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Lee WI, Lam L, Bacchi S, Jiang M, Inglis JM, Smith W, Hissaria P. Antibiotic prophylaxis in immunosuppressed patients - Missed opportunities from trimethoprim-sulfamethoxazole allergy label. World Allergy Organ J 2024; 17:100856. [PMID: 38235260 PMCID: PMC10793173 DOI: 10.1016/j.waojou.2023.100856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic in use for more than 50 years. It has an important indication as first line agent in the prophylaxis of opportunistic infections, particularly Pneumocystis jirovecii pneumonia (PJP), in immunosuppressed patients. For those who have a history of allergy or severe intolerance to TMP-SMX, pentamidine, dapsone or atovaquone may be substituted; however there is evidence that TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis. Compared to pentamidine, it has the added benefit of cost-effectiveness and self-administration as opposed to required hospital attendance for administration. Many patients who report a history of allergy or adverse reaction to TMP-SMX (or "sulfur allergy") will be found not to be allergic; and even those who are allergic may be able to be desensitized. The evaluation and, where appropriate, removal of TMP-SMX allergy label enables the use of TMP-SMX for prophylaxis against opportunistic infections. This is a cost-effective intervention to optimize antimicrobial prescribing and reduce the risk of opportunistic infections in immunosuppressed patients.
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Affiliation(s)
- Wei-I Lee
- Department of Immunology, The Canberra Hospital, Yamba Drive, Garran, ACT, 2605, Australia
- Australian National University, Canberra, ACT, 2601, Australia
| | - Lydia Lam
- University of Adelaide, Adelaide SA 5005, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Melinda Jiang
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Joshua M. Inglis
- University of Adelaide, Adelaide SA 5005, Australia
- Flinders Medical Centre and University, Bedford Park, SA, 5042, Australia
| | - William Smith
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Pravin Hissaria
- University of Adelaide, Adelaide SA 5005, Australia
- Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Department of Immunopathology, SA Pathology, Frome Rd, Adelaide, 5000, Australia
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Fan Z, He Y, Sun W, Li Z, Zhu M, Wang C. Clinical Characteristics, Diagnosis, and Management of Aseptic Meningitis Induced by Trimethoprim-Sulfamethoxazole. Infect Drug Resist 2023; 16:5825-5832. [PMID: 37692468 PMCID: PMC10492553 DOI: 10.2147/idr.s425464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023] Open
Abstract
Objective Trimethoprim sulfamethoxazole (TMP-SMX) is related to aseptic meningitis. However, a detailed description of its phenotype is lacking, which easily leads to misdiagnosis. The purpose of this article is to explore the clinical characteristics of TMP-SMX-induced aseptic meningitis (TSIAM). Methods We collected literature related to TSIAM published before July 31, 2023, by searching Chinese and English databases. Data were extracted and analyzed descriptively. Results The 55 patients were mostly female (60.0%), with a median age of 43 years (range: 2.5-90 years). The first onset time was from a few minutes to 3 months after administration, and the time of reonset was within 12 hours. Fever (98.2%), headache (78.2%), altered mental status (42.3%), nausea and vomiting (41.8%), and neck pain (34.5%) were the most common symptoms. In severe cases, patients presented with low blood pressure, seizures, unconsciousness, or coma. Typical cerebrospinal fluid analysis showed elevated white blood cell counts, with polymorphonuclear leukocytes predominating, elevated protein levels, and normal glucose levels. Brain imaging usually showed no abnormalities. Symptoms resolved rapidly after the discontinuation of TMP-SMX, within a median time of 2 days (range: 1, 60). Readministration of TMP-SMX led to another relapse of aseptic meningitis. Aseptic meningitis usually culminated in a full recovery, although one patient experienced permanent paraplegia. Conclusion Clinicians should be aware that aseptic meningitis is a rare adverse effect of TMP-SMX. TMP-SMX should be discontinued in patients with TSIAM to reduce unnecessary testing and treatment, and readministration of TMP-SMX should be avoided.
