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Various toxicities: case report A 37-year-old woman developed ventricular tachycardia, ventricular fibrillation, torsades de pointes, prolonged QT syndrome, mitral regurgitation, tricuspid regurgitation and asystole/cardiac arrest following treatment with azithromycin for follicular tonsillitis. Additionally, she experienced ineffectiveness on treatment with intravenous amiodarone for arrhythmias. The woman had history of syncopal attacks in 2013, 2014, and 2016 and sinus tachycardia and was receiving unspecified βblocker for symptomatic relief as required. She presented to a secondary hospital’s emergency department multiple times with cough, nausea, sore throat and vomiting and was initially diagnosed with viral pharyngitis. She did not feel well and returned back to the hospital the next day. She received oral azithromycin two capsules of 250mg (500mg) on day 1. But, her symptoms did not improve and she was admitted for follicular tonsillitis. On the same day of admission, she became unresponsive and had cardiac arrest, requiring cardiopulmonary resuscitation (CPR) for 26 min with intubation. The ECG rhythm showed asystole and ventricular fibrillation (VF) during CPR cycles. The woman received two shocks and was initiated on amiodarone. On the following day, she was extubated and her vital signs were stable. A day later, she again developed VF and was electrically cardioverted. In the ICU, she received ceftriaxone, clindamycin and IV continuous infusion amiodarone 10g as loading dose. She experienced 3–4 episodes of non-sustained ventricular tachycardia (VT) and thereafter sustained VT, which was managed with electrical shock. The ECG revealed a dilated left ventricle with severe LV dysfunction with ejection fraction (EF) of less than 20%, severe mitral regurgitation, and moderate tricuspid regurgitation. She had another unstable VT and subsequently underwent cardiac catheterisation and intra-aortic balloon pump was inserted. After a few minutes, she developed cardiac arrest and required 4 shocks and was electively intubated. Then, she was transferred to the tertiary care hospital for further management. During transfer, she again had repeated episodes of VF and torsades de pointes (TdP). She required shocks in the ambulance and reverted back to sinus rhythm. Based on her initial ECG, a veno-arterial extracorporeal membrane oxygenation (ECMO) support was inserted to support her haemodynamics in the Cardiac Surgery Intensive Care Unit (CS-ICU). Serial ECGs from the initial hospital revealed significant QT interval prolongation up to 600 msec at different intervals. She continued to have a prolonged QT interval up to day 5 of admission. Thereafter, she was diagnosed with possible type 3 prolong QT syndrome. During her CS-ICU stay, she received various treatment drugs including heparin, nitroglycerin, hydralazine, sodiumnitroprusside [Nitroprusside], amlodipine, metoprolol-tartrate, captopril, vancomycin and ceftazidime. She showed gradual improvement, until extubation on the day 3 of admission to the CS-ICU.