calcium channel blockers ( ccb ) are a leading cause ( 48% ) of mortality resulting from drug overdose seen in cardiovascular medicine , and amlodipine is a commonly prescribed long - acting ccb . a patient with amlodipine overdose may have profound refractory hypotension , leading to tissue hypoperfusion and target organ damage . a 28-years - old woman , with no significant past history , presented with giddiness , abdominal pain , vomiting , breathlessness , and reduced urine output 12 hours after consuming 50 tablets of amlodipine [ of 5 mg strength ] . she was rushed to a hospital near her home , found to have hypotension with hypoxemia ; was intubated , given gastric lavage , inotropic support and 24 hours later , shifted to our hospital at presentation she was found to have blood pressure ( bp ) : 60/40 mmhg , heart rate : 128/min , respiratory rate : 32/min with spo2 on room air : 85% , raised central venous pressure [ 22 cm of saline ] , anasarca and crepititions in both interscapular area . investigations revealed : total leukocyte count : 18500/ul ; neutrophils : 86% , serum creatinine : 1.8 mg / dl ( normal range : 0.6 - 1.3 mg / dl ) , blood urea nitrogen 42 mg / dl ( normal range : 10 - 20 mg / dl ) , and features of type -1 respiratory failure ( po2 - 48 mmhg , pco2 - 26 mmhg , ph - 7.52 , hco3 - 22 mmhg ) . ionized serum calcium ( 4.8 mg / dl ; normal range : 4.6 - 5.6 mg / dl , serum albumin ( 3.9 mg / dl ; range 3.5 - 5.5 mg / dl ) , and serum amylase ( 32 iu / l ; range 18 - 108 x - ray of chest revealed bilateral reticulonodular opacities , upper lobar zone venous prominence , bilateral pleural effusion , and no cardiomegaly [ figure 1 ] . echocardiography revealed normal - sized chambers , valves , right and left atrial pressures , and left ventricular ejection fraction . intravenous inotropes were continued ( dopamine : 10 - 15 g / kg / min ; noradrenaline : 10 - 12 g / kg / min ) , systolic bp increased to 90 - 110 mmhg when iv frusemide was added . two boluses of calcium gluconate were given ( 10 ml of 10% solution ) 15 minutes apart , thereafter , low - dose infusion ( at the rate 1 mg / kg of calcium ) was started ; ionized serum calcium level was maintained between 4.8 - 5.3 mg / dl . thoracentesis was performed , 300 ml of exudative effusion ( total count : 2800/cmm , leukocytes : 2400/cmm ; predominantly lymphocytes ; lactate dehydrogenase  698 u / l ; protein  3 g / dl ) was drained from either side . she was ventilated initially invasively , later non - invasively ; and empiric broad - spectrum antibiotics covering gram - positive , gram - negative organisms and pseudomonas aeruginosa were started in view of prior hospitalization . monitored parameters included clinical status , central venous pressure , urine output , fluid , and electrolytes including calcium levels and ecg every 4 - 6 hrs for first 48 , thereafter every 12 hours . she was successfully weaned off ventilator after 48 hours ; inotropes ( noradrenaline after 18 hours , dopamine after 48 hours ) and calcium infusion ( after 48 hours ) were gradually tapered off . she was shifted to a step - down ward from icu after 72 hours and discharged after 5 days . calcium channel blockers [ ccb ] are one of the most widely used group of anti - hypertensive agents . amlodipine is a dihydropyridines ccb with long half - life ( 30 - 58 hrs ) and large volume of distribution ( 21 l / kg ) . toxicity is seen in doses up to 5 - 10 times the therapeutic dose and sets within 30 - 60 minutes following ingestion . our patient presented with giddiness caused by hypotension attributable to generalized vasodilatation due to direct effect on vascular smooth muscle ; worsened by negative effect on the cardiac pacemaker and myocardial contractility . hyperglycemia due to reduced insulin release and lactic acidosis seen in ccb overdose also contributes to reduced dromotropic effect . abdominal pain and vomiting seen in our patient has been described ascribed to reduced gastrointestinal motility and stasis of gastric contents . oliguric renal failure with features of fluid overload seen in our patient is well described ; and is attributablee to prolonged hypotension and reduced effective circulatory volume . an unusual finding in our case is bilateral exudative pleural effusion caused by amlodipine , that has not been reported earlier . several disorders may mimic systemic capillary leak syndrome [ scls ] , including severe sepsis , toxic shock syndrome , pancreatitis , ovarian hyperstimulation syndrome , anaphylaxis , and drug reactions including interleukin-2 , granulocyte colony - stimulating factor , interferon alfa , gemcitabine , sirolimus , and acitretin . scls is an episodic disorder characterized by triad of hypotension , hemoconcentration , and hypoalbuminemia associated with generalized edema , ascites , bilateral pleural effusion , pericardial effusion , cerebral edema , and encephalopathy . exact mechanisms involved in pathogenesis are not clear , but it is believed to occur as a result of excess of vasodilators ( histamine , prostaglandins , and bradykinins ) , proinflammatory cytokines ( interleukin -6 , tumor nerosis factor alpha ) , vascular endothelial growth factor , and altered immune response causing excess of cd25 + t cells . scls is complicated by tissue hypoperfusion on the one hand and fluid overload due to overzealous fluid administration on the other . other causes of secondary capillary leak were excluded by history and relevant investigations in our patient . the capillary leak syndrome , alongwith pleural effusions and acute lung injury attributable to the drug toxicity was complicated by renal failure and fluid overload . treatment includes supportive care including maintenance of airway , breathing , and circulation ( abcs ) . hypotension is initially managed with volume loading ; however , as our patient had signs of fluid overload , we did not continue to administer iv fluids . inotropes ( dopamine , norepinephrine , epinephrine ) can be added after normalization of cvp . correction of acid - base disturbances and electrolyte abnormalities optimizes cardiac function . in refractory cases , glucagon ( 5 - 10 mg iv ) and hyperinsulinemic  euglycemia using dextrose and insulin infusion ( with 0.5 iu / kg / hr ) as inotropic agents ; cardiac pacing in third degree heart blocks , intra - aortic balloon pump are also reported to be useful . gastric lavage with water or polyethylene glycol and activated charcoal ( 1 g / kg initially and to be continued for 24 through nasogastric tube ) can be a useful modalities , especially in long - acting preparations . gastric lavage can remove unabsorbed drug from the stomach for an extended time as ccb reduce gastric motility . though definitive evidence of benefit of gastrointestinal decontamination in ccb overdose is lacking , it is still recommended due to potential lethal nature of ccb overdose and lack of specific antidote . calcium gluconate or chloride in continuous infusion ( ca chloride 0.2 ml / kg / hr ) or iv boluses ( 10 ml of 10% calcium chloride/20 - 30 ml of calcium gluconate , every 15 - 20 minutes ; maximum : 30 g over 12 hours ) is given to overcome the competitive blockade of calcium channels . we treated our patient with parenteral calcium and monitored with clinical response , ecg , and serum calcium levels . the course of hospitalization was complicated by oliguric acute renal failure that was managed conservatively though renal replacement therapy may be needed . amlodipine overdose can be potentially fatal owing to non - cardiogenic pulmonary edema , refractory shock , and acute renal failure , and its management can be challenging . outcome can be improved by early and aggressive intensive care , inotropic support , calcium infusion and other supportive measures .
amlodipine is a commonly prescribed calcium channel blocker . 
 its toxicity is the leading cause of drug overdose seen in the practice of cardiovascular medicine . 
 it can lead to profound hypotension and shock . 
 management involves early and aggressive supportive measures and calcium infusion in large doses to overcome competitive blockade . 
 we report one such case that presented with amlodipine overdose and was successfully managed .