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Acute Amphotericin B Overdose

Clinical Fellow Nephrology, Division of Renal Diseases and Hypertension, The University of Texas Medical School, Houston, TX

Rajiv Lal, MD FABHP

Clinical Fellow Nephrology, Division of Renal Diseases and Hypertension, The University of Texas Medical School

Kevin W Finkel, MD FACP FASN

Associate Professor, Division of Renal Diseases and Hypertension, The University of Texas Medical School

Joshua Samuels, MD MPH

Assistant Professor, Division of Renal Diseases and Hypertension, The University of Texas Medical School

John R Foringer, MD

Assistant Professor, Division of Renal Diseases and Hypertension, The University of Texas Medical School

Reprints: Dr. Foringer, Division of Renal Diseases and Hypertension, The University of Texas Medical School, 6431 Fannin St., MSB 4.148, Houston, TX, 77030-0708, fax 713/500-6882, john.R.Foringer{at}uth.tmc.edu

OBJECTIVE: To report the clinical course of a woman with cryptococcal meningitis and no previous cardiac disease who developed a fatal cardiac arrhythmia after an acute overdose of amphotericin B and to review its toxicity.

CASE SUMMARY: A 41-year-old woman with a history of proliferative glomerulonephritis from systemic lupus erythematosus was admitted with a diagnosis of cryptococcal meningitis. Liposomal amphotericin B was prescribed at the standard dose of 5 mg/kg/day; however, amphotericin B deoxycholate 5 mg/kg was inadvertently administered (usual dose of the deoxycholate formulation is 0.5-0.8 mg/kg/day). The patient developed cardiac arrhythmias, acute renal failure, and anemia. The medication error was noticed after she had received 2 doses of amphotericin B deoxycholate, and it was then discontinued. Despite treatment in the intensive care unit, the woman died on the sixth day after admission.

DISCUSSION: Amphotericin B deoxycholate has been reported to produce significant cardiac toxicity, with ventricular arrhythmias and bradycardia reported in overdoses in children and in adults with preexisting cardiac disease, even when administered in conventional dosages and infusion rates. Use of the Naranjo probability scale indicated a highly probable relationship between the observed cardiac toxicity and amphotericin B deoxycholate therapy in this patient.

CONCLUSIONS: Given the fulminant course of amphotericin B deoxycholate overdosage and lack of effective therapy, stringent safeguards against its improper administration should be in place.

Key Words: amphotericin B, toxicity

Published Online, November 7, 2006. www.theannals.com, DOI 10.1345/aph.1H157