Authors: La Brocca U et al.
Cureus • December 2025
Summary
This case report describes a 78-year-old woman with severe ARDS caused by a combination of Haemophilus influenzae pneumonia and chronic amiodarone pulmonary toxicity. Despite a profound P/F ratio nadir of 58 on high-flow nasal oxygen, she remained alert, stable, and without signs of respiratory collapse. Clinicians identified pre-existing interstitial disease on older CT imaging, leading to the conclusion that acute amiodarone toxicity was a major contributor.
Steroids were escalated to high-dose prednisone (160 mg/day), and a deliberate “permissive hypoxemia” strategy was initiated to avoid intubation because of her high infection risk on steroids and the likelihood of rapid reversibility. Over several days, oxygenation gradually improved, inflammatory markers reduced, and CT imaging showed dramatic radiologic resolution. She recovered fully without mechanical ventilation.
The case emphasizes the difficulty in diagnosing amiodarone pulmonary toxicity when infection coexists, the value of reviewing prior imaging, and the potential—under extremely selective conditions—for noninvasive management even in severe ARDS when the patient remains clinically stable.
Key Points
• Mixed amiodarone pulmonary toxicity and bacterial pneumonia can mimic isolated severe pneumonia and mislead diagnosis.
• Reviewing older imaging is essential for uncovering underlying chronic toxicity.
• Severe ARDS (P/F < 60) was managed without intubation through a monitored permissive hypoxemia strategy.
• High-dose corticosteroids rapidly improved amiodarone-related inflammatory lung injury.
• Noninvasive management in severe ARDS is not generalizable—appropriate only when the patient is stable, cooperative, and expected to improve quickly.
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