Itraconazole
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Congestive heart failure exacerbation in an elderly patient: case report A 75-year-old man developed congestive heart failure (CHF) exacerbation during treatment with itraconazole for histoplasmosis [duration of treatment to reaction onset not clearly stated]. The man, who had a history of rheumatoid arthritis, was diagnosed with histoplasmosis in July 2008 and began receiving oral itraconazole 200mg three times daily. He was subsequently hospitalised with acute renal failure, impaired mental status and multiple electrolyte abnormalities. The man was treated with amphotericin B for 2 weeks. He experienced an ST-elevation myocardial infarction, and pravastatin and lisinopril were added to his current regimen of aspirin and metoprolol. In August 2008, he was discharged to a nursing facility on oral itraconazole 200mg twice daily. In October 2008, he began receiving metolazone and furosemide due to leg swelling and shortness of breath. A few weeks later, he presented to the emergency department with a 2-week history of cough, orthopnoea, dyspnoea and increased leg swelling. He had rales in the peripheral bases of the lungs, with tachypnoea, decreased breath sounds, jugular venous distension and pretibial oedema. He was diagnosed with CHF, exertional dyspnoea and volume overload. Upon admission, he had a brain natriuretic peptide level of 296 pg/mL and a calculated creatinine clearance of approximately 80 mL/min. He began receiving furosemide, and was discharged 5 days later on itraconazole 200mg twice daily. In November 2008, he was hospitalised with CHF exacerbation. His brain natriuretic peptide level was 800 pg/mL and an echocardiogram disclosed an ejection fraction of 55-60%. He was treated with furosemide and discharged. In December 2008, he was switched from itraconazole to posaconazole. He completed 20 months of posaconazole therapy with no further CHF symptoms. Author comment: "Although we feel strongly that itraconazole was the etiology for our patient’s CHF exacerbations, we cannot discount the fact that our patient had underlying issues that could have lent support to the adverse events. . . the CHF episodes were consistent with itraconazole therapy, recurred on rechallenge of the drug after the initial occurrence, and have been nonexistent since the implementation of posaconazole." Liedtke MD, et al. Congestive heart failure exacerbation secondary to itraconazole therapy. Infectious Diseases in Clinical Practice 19: e19-e20, No. 6, Nov 2011. Available from: URL: http://dx.doi.org/10.1097/ipc.0b013e3182156810 803065945 USA
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Reactions 21 Jan 2012 No. 1385
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