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2020년 제 71차 대한내과학회 추계학술대회
￭S-183 ￭ Systemic capillary leak syndrome in Variant angina
서울대학교병원 내과1, 서울대학교병원 순환기내과2
김재현1, 장민옥1,2
Introduction: Systemic capillary leak syndrome (SCLS) is characterized by hypoproteinemia, hypotension, diffuse generalized edema, and noncardiogenic pulmonary edema. Although peripheral edema is a common complication of amlodipine, there have been no reports on amlodipine induced SCLS.
Case report: A 67-year-old man with Ergonovine provocation test proven variant angina developed hypertension. He was on diltiazem 90mg twice a day, isosorbide mononitrate 60mg twice a day, molsidomine 4mg 3 times a day and nicorandil 5mg 3 times a day for last 2 years. Amlodipine 5mg twice a day was added to control hypertension. While his angina and hypertension were controlled after prescribing, he newly developed NYHA class III dyspnea and generalized edema with 10kg of weight gain and referred to ER. At ER, V/S checked 94/53 mmHg, 72beats/min. Mild hypoxemia in ABGA, hypoalbuminemia (3.1g/dL) and normal cardiac enzyme levels in laboratory tests, bilateral pleural effusion with cardiomegaly at chest X-ray were observed. Echocardiography showed normal ejection fraction without regional wall motion abnormality, but a moderate amount of pericardial effusion was newly noted compared to 2 months ago. Pleural fluid analysis revealed transudate properties. Nephrotic syndrome, hypothyroidism, liver cirrhosis, autoimmune disease, and protein-losing enteropathy were all excluded through additional examinations. After diuretic therapy, symptoms improved, but scrotal edema persisted. As he developed symptoms after amlodipine use, we tentatively diagnosed this patient as amlodipine induced SCLS and discontinued amlodipine. A month later, symptoms related to SCLS, including pericardial effusion, all disappeared. Serum albumin level recovered to 4.3 g/dL.
Discussion: Amlodipine predominantly act as an arteriolar vasodilator. As diltiazem can increase the blood concentration of amlodipine by 57% through reversibly inhibiting CYP3A4 pathway, the concomitant use of amlodipine and diltiazem may induce generalized vasodilation and increased capillary leak, which leads to SCLS. Thus, we should be aware of CCB induced SCLS when prescribing medications in variant angina patients.
