Fatal Myocarditis Following Administration of Zoledronic Acid: A Case Report

Abstract

Myocarditis is a potentially life-threatening condition which occurs due to inflammation of the cardiac muscle. It has a multitude of causes including certain medications. Zoledronic acid is a bisphosphonate given as an intravenous preparation for bone-related diseases. Medical literature provides details about only very few cases of Zoledronic acid-induced myocarditis and all of them were non-fatal. We report a fatal case of myocarditis due to the administration of intravenous Zoledronic acid. A 40-year-old male with a history of multiple joint pain and swelling for one week and right knee joint swelling for three months was administered intravenous Zoledronic acid. One day after the administration of Zoledronic acid patient developed dizziness and eventually became drowsy. His ECG revealed ST depressions in leads I, II, and aVF, as well as leads V3 to V5. Highly sensitive Troponin I was elevated to 2195.3 pg/ml (normal:<26.5 pg/ml) and Echocardiogram showed an ejection fraction of 30% with hypokinetic wall segments and regional wall motion abnormalities. He went into cardiogenic shock and was pronounced dead. At the autopsy, the macroscopic examination did not reveal any noticeable fatal pathology. However histological examination of the myocardium revealed diffuse infiltration of mononuclear cells with myocyte necrosis. Although life-threatening adverse effects of Zoledronic acid such as severe systemic inflammatory response syndrome and myopericarditis have been previously reported, fatalities due to Zoledronic acid-induced myocarditis, like in this case, has not been reported. This case highlights the importance of being vigilant in using this drug.