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|Year : 2009 | Volume
| Issue : 4 | Page : 316
Paroxysmal atrial tachycardia associated with prednisolone administration
Department of Internal Medicine, General Hospital of Sitia, Greece
|Date of Web Publication||14-Jan-2010|
Department of Internal Medicine, General Hospital of Sitia
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Cholongitas E. Paroxysmal atrial tachycardia associated with prednisolone administration. J Postgrad Med 2009;55:316
A 64-year-old woman was admitted with fever, fatigue, dyspnea and moderate chest pain of 10 days' duration. She was diagnosed to have rheumatoid arthritis three years ago and was receiving methotrexate and folic acid for the last one year. On admission, the patient was febrile (37.5°C). A clinical diagnosis of pericardial effusion was made on the basis of distant heart sounds and dullness extending beyond the cardiac apex. The electrocardiogram (ECG) showed sinus rhythm (95/min) with low (No full form) QRS voltage. Abnormal laboratory test results included: Hematocrit: 34%, Hb concentration: 10.7 g/ dL, Erythrocyte Sedimentation Rate: 94 mm at the end of 1 h, C-reactive protein: 188 mg/ dL, Alkaline phosphatase: 828 IU/L [upper normal levels (UNL) < 280], G-GT: 423 IU/L (UNL < 45) and Rheumatoid factor: 75 IU/L (UNL < 25 IU/L). The chest radiograph showed an enlarged cardiac shadow, while trans-thoracic echocardiography revealed a moderate pericardial effusion without diastolic collapse. Computed tomography (CT) of the chest showed a pericardial effusion with no other abnormal findings, while CT of the abdomen was normal. Extensive investigation revealed no specific cause for pericarditis. Therapy was initiated with the administration of prednisolone (25 mg tid intravenously). Methotrexate was discontinued due to the presence of abnormal liver function tests.
On the third day the patient's clinical condition had improved with disappearance of chest discomfort and reduction in the amount of accumulated pericardiac fluid on echocardiography. The next day, the patient reported a sudden onset of palpitations after intravenous infusion of prednisolone. The symptoms lasted for only a few seconds and the ECG taken thereafter did not reveal any abnormality in cardiac rhythm. A similar episode recurred on the subsequent dose of prednisolone, which lasted for 5 min. The ECG recorded at this episode showed the presence of paroxysmal atrial tachycardia (PAT) (supra-ventricular regular rhythm with rate 165/min). The patient was put under telemetry monitoring and a third episode was recorded again after administration of prednisolone intravenously, but this time, the arrhythmia was not self-limited The patient received amiodarone 600 mg intravenously in 2 h and then 900 mg in 24 h. The sinus rhythm was restored after 24 h. Due to the close temporal association between prednisolone administration and the arrhythmia, atrial tachycardia was thought to be causally related to prednisolone and hence the drug was withdrawn, while the patient was commenced on hydroxychloroquine per os instead of methotrexate for her rheumatoid arthritis. On the following days, the patient remained in a good clinical condition without recurrence of palpitations and repeated ECG showed sinus rhythm. The patient, six months later, is receiving hydroxychloroquine 200 mg/day without recurrence of pericarditis or any cardiac arrhythmia. In addition, further investigation for underlying cardiac artery disease with dobutamine stress echocardiography has not revealed any abnormality.
In the literature, there are only few case reports of cardiac arrhythmias associated with high dose of steroids given for autoimmune (e.g. systemic lupus erythematosus, glomerulonephritis) , or lung diseases.  The exact pathogenesis has not been elucidated, but massive potassium efflux via cellular membranes has been implicated.  Although episodes of arrhythmia are observed during the course of pericarditis,  pericardial disease seems to be an unlikely cause in our patient as the episodes commenced when the effusion had subsided. Given the close temporal association between appearance of PAT and prednisolone administration, we think the latter to be causally responsible for the arrhythmia. Analysis using Naranjo ADR Probability Scale  indicated that the causal relationship between prednisolone and PAT was possible (Score 4). We would like to emphasize that clinicians should be aware of the possibility that cardiac arrhythmias might be the result of steroid administration and not of the underlying disease. This will help them take the appropriate decision regarding withdrawal of the incriminating drug and initiate an alternative treatment, whenever necessary.
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