UNUSUAL PRESENTATION OF AMIODARONE PULMONARY TOXICITY (APT) WITH MULTIPLE LUNG NODULES

Abstract

SESSION TITLE: Diffuse Lung Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: The incidence of amiodarone-induced pulmonary toxicity (APT) is 5%-15%. Diffuse interstitial infiltrate is the most common radiographic finding associated with APT. Fewer than 10 cases of multiple pulmonary nodules due to APT have been reported in the literature. We report a case of APT presenting as bilateral multiple pulmonary nodules. CASE PRESENTATION: A 59-year-old female presented to the pulmonary clinic for evaluation of multiple pulmonary nodules found incidentally on cardiac MRI. Patient’s complaints consisted of progressive DOE, persistent dry cough without any constitutional symptoms. A dedicated chest CT revealed multiple, various sized, bilateral pulmonary nodules. The nodules were predominantly in the lower lung zones. Her PMHx was significant for HFpEF, PAF on chronic amiodarone, and papillary thyroid cancer s/p left thyroidectomy one year ago. Given the history of malignancy and a high suspicion for metastatic disease, the patient was sent for VATS. Diagnostic lung wedge biopsies revealed an intense lymphoplasmacytic interstitial infiltrate and alveoli filled with macrophages with fine vacuolization on histopathologic examination. In some nodules, there were minor foci of organizing pneumonia. There was no evidence of granulomas or metastatic thyroid tumor. The finding was suggestive of inflammatory process most consistent with amiodarone toxicity. DISCUSSION: The clinical presentation of APT varies from non-productive cough, dyspnea on exertion to acute respiratory failure. Typically, pulmonary toxicity of amiodarone consists of diffuse alveolar damage, organizing pneumonia, hypersensitivity pneumonitis, and irreversible pulmonary fibrosis. Multiple lung nodules due to APT has been reported but rare in the literature. Nodular pulmonary disease is thought to be an inflammatory response to drug-induced phospholipid accumulation in the alveolar cells. Therefore, the lung nodules due to APT may be reversible and has a favorable outcome by discontinuing the drug. The use of corticosteroid also has been shown to be helpful. The diagnosis of APT is challenging due to the complex nature of clinical and radiographic findings. CONCLUSIONS: In summary, APT presenting with diffuse nodular pulmonary disease is rare; however, clinicians must be aware of the variability of clinical and radiographic finding of APT. APT should be considered in patients taking amiodarone present with new pulmonary nodules radiographically. Reference #1: 1. Morell, EB et al., 2005. Multiple pulmonary noduels and amiodarone. KL-6 as a new diagnostic tool. Rev Esp Cardiol 58(4):447-449 Reference #2: 2. Rodriguez-Garcia, JL et al., 2001. Pulmonary mass and multiple lung nodules mimicking a lung neoplasm as amiodarone-induced toxicity. Eur J Intern Med 12(4):372-376 Reference #3: 3. Wolkove, N et al., 2009. Amiodarone pulmonary toxicity. Can Respir J 16(2):43-48 DISCLOSURES: No relevant relationships by Michael Ayers, source=Web Response No relevant relationships by Debabrata Bandyopadhyay, source=Web Response No relevant relationships by Anna Kyu Chen, source=Web Response No relevant relationships by Md Islam, source=Web Response No relevant relationships by Matthew Stanton, source=Web Response