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Affiliation(s)
- Zhiqiang Fan
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, 410007, People’s Republic of China
| | - Yang He
- Department of Pharmacy, The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, 410007, People’s Republic of China
| | - Wei Sun
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Min Zhu
- Department of Ophthalmology, Central South University, Changsha, Hunan, 410013, People’s Republic of China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, Hunan, 410013, People’s Republic of China
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Pata G, Montagna M, Bosi E, Davalli A, Rovere Querini P. Trimethoprim-sulfamethoxazole induced aseptic meningitis case report. Medicine (Baltimore) 2023; 102:e32475. [PMID: 36607874 PMCID: PMC9829252 DOI: 10.1097/md.0000000000032475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
RATIONALE Drug-induced aseptic meningitis (DIAM) is an uncommon meningitis and trimethoprim with or without sulfamethoxazole is the most involved antibiotic. Although DIAM is easily treated with the discontinuation of the causative drug, the diagnosis is a big challenge for physicians, as it remains a diagnosis of exclusion. Here, we present a case report of trimethoprim-sulfamethoxazole induced aseptic meningitis in a woman with acute osteomyelitis. PATIENT CONCERNS A 52-year-old woman was admitted to the hospital for septic shock and acute osteomyelitis of the right homerus. She was started on antibiotic therapy with oxacillin and daptomycin, then oxacillin was replaced with cotrimoxazole, due to its excellent tissue penetration, including bone tissue. During cotrimoxazole therapy, the patient developed a fluent aphasia with ideomotor apraxia and muscle hypertonus. DIAGNOSIS AND INTERVENTIONS Having excluded infectious, epileptic and vascular causes of the acute neurologic syndrome of our patient, given the improvement and full recovery after discontinuation of cotrimoxazole, we hypothesized a DIAM. OUTCOMES After discontinuation of cotrimoxazole, in 48 hours the patient had a full recovery. LESSONS Although DIAM can be easily managed with the withdrawal of the causative drug, it can be difficult to recognize if it is not included in the differential diagnosis. An antimicrobial stewardship program with a strict monitoring of patients by infectious disease specialists is essential, not only to optimize the appropriate use of antimicrobials, but also to improve patient outcomes and reduce the likelihood of adverse events.
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Affiliation(s)
- Giulia Pata
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Emanuele Bosi
- Vita-Salute San Raffaele University, Milan, Italy
- Diabetes and Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Davalli
- Diabetes and Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Rovere Querini
- Vita-Salute San Raffaele University, Milan, Italy
- Diabetes and Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
- * Correspondence: Patrizia Rovere Querini, Vita-Salute San Raffaele University, Milan 20132, Italy (e-mail: )
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O’Brian M, Rose EK, Mauskar MM, Dominguez AR. Sudden Conjunctivitis, Lymphopenia, and Rash Combined With Hemodynamic Changes (SCoRCH) After Trimethoprim-Sulfamethoxazole Use: A Case Series Study of a Hypersensitivity Reaction. JAMA Dermatol 2023; 159:73-78. [PMID: 36350597 PMCID: PMC9647562 DOI: 10.1001/jamadermatol.2022.4657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/05/2022] [Indexed: 11/11/2022]
Abstract
Importance Trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity reaction, ranging from circulatory shock to aseptic meningitis and respiratory failure, is a potentially life-threatening condition with dermatologic relevance. Objective To describe the mucocutaneous findings and clinical features of TMP-SMX hypersensitivity reaction. Design, Setting, and Participants This was a retrospective case series study of 7 patients who developed a characteristic rash, hemodynamic changes, and end-organ dysfunction after treatment with TMP-SMX at a large university hospital system during January 2013 to March 2022. Exposures Treatment with TMP-SMX within 2 weeks of the reaction. Main Outcome and Measures Descriptions of the condition, including the demographic information of the affected population, the reaction timeline, and mucocutaneous and clinical features. Results The cohort comprised 7 patients (median [range] age, 20 [15-66] years; 4 female and 3 male). The most common mucocutaneous findings were generalized sunburn-like erythema without scale, conjunctivitis, and mild facial and acral edema. Three patients had previous exposure to TMP-SMX and developed symptoms in 1 day or less, while those without prior exposure presented from 4 to 11 days after drug initiation. Among the 7 patients, 6 had fever, 7 had hypotension, and 7 had tachycardia. All patients had lymphopenia and evidence of end-organ dysfunction with either kidney or liver involvement. Median (range) time to resolution was 72 (48-96) hours. Conclusions and Relevance This retrospective case series indicates that SCoRCH (sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes) should be considered in the differential diagnosis of patients presenting with acute generalized sunburn-like erythema, conjunctivitis, systemic symptoms, and hemodynamic changes in the setting of recent TMP-SMX use.
