A Young Patient Presenting with Dilated Cardiomyopathy and Renal Infarction during Treatment with Isotretinoin: Mere Coincidence or Serious Side Effect of a Drug Commonly Used in Adolescence?

Abstract

Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drugs for the treatment of severe acne vulgaris. Despite being deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We report a case of heart failure due to dilated cardiomyopathy (DCM) and concomitant renal infarction occurring after 5 months of isotretinoin use in a previously healthy 18-year-old male. The patient, with a history of acne vulgaris, presented to our emergency department with left iliac fossa pain and effort dyspnea. A trans-thoracic echocardiogram showed DCM and severely reduced left ventricle ejection fraction (LVEF: 29%). During hospitalization, a total body computed tomography (CT) showed an ischemic lesion in the left kidney. Ischemic, autoimmune, infective, and heritable causes of DCM were ruled out. Cardiac magnetic resonance (CMR) evidenced LV circumferential mid-wall late gadolinium enhancement. Heart failure therapy was promptly started and up-titrated, but only poor LVEF improvement was detected overtime. Our case aims to raise awareness on rare life-threatening cardiovascular events possibly associated with isotretinoin use. To the best of our knowledge, this is the first described case of renal thromboembolism and severe DCM leading to implantable cardioverter-defibrillator (ICD) implantation occurring during isotretinoin treatment.

The effect of isotretinoin therapy on the circulatory system

“…1). Accordingly, bisoprolol, sacubitril/valsartan, and eplerenone were initiated and subsequently increased to the maximum tolerated doses, with only a weak improvement in LVEF [17]. This is the first reported case of renal disease thromboembolism and DCM requiring implantation of a subcutaneous implantable cardioverter defibrillator (S-ICD) and heart transplantation, occurring during isotretinoin treatment [17].…”

“…In August 2021, an 18-year-old man was admitted to the emergency department (ED) with a history of acne vulgaris due to left hip fossa pain and exertional dyspnoea [17]. Computed tomography (CT) scans revealed left renal infarction and echocardiography showed global left ventricular dilatation with a significantly reduced left ventricular ejection fraction (LVEF) (Fig.…”

“…Coronary artery disease, autoimmune, infectious or hereditary causes of dilated cardiomyopathy (DCM) have been excluded [17]. Cardiac magnetic resonance imaging revealed late gadolinium enhancement [17] in the medial wall of the left ventricle, and ECG monitoring revealed several unfixed episodes of ventricular tachycardia (Fig. 1).…”

“…Figure 1.Echocardiography of an 18-year-old patient treated with isotretinoin admitted to the ED due to sudden pain in the left iliac fossa and exertional dyspnoea[17] …”

“…Laboratory parameters of patients aged 9-35 years with acne vulgaris taking isotretinoin at a dose of 40 mg/d for at least 4 weeks[14][15][16]; however, there are also reports indicating the emergence of a high cardiovascular risk associated with the use of isotretinoin in young patients[17][18][19][20][21][22] …”