title: Long QT Syndrome Leading to Multiple Cardiac Arrests After Posaconazole Administration in an Immune-Compromised Patient with Sepsis: An Unusual Case Report.
abstract: BACKGROUND
  We present the case of a septic patient with severe immunodeficiency, who developed QT interval prolongation followed by episodes of lethal cardiac arrhythmia. Cardiac events occurred after posaconazole administration, incriminating posaconazole use, alone or in combination with voriconazole, as the culpable agent.
  
  
  METHODS
  A 26-year-old female patient underwent orthopedic surgery to remove ectopic calcifications in her left hip joint. On the first post-operative day she became septic due to a surgical wound infection. Despite being treated according to the therapeutic protocols for sepsis, no clinical improvement was noticed and further assessment revealed an underlying immunodeficiency. Considering the underlying immunodeficiency and to that point poor clinical response, an antifungal agent was added to the antibiotic regiment. Following discontinuation of multiple antifungal agents due to adverse effects, posaconazole was administered. Posaconazole oral intake was followed by episodes of bradycardia and QT interval prolongation. The patient suffered continuous incidents of cardiac arrest due to polymorphic ventricular tachycardia (torsades des pointes) that degenerated to lethal ventricular fibrillation. Posaconazole was immediately discontinued and a temporary pacemaker was installed. The patient finally recovered without any neurological deficit, and was discharged in a good clinical status.
  
  
  CONCLUSIONS
  Close cardiac monitoring is recommended in cases where posaconazole administration is combined with coexisting risk factors, as they may lead to severe ECG abnormalities and cardiac arrhythmias such as long QT interval syndrome and torsades de pointes. Posaconazole interactions with medications metabolized via the CYP3A4 pathway should be considered an additional risk factor for lethal cardiac incidents.
authors.affiliation: Department of Internal Medicine, University Hospital of Patras, Patras, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Panos
authors.affiliation: Department of Internal Medicine, University Hospital of Patras, Patras, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Velissaris
authors.affiliation: Department of Internal Medicine, University Hospital of Patras, Patras, Greece.
authors.forename: Vasilios
authors.initials: V
authors.lastname: Karamouzos
authors.affiliation: Department of Orthopedic Surgery, University Hospital of Patras, Patras, Greece.
authors.forename: Charalampos
authors.initials: C
authors.lastname: Matzaroglou
authors.affiliation: Department of Orthopaedic Surgery, University Hospital of Patras, Patras, Greece.
authors.forename: Minos
authors.initials: M
authors.lastname: Tylianakis
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000009:adverse effects*; D005260:Female; D006323:Heart Arrest / Q000139:chemically induced*; D006801:Humans; D016867:Immunocompromised Host; D008133:Long QT Syndrome / Q000139:chemically induced*; D018805:Sepsis / Q000188:drug therapy* / Q000382:microbiology; D013530:Surgical Wound Infection / Q000150:complications; D014230:Triazoles / Q000009:adverse effects*
chemical_list: D000935:Antifungal Agents; D014230:Triazoles; C101425:posaconazole