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Loperamide Overdose and Torsades de Pointes, a Case of Long QT Syndrome
Griffith, S, OMSIII, Rivard, G, D.O.
University of New England College of Osteopathic Medicine, Biddeford, Maine
Central Maine Medical Center Clinical Campus
Introduction: Long QT syndrome (LQTS) is a condition characterized by a prolonged
cardiac repolarization that predisposes a person to life threatening arrhythmias. The QT
interval, normally 370ms - 440ms, is a common measurement found on
electrocardiogram tracings. LQTS is an acquired syndrome caused by certain
medications and/or electrolyte imbalances, however, several genetic mutations in
specific cardiac channels have been found leading to Congenital LQTS (CLQTS).
According to the literature, the prevalence of CLQTS is about 1:7000. The presentation
and age of onset for CLQTS is quite variable and appears multi-factorial. While factors
such as stress and QT prolonging medications are known to correlate with symptom
onset, it is unclear whether presumed cardiac safe drugs in high amounts have any
influence.
Case: A 24 year old homeless female, who no longer has custody of her 3 children, was
brought to the emergency room at night for syncope. The patient described an episode
of severe anxiety and minor chest pressure that caused her to experience a brief
episode of syncope. The patient’s history was significant for anxiety and consumption of
20-30 tablets of loperamide throughout the day in an attempt to control opiate
withdrawal. In the emergency room the patient experienced a 15 second run of
Torsades de Pointes. She was subsequently transferred to the cardiac care unit where
she was noted to have a QT prolongation of 600ms and some inter ventricular
conduction delays. Metoprolol 25 mg was initiated but ultimately withheld due to
bradycardia. Ultimately, a dual chamber pacemaker and internal defibrillator were
placed in an attempt to prevent future sudden cardiac death.
Discussion: It is often unclear whether or not previous medications or overdoses play
any role in CLQTS symptom onset. According to the literature there have been cardiac
related side effects to loperamide overdoses, but evidence of its link to a prolonged QT
interval is lacking. This case presents a challenging treatment decision. If a washout
period of literature confirmed QT prolonging drugs is unresponsive, the question
becomes whether to continue conservative therapy like a beta blocker, or implant a
defibrillator. It is a significant life changing decision to put an internal defibrillator in a
young female pt prior to an actual confirmed genetic condition. Due to the patient’s
complicated social history and possible poor medication compliance, an axillary
implantable defibrillator was placed to correct any life threatening arrhythmias. This
case conveys the treatment and management dilemma a physician faces in the lengthy
period of time before CLQTS can be confirmed with genetics.