An unusual case of asymptomatic diffuse alveolar hemorrhage related to amiodarone induced INR elevation

Abstract

Pulmonary adverse effects of amiodarone are an important cause of morbidi-ty. Such effects may rarely manifest as diffuse alveolar hemorrhage. Another important amiodarone-induced adverse effect is hepatotoxicity. Hepatotoxicity mostly presents as asymptomatic elevation of liver enzymes. To the best of our knowledge, in amiodarone-induced hepatotoxicity, AST and ALT elevation is well known; however, there are no clear data regarding high International Nor-malized Ratio (INR) levels in such a condition. In the present report, we describe the case of a patient under management with chronic low-dose amiodarone, who was admitted to the emergency department for lingual hematoma. During the assessment for bleeding diathesis, the INR was found to be 8.59. After exclud-ing all other possible causes for the high INR level, amiodarone was suggested to be the cause. Since there were diffuse infiltrations on chest x-ray, the patient underwent thorax tomography. Asymptomatic diffuse alveolar hemorrhage sec-ondary to INR elevation was considered. This patient is the first case who had amiodarone-induced INR elevation, and as a consequence, developed asymp-tomatic diffuse alveolar hemorrhage.

Keywords

• Amiodarone toxicity,diffuse alveolar hemorrhage,Elevated international normalized ratio

References

1. Adverse effects of amiodarone: even after the end of treatment. (2006). Prescrire Int, 15(82), 62. Cengiz Sahutoglu, Z. P., Seden Kocabas, Fatma Zekiye Askar,Aslı Hepkarsı, Cağatay Engin. (2013). Anaesthetic Management in a Heart Transplantation Patient with Amiodarone Associated Thyrotoxicosis. Journal of The Society of Thoracic Cardio-Vascular Anaesthesia and Intensive Care, 19(4), 206-210. doi:10.5222/GKDAD.2013.206Goldschlager, N., Epstein, A. E., Naccarelli, G. V., Olshansky, B., Singh, B., Collard, H. R., . . . Electrophysiology. (2007). A practical guide for clinicians who treat patients with amiodarone: 2007. Heart Rhythm, 4(9), 1250-1259. doi:10.1016/j.hrthm.2007.07.020Holm, J., Lindh, J. D., Andersson, M. L., & Mannheimer, B. (2017). The effect of amiodarone on warfarin anticoagulation: a register-based nationwide cohort study involving the Swedish population. J Thromb Haemost, 15(3), 446-453. doi:10.1111/jth.13614Lu, Y., Won, K. A., Nelson, B. J., Qi, D., Rausch, D. J., & Asinger, R. W. (2008). Characteristics of the amiodarone-warfarin interaction during long-term follow-up. Am J Health Syst Pharm, 65(10), 947-952. doi:10.2146/ajhp060415Podrid, P. J. (1995). Amiodarone: reevaluation of an old drug. Ann Intern Med, 122(9), 689-700. Qin, D., Leef, G., Alam, M. B., Rattan, R., Munir, M. B., Patel, D., . . . Saba, S. (2015). Mortality risk of long-term amiodarone therapy for atrial fibrillation patients without structural heart disease. Cardiol J, 22(6), 622-629. doi:10.5603/CJ.a2015.0055