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Amphotericin B--not so terrible
J Bishara1, M Weinberger, A Y Lin
1Department of Internal Medicine C, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Petach Tikva, Israel.
Objective:
To describe a patient who developed adverse reactions to two different lipid formulations of amphotericin B: liposomal amphotericin B (AmBisome) and amphotericin B colloidal dispersion (ABCD, Amphocil), yet tolerated amphotericin B deoxycholate (Fungizone) despite renal toxicity.
Case Summary:
A 72-year-old woman with acute myelomonocytic leukemia was treated with amphotericin B deoxycholate for suspected pulmonary aspergillosis; the drug was well tolerated but resulted in renal failure. Antifungal therapy was then changed to liposomal amphotericin B. Within 10 minutes of liposomal amphotericin B infusion, the patient developed severe dyspnea, chest pain, and a feeling of imminent death. On the following day, liposomal amphotericin B was switched to amphotericin B colloidal dispersion. Again, within 10 minutes of this infusion, the patient developed fever, chills, hypotension, severe chest pain, dsypnea, and a feeling of imminent death. The patient refused any further treatment with these drugs and insisted on switching back to amphotericin B deoxycholate, which was then administered for 10 days and was well tolerated.
Discussion:
Severe adverse reactions, such as anaphylaxis, cardiac toxicity, and respiratory failure, following administration of all three lipid formulations of amphotericin B have been reported. In most reported cases, switching to a different lipid formulation of amphotericin B was well tolerated. This is in contrast to our case, where a severe reaction was repeated when another lipid preparation was given, necessitating switching back to amphotericin B deoxycholate despite its nephrotoxicity.
Conclusions:
In some patients, paradoxically, lipid formulations of amphotericin B may be less tolerable than conventional amphotericin B.
Insights
A patient experienced severe reactions to liposomal amphotericin B and amphotericin B colloidal dispersion but tolerated amphotericin B deoxycholate. This case highlights that lipid formulations may not always be better tolerated than conventional amphotericin B.
Area of Science:
- Mycology
- Clinical Pharmacology
- Patient Safety
Background:
- Amphotericin B is a critical antifungal agent used for severe fungal infections.
- Lipid formulations of amphotericin B (AmBisome, Amphocil) were developed to reduce toxicity, particularly nephrotoxicity.
- Conventional amphotericin B deoxycholate (Fungizone) is associated with significant renal toxicity.
Observation:
- A patient with acute myelomonocytic leukemia developed renal failure on amphotericin B deoxycholate.
- The patient experienced immediate, severe anaphylactoid reactions to both liposomal amphotericin B and amphotericin B colloidal dispersion.
- These reactions included dyspnea, chest pain, hypotension, fever, and chills.
Findings:
- The patient tolerated subsequent treatment with amphotericin B deoxycholate, despite its known nephrotoxicity.
- This case contrasts with typical findings where switching between lipid formulations is usually well-tolerated.
- It suggests a potential idiosyncratic hypersensitivity to lipid-based amphotericin B preparations in certain individuals.
Implications:
- Clinicians should be aware that lipid formulations of amphotericin B can cause severe hypersensitivity reactions.
- In rare cases, conventional amphotericin B deoxycholate may be a more tolerable option than lipid formulations.
- This case underscores the importance of individualized patient assessment and careful monitoring during antifungal therapy.