Introduction: Calcium channel blocker (CCB) toxicity can lead to many complications including bradycardia, hypotension, and shock. An unusual complication of CCB toxicity is capillary leak syndrome, which describes a constellation of disease manifestations associated with increased capillary permeability to proteins and can lead to distributive shock, acute respiratory distress syndrome (ARDS), and acute tubular necrosis, as seen in our patient’s case.
Description: A 39 year old Vietnamese speaking male presented to our institution after ingestion of 80 tablets of 10mg Amlodipine 6 hours prior to presentation in an attempted suicide. Prior history was significant for hypertension, for which he was prescribed Amlodipine. There was no history of prior suicide attempts, however, the patient reported an extensive history of family conflict and reported having an argument the day of the overdose. On admission, the patient was fully oriented but severely hypotensive, with mottled, cool extremities on exam. Labs showed severe lactic acidosis and acute renal injury. Patient received activated charcoal and intravenous fluids before transfer to the intensive care unit where he was initiated on infusions of calcium chloride, glucagon, insulin, and dextrose 5% in water, as well as lipid emulsion bolus. He was also intubated for airway protection. The next day, he was increasingly hypotensive and required maximal support on four vasopressors. He also developed worsening respiratory failure with significant bilateral pulmonary infiltrates and PaO2:FiO2 ratio of 45 indicative of severe ARDS. Despite aggressive treatment, patient became increasingly acidotic in setting of hypoxemia and renal failure. Extracorporeal membrane oxygenation (ECMO) was initiated, along with dialysis. After 4 days of ECMO, patient was de-cannulated and extubated, and eventually made a full recovery.
Discussion: The mechanism by which CCB toxicity can cause capillary leak syndrome is not fully understood, but may be caused by selective precapillary arteriolar dilation and possibly L type calcium channel modulation of vascular endothelium permeability. This is a rare case of capillary leak syndrome resulting in distributive shock, ARDS, and severe end organ damage which was successfully treated with ECMO.
