Cardiac arrest provoked by itraconazole and amiodarone interaction: a case report

A 65-year-old Caucasian man was admitted to the Intensive Care Unit at our facility for an extensive ischemic stroke associated with atrial fibrillation. Due to rapid ventricular response he was started on intravenous amiodarone and few days later itraconazole was also prescribed for presumed candidemia. After receiving the first dose our patient became profoundly hypotensive but responded rapidly to fluids and adrenaline. Then, two months later, itraconazole was again prescribed for confirmed fungemia. After receiving the first dose via a central venous catheter our patient became hypotensive and subsequently arrested. He was resuscitated successfully, and as no other cause was identified the arrest was attributed to septic shock and his antifungal treatment was changed to caspofungin. When sensitivity test results became available, antifungal treatment was down-staged to itraconazole and immediately after drug administration our patient suffered another arrest and was once again resuscitated successfully. This time the arrest was related to itraconazole, which was discontinued, and from then on our patient remained stable until his discharge to our neurology ward.Itraconazole and amiodarone coadministration can lead to serious cardiovascular adverse events in patients who are critically ill. Intensivists, pharmacists and medical physicians should be aware of the interaction of these two commonly used drugs.Itraconazole has been widely used in the treatment of fungal diseases including chronic necrotizing pulmonary aspergillosis [1]. Patients in intensive care units with persistent high temperature despite broad-spectrum antibiotic treatment should be considered for empirical antifungal treatment due to the high incidence of candidemia and high mortality rates reported [2]. Azoles, fluconazole and itraconazole are the most justified options in this situation [3]. Itraconazole use has been associated with occasional adverse cardiovascular events, including congestiv