Miconazole-induced fatal dysrhythmia

Miconazole is an imidazole antifungal agent that is available in topical, vaginal, and parenteral formulations. Indications for the parenteral product have become rare with the development of newer, more effective agents. A 54-year-old man who had undergone orthotopic heart transplantation developed a widespread subcutaneous Scopulariopsis infection that progressed despite treatment with amphotericin B and itraconazole. Intravenous miconazole was added to his regimen. During the infusion he developed a bradyarrhythmia that resolved after miconazole was discontinued. On rechallenge with a lower dosage, bradyarrhythmia recurred and progressed to ventricular fibrillation. The patient died despite full resuscitation efforts. Only a few case reports exist of miconazole-induced cardiac arrhythmias, and these events were attributed to rapid intravenous administration, insufficient dilution, and the drug's vehicle. We believe that intravenous miconazole should be given with caution to patients with underlying heart disease.