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Affiliation(s)
- Madeleine O’Brian
- University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, Dallas
| | - Elysha K. Rose
- University of Texas Southwestern Medical School, University of Texas Southwestern Medical Center, Dallas
| | - Melissa M. Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Arturo R. Dominguez
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Hatcher VR, Brooks RM, Barker KB, Coop CA. A Case of Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis Masquerading as Septic Shock. Mil Med 2021; 188:usab524. [PMID: 34910163 DOI: 10.1093/milmed/usab524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Trimethoprim-sulfamethoxazole-induced aseptic meningitis (TSIAM) is a rare adverse reaction to a commonly prescribed antibiotic. We describe a case of severe TSIAM which resembled septic shock. A 30-year-old male with relapsed Hodgkin's lymphoma 25 days status post autologous stem cell transplant presented to our clinic for evaluation of trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity. After review of patient's history and records, we had a low suspicion for a TMP-SMX adverse reaction and conducted an oral challenge to one 160 mg/800 mg tab of TMP-SMX. Four hours later, the patient developed vomiting, lightheadedness, and disorientation with progression to rigors, fever, tachycardia, and hypotension. He was admitted for fluid resuscitation and broad-spectrum antibiotic coverage for neutropenic fever and possible septic shock. A lumbar puncture performed due to complaints of headache, photophobia, and neck pain showed 375 white blood cells/µL with 73% neutrophil predominance, normal glucose (75 mg/dL), and elevated protein (101 mg/dL); additional cerebrospinal fluid (CSF) studies were negative for infectious etiologies. Fever and headache resolved by hospital day 4, at which time patient was discharged home. We believe this case represents TSIAM given the characteristic timing of symptom onset, CSF findings, and timing of symptom resolution without other clear etiology found on extensive infectious evaluation. It is important for allergists to recognize TSIAM, including its potential presentation as shock, in order to appropriately diagnose and counsel patients who seek evaluation for TMP-SMX adverse reactions.
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Affiliation(s)
- Vishaka R Hatcher
- Department of Pediatrics, Wright-Patterson Medical Center, Wright-Patterson AFB, OH 45433, USA
| | - Robert M Brooks
- Department of Allergy and Immunology, Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX 78236, USA
| | | | - Christopher A Coop
- Department of Allergy and Immunology, Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX 78236, USA
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van Asperdt JAA, De Moor RA. Aseptic meningitis, hepatitis and cholestasis induced by trimethoprim/sulfamethoxazole: a case report. BMC Pediatr 2021; 21:345. [PMID: 34399711 PMCID: PMC8365906 DOI: 10.1186/s12887-021-02820-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drug-induced aseptic meningitis is a rare, but challenging diagnosis, most commonly reported with nonsteoroidal anti-inflammatory drugs (NSAIDs) and antibiotics. Trimethoprim/sulfamethoxazole (TMP/SMX) is a sulfonamide that is widely used in clinical practice for the treatment and prophylaxis of various infections. The most common side effects associated with TMP/SMX are generally mild and self-limited, but serious side effects have been reported, including liver injury and aseptic meningitis. CASE PRESENTATION We report a 2,5 year old Dutch girl with both drug-induced aseptic meningitis and drug-induced liver injury while using TMP/SMX prophylaxis. Ursodeoxycholic acid was started because of cholestatic injury. After cessation of TMP/SMX, full convalescence was reached within weeks. CONCLUSIONS This is the first report of a young patient with both aseptic meningitis and drug-induced liver injury caused by TMP/SMX. Drug-induced aseptic meningitis and cholestatic hepatitis constitute a considerable diagnostic challenge to clinicians. In addition to a thorough evaluation for infectious causes, clinicians should be aware of drug-induced aseptic meningitis and cholestatic hepatitis.
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Affiliation(s)
- J A A van Asperdt
- Department of Paediatrics, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweek 60, 5022 GC, Tilburg, The Netherlands.
| | - R A De Moor
- Department of Paediatrics, Elisabeth-Tweesteden Hospital, Hilvarenbeekseweek 60, 5022 GC, Tilburg, The Netherlands
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7
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Elmedani S, Albayati A, Udongwo N, Odak M, Khawaja S. Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis: A New Approach. Cureus 2021; 13:e15869. [PMID: 34327094 PMCID: PMC8302234 DOI: 10.7759/cureus.15869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 11/05/2022] Open
Abstract
Inflammation of the meningeal linings of the central nervous system (CNS), also known as meningitis, is one of the serious presentations in the emergency because it carries high morbidity and mortality. The most common cause is pus-producing organisms. However, non-suppurative meningitis, termed aseptic meningitis, is another cause of meningeal inflammation. Many etiologies stand behind aseptic meningitis. Those etiologies include viral and non-viral, drug-induced, malignancy, and systemic inflammation. Drug-induced aseptic meningitis is a rare type of meningitis. Although it is easily treated, it can be a challenging disease if not present in the differential diagnosis. It is commonly associated with nonsteroidal anti-inflammatory drugs (NSAIDs). Nonetheless, other medications have been also reported to cause aseptic meningitis, including antibiotics. Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the most prescribed antibiotics as a prophylactic and therapeutic drug due to its effectiveness and low cost. Although immunocompromised patients are at a higher risk to develop aseptic meningitis, immunocompetent patients are also at risk. Unrelated to the source of the infection, TMP-SMX carries a risk of aseptic meningitis and should be considered as an etiology in patients presenting with meningeal signs and symptoms. Hereby, we report a young immunocompetent patient who developed aseptic meningitis eight days after being prescribed TMP-SMX. Like all drug-induced aseptic meningitis, all his symptoms resolved two days after stopping the medication.
