Case Report: Voriconazole induced refractory hyperkalemia and adrenal insufficiency

Ezza Fatima Tariq,Hajra Asif,Muhammad Shoaib,Usman A Khan,Yusra Irshad

doi:10.12688/f1000research.26017.1

Abstract

Voriconazole, an azole drug, inhibits cytochrome P450 dependent lanosterol 14-alpha-demethylase. It is a potent anti-fungal agent. Adverse effects include neurotoxicity, cardiac arrhythmias, electrolyte disturbances and adrenal insufficiency. Hyperkalemia is a rare adverse effect that has been described, but is not well reported, in the literature. We present a case of intractable hyperkalemia resulting from voriconazole use. A 47-year-old male presented with worsening shortness of breath, requiring mechanical ventilation within 24 hours of presentation. Diagnosis of acute respiratory distress syndrome was made. Empirical treatment with broad-spectrum antibacterial coverage resulted in no improvement. Voriconazole was added for anti-fungal coverage, causing treatment resistant hyperkalemia necessitating continuous renal replacement therapy (CRRT). Renal function remained normal. Stopping voriconazole restored normal potassium levels. CRRT was discontinued. Hyperkalemia caused by voriconazole occurs in less than 2% of cases. It is a potentially life-threatening side effect. Physicians should be aware of this association and seek alternative treatment when necessary.

Highlights

Voriconazole is a second-generation azole anti-fungal drug
In our literature review we found a case report of adrenal insufficiency due to concomitant use of voriconazole and glucocorticoids3, a case series of hyponatremia associated with voriconazole use2 and a case of iatrogenic Cushing syndrome associated with concomitant use of voriconazole and budesonide4
We present a case of hyperkalemia caused by voriconazole in a hospitalized patient

Summary

Introduction

Voriconazole is a second-generation azole anti-fungal drug. One side effect of Voriconazole is interference with CYP 450 as it is a potent inhibitor of CYP 450.This can cause interactions with other drugs. Immediate medical management with intravenous furosemide 80mg, rectal sodium polystyrene sulfonate 60 gm., and intravenous regular insulin 7 units were given, with 50 ml of 50% dextrose, continuous albuterol 2.5 mcg nebulization, and intravenous sodium bicarbonate 50 mEq intravenous push .this failed to improve the hyperkalemia. His urine output during this period was within normal range. Up chemistry showed Na+ levels of 139 mEq/L (Normal range: 135 mEq/L– 145 mEq/ L), K+ levels of 4 mEq/L (Normal range: 3.5mEq/L–5.5mEq/L), HCO levels of 20 mEq/L ( Normal range: 23mEq/L – 30mEq/L) , Creatinine level of 1.3 mg/dl (Normal range: 0.7– 1.5 mg/dL)

Discussion

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Conclusion