Loperamide overdose
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Various toxicities: case report A 39-year-old man developed bradyarrhythmia induced cardiac arrest, bradycardia, very wide QRS and QTc complex following loperamide toxicity secondary to loperamide overdose [time to reactions onsets not stated]. The man, who had diarrhoea predominant irritable bowel syndrome, presented with presyncope and light-headednes. He had been receiving loperamide [route not stated], insulin, iron and patiromer. An examination revealed BP 82/56mm Hg and HR 32 beats/minutes. An ECG showed idioventricular rhythm at a rate of 34 beats/minutes, QTc 444ms and QRS duration 154ms. His laboratory investigations revealed serum creatinine 1.95 mg/dL and TSH 0.05 mIU/L. He had two similar presentations to a different institution. During his prior presentation, cardiac catheterisation was done, which did not reveal any significant coronary artery disease. However, he had hospitalised following diagnosis of bradyarrhythmia induced cardiac arrest. Subsequently, he received a non-MRI conditional permanent pacemaker for bradyarrhythmia induced cardiac arrest. His bradyarrhythmia induced cardiac arrest was then recovered. After 6 months (during his current presentation), he was again hospitalised due to severe bradycardia and a very wide QRS rhythm with failure of pacemaker to capture. Subsequently, his pacemaker was extracted. A cardiac MRI revealed normal right and left ventricular function with no evidence of any infiltrative or structural heart disease. His routine reversible causes of bradycardia were ruled out. A leadless pacemaker device implantation was attempted; however, attempts to capture right ventricular (RV) septum at various positions failed. Thereafter, a quadripolar RV catheter was introduced which was only able to capture the RV apex and outflow tract intermittently at 20mA with a QRS as wide as 500ms. During hospitalisation, he demanded high doses of loperamide for diarrhoea. Eventually, he admitted to taking doses up to 40-60mg twice daily (Maximum dose: 16mg daily) since last 2 years for diarrhoea. His bradycardia recovered; however, he had an atypical right bundle branch block. He continued to have a very wide QRS complex 198ms and QTc 578ms on ECG for 5 days. On hospital day 10, atypical right bundle branch block recovered. His QRS and QTc returned to normal (88ms and 454ms, respectively). Author comment: "When overdosed, loperamide blocks Na and IKr channels resulting in a variety of cardiac rhythm abnormalities including severe bradycardia, widening of the QRS, QTc prolongation". "Loperamide overdose is a toxidrome that remains underrecognized, and in patients with unexplained cardiac arrhythmias, loperamide toxicity should be suspected." Teigeler T, et al. Electrocardiographic changes in loperamide toxicity: Case report and review of literature. Journal of Cardiovascular Electrophysiology 30: 2618-2626, No. 11, Nov 2019. Available from: URL: http://doi.org/10.1111/ 803437382 jce.14129 - USA
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