An unintended consequence: fatal amiodarone pulmonary toxicity in an older woman

Amiodarone pulmonary toxicity represents the most serious adverse reaction from amiodarone use. It remains underdiagnosed and can have a variable presentation. The elderly population is at increased risk for amiodarone pulmonary toxicity. Thus, clinicians should prescribe the lowest dosage possible in the elderly and have a low threshold to discontinue the amiodarone for anyone with unexplained fatigue, dyspnea, cough, or weight loss. We present the case of an 89-year-old female who presented with a several month history of fatigue and recent development of dyspnea on exertion and a dry cough. She had been taking amiodarone for 1 year secondary to atrial fibrillation. Chest x-ray and chest CT revealed multilobar airway opacities. An infectious work-up was negative and a transbronchial biopsy revealed prominent intra-alveolar foamy macrophages, consistent with amiodarone pulmonary toxicity. Despite the prompt discontinuation of her amiodarone and a trial of intravenous steroids, the patient succumbed to respiratory failure. The risk factors, clinical presentation, diagnosis, treatment, and prevention of amiodarone pulmonary toxicity are discussed.