Low-dose amiodarone causes cirrhosis: a case report.

Amiodarone is used to treat supraventricular and ventricular tachyarrhythmias. Asymptomatic elevation of serum aminotransferases occurs in 25% of those treated. Symptomatic hepatic dysfunction occurs in 2 years. This report describes a patient who developed hepatic cirrhosis following treatment with 200 mg of amiodarone for 18 months. A 63-year-old Caucasian male was hospitalized for abdominal distension of 1 week's duration. He also had a history of coronary artery disease prior to coronary artery bypass grafting, for which he received aspirin. Other medications included oral simvastatin for hypercholesterolemia and amiodarone 200 mg orally per day for symptomatic atrial fibrillation, which occurred 18 months prior to this admission. He denied use of alcohol. He denied current cardiovascular, pulmonary or gastrointestinal/hepatic symptoms except for abdominal distension. His vital signs were normal. Positive findings on physical examination were gynecomastia, spider angiomata, ankle edema and marked ascites characterized by bulging flanks, a fluid wave and shifting dullness. The alanine and aspartate aminotransferases were 82 and 114 IU/L, respectively. The serum bilirubin was 1.4 mg/dL. The fasting serum lipid profile. electrocardiogram and chest x-ray were normal. A computed tomogram of the abdomen showed a large quantity of ascites and a small liver with irregular borders consistent with cirrhosis. The hepatitis panel was normal. Serum anti-nuclear, anti-smooth muscle, anti-mitochondrial or anti-LVCM antibodies were absent. Serum iron studies, ceruloplasmin level, and a 24-hour urine for copper were normal. Serum Alpha-1 antitrypsin level was normal. The asceticfluid was transudative and cytology was normal. A transthoracic echocardiogram showed inferior wall hypokinesis with normal overall left ventricular systolic function. A liver biopsy showed evidence of grade 3 chronic hepatitis that had evolved into stage IV cirrhosis. The presence of striking microvesicular steatosis suggested amiodarone toxicity. Amiodarone-induced cirrhosis is extremely rare. All previously reported cases have been treated with oral doses *400 mg per day for a minimum of 24 months. Statins do not cause cirrhosis but may facilitate hepatotoxicity in patients receiving AD. This is the first reported case of cirrhosis induced by oral amiodarone at a dose of 200 mg per day for 18 months.

Srinivas R. Puli, MD, Matt Fraley, MD, Martin A. Alpert, MD, and Vanaja Puli, MD. St John's Mercy Medical Center, St Louis, MO.