Early Amiodarone Use in A Patient With COVID-19 Pneumonia

Introduction

Novel coronavirus disease-19 (COVID-19) is a global pandemic disease with multiorgan involvement [1]. COVID-19 virus enters the host cell via interaction with the Angiotensin converting enzyme 2 (ACE-2) receptor. Afterwards it is transmitted to the endosome where it undergoes important steps for viral replication [2]. Amiodarone can accumulate in the endosome, disrupting its environment and interfering with the viral replication process [3].

Case Presentation

The patient is a 66-years old male with a history of hypertension, diabetes mellitus type 2, obesity with body mass index of 40, chronic kidney disease stage-III, and paroxysmal atrial fibrillation who presented with 1 week of fever, chills, altered mental status and shortness of breath with a productive cough. Upon presentation his blood pressure was 102/55 mmHg, heart rate 121 beats per minute, respiratory rate 25 breaths per minute, temperature 38.3°C, and his oxygen saturation was 86% on room air. He had diffuse crackles on pulmonary auscultation, an irregular rhythm and a Glasgow Coma Scale of 7 without any focal neurologic deficits. Chest x-ray and CT scan revealed a right small pneumomediastinum in addition to bilateral infiltrates with diffuse ground glass opacities (Figure 1). His electrocardiogram showed atrial fibrillation (AF) with rapid ventricular response (RVR). His labs showed acute kidney injury, elevated inflammatory markers and troponin, lymphopenia, in addition to findings consistent with diabetic ketoacidosis (DKA) (Table 1). His polymerase chain reaction (PCR) for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) was positive.

Figure 1: CT scan of the chest showing bilateral infiltrates, bilateral ground glass opacities and pneumomediastinum.

Treatment and Outcome

Our patient was intubated in the emergency department and required norepinephrine for hypotension. Intravenous (IV) and oral Amiodarone were started 9 hours after intubation to control his atrial fibrillation. He required high oxygen support with a PaO2: FiO2% ratio of 158 initially which was consistent with moderate acute respiratory distress syndrome (ARDS). However, we were able to downgrade his oxygen requirements within 4 hours of starting Amiodarone (Table 2). He was extubated to 3 L nasal canula within 45 hours of intubation. His DKA resolved with IV insulin, fluids, and his pneumomediastinum was monitored with no surgical intervention. He also received IV Vancomycin, Piperacillin-Tazobactam, Interleukin 6 inhibitor (Tocilizumab 400 mg IV x 1 after 18 hours of intubation), methylprednisolone and he was started on IV unfractionated heparin for atrial fibrillation and elevated CHA2DS2-VASc score. He was also started on hemodialysis due to oliguric acute kidney injury. The patient was transferred out of the ICU on day 7 requiring 3 Liters of oxygen on the nasal canula. His post ICU course was complicated by Methicillin sensitive Staphylococcus aureus for which he completed a course of Cefazolin and unexplained altered mental status [4]. He required a total of 4 sessions of hemodialysis. The patient was later discharged to a rehabilitation facility with normal mental status, off any supplemental oxygen and off hemodialysis with creatinine close to baseline (1.74 mg/dL).

Table 1: Laboratory values on admission.

Abbreviations: BUN: Blood Urea Nitrogen; BNP: Brain Natriuretic Peptide; ALT: Alanine Aminotransferase; AST: Aspartate Aminotransferase; WBC: White Blood Cells Count; LDH: Lactate Dehydrogenase; BHB: Beta Hydroxybutyrate

Table 2: Ventilator settings with corresponding arterial blood gas analysis and vital signs.

Abbreviations: AF: Atrial Fibrillation; ABG: Arterial Blood Gas; PaO2: Arterial Partial Pressure of Oxygen; PCO2: Partial Pressure of Carbon Dioxide; SaO2%: Oxygen Saturation Percentage; VT: Tidal Volume; RR: Respiratory Rate; FIO2%: Fraction of Inspired Oxygen; PEEP: Positive End Expiratory Pressure

Discussion

Amiodarone was reported to have antiviral activity in vitro against Filovirus species [3,5]. It had also been tested during the Ebola virus crisis with inconclusive data [6,7], and its antiviral activity may potentially be extrapolated to SARS-CoV-2. Although our patient received multiple medications that can confound his rapid clinical improvement, he did have a measurable improvement after starting amiodarone early in the course of the disease leading to an early extubation. His kidney function and mental status were also back to normal by the time of discharge. In light of this clinical response and the previous reports about the antiviral activity of amiodarone, we feel that these observations are important to report. There has not been any proven effective treatment for COVID-19 virus to date and we feel that future animal and observational studies can shed some light on the potential role of amiodarone in COVID-19 infection, especially if introduced early in the course of the disease.

Acknowledgements

We would like to express our gratitude to all the health care workers fighting on the front lines during this global crisis.

Conflict of Interest

The authors declare that there is no conflict of interest.

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