Repeated occurrence of severe hypotension associated with azithromycin infusion in a patient with fulminant myocarditis: a case report.

Background: Intravenous administration of azithromycin has been linked to severe hypotension in some case reports in the past. We report a further case of profound shock requiring excessive use of vasopressors and extracorporeal membrane oxygenation (ECMO). Case summary: An 18-year-old Caucasian male was admitted due to fulminant myocarditis and signs of cardiogenic shock. He had to be put on venoarterial ECMO only hours after admission. Due to the occurrence of disseminated intravascular coagulation and heparin-induced thrombocytopenia, haemodynamic support was discontinued on Day 8. On Day 11 of his stay, the patient started to exhibit signs of severe infection and a single 1500 mg dose of azithromycin was prescribed. Immediately after starting the infusion, the patient developed profound hypotension and signs of cardiogenic shock. Consecutively, venoarterial ECMO had to be re-established, and the azithromycin infusion was stopped in the process. It took the restart of the compound to recognize the connection between the administration of the therapy and the occurrence of cardiogenic shock. After discontinuing azithromycin, no further sudden hypotensive episodes were recorded, and the patient received left ventricular assist device implantation as a bridge to recovery or transplant. Discussion: Rapid-onset hypotension appears to be a very rare but important adverse drug reaction associated with intravenous administration of azithromycin. Factors such as preceding infection and reduced biventricular function may facilitate the described occurrence.