Pulmonary drug toxicity is a common and possibly underdiagnosed cause of acute and chronic lung disease. Amiodarone is an antiarrhythmic agent commonly used to treat supraventricular and ventricular arrhythmias. This drug is an iodine-containing compound that tends to accumulate in several organs, including the lungs. Amiodarone pulmonary toxicity (APT) occurs in approximately 5% - 10% of patients usually within months of starting therapy. Although there is no correlation between the development of drug toxicity and the duration of therapy or total accumulative dose, the risk is increased if the daily maintenance dose is greater than 400mg and if the patient is elderly. Although the incidence of this complication has decreased with the use of lower doses of amiodarone, it can occur with any dose.
Radiology plays a central role in diagnosis. Chest x-rays reveal patchy of diffuse infiltrates, which are commonly bilateral. Nonspecific interstitial pneumonia (NSIP) pattern is the most common manifestation of amiodarone-induced lung disease. Pleural inflammation is an accompanying feature and can manifest as pleural effusion. Organizing pneumonia (OP) pattern is less common and typically occurs in association with NSIP. Focal, homogeneous pulmonary opacities are typically peripheral in location and of high attenuation at CT due to the incorporation of amiodarone into the type II pneumocytes.
Patients usually have dyspnea, hypoxemia, exertional desaturation and sometimes weight loss. Diffuse crackles are heard on auscultation.
With early detection, the prognosis is good, with most patients improving after discontinuation of therapy and administration of corticosteroids. A minority of patients experience acute, severe lung injury resulting in death.
References
1. Rossi SE, Erasmus JJ, McAdams HP, Sporn TA, Goodman PC. Pulmonary drug toxicity: radiologic and pathologic manifestations. Radiographics. 2000;20(5):1245-1259. doi:10.1148/radiographics.20.5.g00se081245
2. Wolkove N, Baltzan M. Amiodarone pulmonary toxicity. Can Respir J. 2009;16(2):43-48. doi:10.1155/2009/282540
Keywords

No. of Applicants : 82

▶ Correct Answer : 57/82,  69.5%
  • - , Japan HIROAKI ARAKAWA
  • - The University of Tokyo Hospital , Japan JUN KANZAWA
  • - , Japan KYOKO NAGAI
  • - Chonnam National University Hwasun Hospital , Korea (South) SEONGWOO CHO
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Seoul National University Hospital , Korea (South) HYUNGIN PARK
  • - Chonnam National University Hospital , Korea (South) HYUNJIN KIM
  • - Healthy Longevity Medical Center , Japan SHIN-ICHI CHO
  • - Chonnam National University Hwasun Hospital , Korea (South) DONGHUN HAN
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - , China FANG YING GEN
  • - Secomedic Hospital , Japan FUMINORI MIYOSHI
  • - Oita University, Faculty of Medicine , Japan FUMITO OKADA
  • - Inje University Pusan Paik Hospital , Korea (South) GANGWON JEONG
  • - The University of Tokyo Hospital , Japan WATARU GONOI
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Osaka University , Japan AKINORI HATA
  • - Korea University Guro Hospital , Korea (South) HEEJUN PARK
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - Soonchunhyang University Hospital Bucheon , Korea (South) HYEJOO PARK
  • - OITA UNIVERSITY , Japan FUMIKA ISHITOBI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - , Korea (North) JUNG HAN WOO
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Samsung Medical Center , Korea (South) MIN YEONG KIM
  • - Chonbuk National University Hospital , Korea (South) HYUNSOO BAE
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan SHUNJIRO NOGUCHI
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Korea University Guro Hospital , Korea (South) LEE DAKYONG
  • - Manipal hospital Hebbal, Bengaluru , India PRAVIN KUMAR M
  • - Seoul National University Hospital , Korea (South) SUNGHO HONG
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Kyung-hee University Medical Center , Korea (South) HYE SUN RYU
  • - Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
  • - Chonbuk National University Hospital , Korea (South) SUBIN LEE
  • - Hanyang University Hospital , Korea (South) SUNJIN RYU
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
  • - The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
  • - Inje University Pusan Paik Hospital , Korea (South) GEOJEONG SEO
  • - Chonnam National University Hospital , Korea (South) SEUNG WAN KANG
  • - , Japan YUMI MAEHARA
  • - Toyota Kosei Hospital , Japan YUKI HAYASHI
  • - , Korea (South) HM PARK
  • - Kyoto university , Japan AKIHIKO SAKATA
  • - Seoul National University Hospital , Korea (South) YELIM CHOI
  • - , Korea (South) JIN WOO YOON
  • - Juntendo University , Japan YUTAKA IKENOUCHI
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Semi-Correct Answer : 8/82,  9.8%
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - The University of Tokyo , Japan MOTO NAKAYA
  • - Other , Korea (South) CHAEHUN LIM
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - Kyoto University , Japan SHO KOYASU
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