Background: Amiodarone is a class III antiarrhythmic agent used for the management of certain cardiac arrhythmias. Although effective and relatively safe, amiodarone is associated with a spectrum of adverse effects including neurotoxicity. There have been sparse reports of drug-induced parkinsonism (DIP) as a consequence of amiodarone use; however, the mechanism and clinical implications remain an area of limited understanding and documentation. Parksinon’s disease (PD) is associated with degeneration of dopaminergic pathways in the basal ganglia, manifesting in the classic constellation of symptoms, including “pill-rolling” tremors. These dopaminergic pathways can also be disrupted by certain medications, notably antipsychotics, antiemetics, and antiepileptics, which may mimic the symptoms of PD.

Case Presentation: 92 year-old female with a past medical history of atrial fibrillation, hypothyroidism, heart failure, COPD, and dementia presented with resting tremors of the bilateral hands for 2 months. Pt endorsed no new bradykinesia, loss of balance, or muscle stiffness. Denied any fever, chills, myalgia, cough, dysuria, nausea, vomiting, diarrhea, or weight gain or loss. Physical exam demonstrated isolated bilateral resting tremors, with an otherwise unremarkable neurologic exam. There was no muscle rigidity, cerebellar dysfunction, motor/sensory deficits, or bradykinesia compared to baseline. Vital signs were normal and labwork including TSH, RPR, and vitamins B12 and B9 were unremarkable. Following review of the patient’s medication regimen, we reduced amiodarone dosing from 200mg to 100mg due to concern for neurotoxicity rather than late-onset PD. On follow up at 2 weeks and 1 month, resting tremors resolved completely and the patient had no further concerns.

Discussion: Despite the established neurotoxicity of amiodarone, reports of amiodarone-induced Parkinsonism remain sparse. Here, we present a case of Parkinsonism occurring in a patient receiving long-term amiodarone therapy. Through this case report, we aim to broaden understanding of potential neurotoxic effects of amiodarone and emphasize the importance of recognizing drug-induced parkinsonism (DIP). DIP is a reversible form of Parkinsonism caused by the blockade of dopamine receptors or interference with dopamine transmission in the basal ganglia, mimicking the dopaminergic deficiency seen in PD. Misdiagnosing DIP as Parkinson's disease could lead to inappropriate treatment, potentially causing harm. Hence, clinical vigilance is warranted in patients receiving long-term therapy with amiodarone. 


Amiodarone-Induced Parkinsonism: A Case Report Highlighting Neurotoxicity and Clinical Vigilance in Long-Term Therapy

Background: 
Gallstone ileus is a rare form of bowel obstruction caused by the passing of a gallstone through a biliary-enteric fistula with subsequent bowel impaction. This fistula is usually created between the gallbladder and duodenum due to chronic cholecystitis. Patients typically present with signs and symptoms of bowel obstruction and radiological evidence of biliary-enteric fistula. Although accounting for less than 0.1% of all mechanical bowel obstructions, gallstone ileus is associated with relatively high mortality rates ranging from 12% to 27%. In addition to enterolithotomy, surgical management may include cholecystectomy and fistula closure, depending on the clinical presentation. Here we present a case of gallstone ileus which was laparoscopically managed by enterolithotomy only.

Case Presentation: 
A 74-year-old female with past medical history of hypertension and hyperlipidemia presented with worsening abdominal pain, nausea, and vomiting for two days. On physical examination, abdominal distension and generalized abdominal tenderness was appreciated. Initial laboratory results demonstrated serum lipase of 1,260 U/L. Abdominal CT revealed Rigler’s triad, consisting of pneumobilia, small bowel obstruction, and an ectopic calcified gallstone. The patient underwent laparoscopic enterolithotomy, during which the impacted gallstone was removed and the enterotomy was repaired primarily. There was evidence of significant scarring in the upper abdomen from a previous inflammatory process with no signs of acute infection. Pathological evaluation demonstrated a 3 x 2.5 x 2 cm cholesterol gallstone. Postoperative course was unremarkable, and the patient was discharged home two days after surgery.

Discussion: 
Surgical management of gallstone ileus has engendered controversy around whether to perform a cholecystectomy and fistula closure during the enterolithotomy, on a later date, or not at all. Furthermore, while the current standard is laparotomy, there are increasing reports of successful laparoscopic management. As represented in this case, laparoscopic management of gallstone ileus by enterolithotomy alone is a safe and effective alternative offering less postoperative pain, faster recovery, and lower morbidity.

Laparoscopic Management of Gallstone Ileus by Enterolithotomy alone

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Clinical Vignettes | General Surgery

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Eric Abedi

2

1

Presentations

Amiodarone-Induced Parkinsonism: A Case Report Highlighting Neurotoxicity and Clinical Vigilance in Long-Term Therapy

Laparoscopic Management of Gallstone Ileus by Enterolithotomy alone

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