Complete heart block in a neutropenic patient with aspergillosis: An unusual adverse effect of caspofungins
We report the case of a 58-year-old female who was admitted to the Medicine Department of S.C.B Medical College and Hospital, Cuttack in june 2010 because of generalized lymphadenopathy and vomiting. Her peripheral blood smear showed leukocytosis with a WBC of 93,500/microliters, and the bone marrow picture revealed a predominance of blast cells. The blasts were negative for peroxidase, alpha-naphthyl butyrate esterase and PAS. A diagnosis of AML, M0 was made, based on the FAB criteria. She was treated with 3+7 induction therapy, where daunorubicin was given in a dose of 60mg/m2/day for 3 days and cytarabine in a dose of 100 mg/ m2/day for 7 days. Post induction remission chemotherapy bone marrow evaluation confirmed the achievement of complete haematological remission. Subsequently she received high dose cytosine arabinoside in a dose of 3 gm/m2/dose. After 9 days of this high dose chemotherapy she developed mucosal toxicities and high fever with cough during the hospital course. This febrile episode was associated with neutropenia with absolute neutrophil count 500 mm3. So empirical antimicrobial therapy with cefepime and amikacin was started. Although there was a slight decrease in her temperature and moderate improvement in her general condition, she developed sudden tachypnea, dyspnea, fever, bilateral pulmonary infiltrates and acute respiratory distress on the sixteenth day for which she had to be put in a ventillator. Blood, urine and nasopharyngeal swab cultures were negative. Radiological investigations revealed the presence of bilateral consolidations. Pulmonary CT scan was performed which showed bilateral diffuse pulmonary infiltrations suggesting fungal or bacterial pneumonia. There was also no sign of pericardial involvement. Diagnosis of invasive pulmonary aspergillosis (IPA) was done on the basis of isolation of an Aspergillus species from the sputum and from bronchoalveolar lavage samples. The admission electrocardiogram (ECG) had revealed normal sinus rhythm. Basing on the laboratory diagnosis she was administered a single loading dose of 70-mg of caspofungin as intravenous infusion over a period of 1 h. But 45 minutes after the start of the infusion, She developed bradycardia and hypotension which did not respond to frequent fluid boluses. The ECG showed complete atrioventricular (AV) block. In spite of cardiopulmonary resuscitation, the patient died of complete AV block on the same day.