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Affiliation(s)
- Sarah Elmedani
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Asseel Albayati
- Internal Medicine, Jersey Shore University Medical Center, Neptune City, USA
| | - Ndausung Udongwo
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Mihir Odak
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
| | - Sharif Khawaja
- Internal Medicine, Jersey Shore University Medical Center, Neptune, USA
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Ko AWK, Ghaffari-Rafi A, Chan A, Harris WB, Imasa A, Liow KK, Viereck J. A Case Report of Antibiotic-Induced Aseptic Meningitis in Psoriasis. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:129-133. [PMID: 34195619 PMCID: PMC8237324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although frequently prescribed, certain antibiotics such as trimethoprim-sulfamethoxazole carry the risk of a rare yet life-threatening adverse effect, termed drug-induced aseptic meningitis. Morbidity can be avoided if the medication is identified and discontinued. Patients in reported cases tend to be female and have an autoimmune disease or prior adverse reaction to the offending agent. As a rare and poorly characterized condition, the subset of patients using antibiotics at risk for aseptic meningitis remains unclear; hence, cataloging these adverse events remains critical for better elucidating the disease. Here, we report a 62-year-old man with psoriasis and no prior history of sulfa allergy, who presented with a sudden onset of fever, chills, vomiting, and muscle aches 5 hours after taking single doses of trimethoprim-sulfamethoxazole and ciprofloxacin. Common infectious causes were ruled out, and his medications were discontinued. Despite initial symptom resolution with discontinuation, the patient neurologically deteriorated over the next two days before eventually recovering with supportive care. This case highlights the variable presentation of drug-induced aseptic meningitis. In contrast to previous reports of drug-induced aseptic meningitis, our patient was male, older than the median age of 40 years, and did not have a prior adverse reaction to the antibiotic. Furthermore, to the best of our knowledge, we report a possible case of antibiotic-induced aseptic meningitis in a patient with psoriasis. Lastly, the case emphasizes not only the value of a thorough medication history but also the importance of recognizing that patients may deteriorate in the first 48 hours before resolution.
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Affiliation(s)
- Andrew Wai Kei Ko
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Arash Ghaffari-Rafi
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Alvin Chan
- University of California Riverside School of Medicine, Riverside, CA (AC)
| | - William B. Harris
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Arcelita Imasa
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Kore Kai Liow
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
- Hawai‘i Pacific Neuroscience Institute, Honolulu, HI (KK, JV)
- John A. Burns School of Medicine, Clinical and Translational Research, Department of Quantitative Health Sciences, University of Hawai‘ at Mānoa, Honolulu, HI (KK, JV)
| | - Jason Viereck
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
- Hawai‘i Pacific Neuroscience Institute, Honolulu, HI (KK, JV)
- John A. Burns School of Medicine, Clinical and Translational Research, Department of Quantitative Health Sciences, University of Hawai‘ at Mānoa, Honolulu, HI (KK, JV)
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Negron-Diaz JA, Klumpp LC, Mayer CA, Jordan J. Aseptic Meningitis Secondary to Antibiotic Therapy. Cureus 2021; 13:e14454. [PMID: 33996314 PMCID: PMC8117791 DOI: 10.7759/cureus.14454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Drug-induced aseptic meningitis is a rare entity. Diagnosis of drug-induced aseptic meningitis can be challenging due to the difficulty in distinguishing clinical presentation from bacterial or viral meningitis. We present a case of a 52-year-old Caucasian female patient who presented to the emergency room on two different occasions with severe headache, neck pain, and confusion. Initial cerebrospinal fluid (CSF) analysis showed lymphocytic pleocytosis, and empirical intravenous acyclovir was initiated. Bacterial and viral CSF analysis and cultures were negative. The patient completely recovered. Several days later, the patient returned to the emergency room with similar symptoms. Second CSF analysis revealed neutrophilic pleocytosis, and empirical intravenous antibiotic and antiviral therapy were started. Bacterial, fungal, and viral CSF analysis and cultures were negative. Imaging studies of the brain were unremarkable on both occasions. The patient reported taking trimethoprim-sulfamethoxazole (TMP-SMX) for right foot infection before and after the initial presentation. The patient's symptoms resolved without neurological sequelae after discontinuation of TMP-SMX. This case report highlights the importance of taking a detailed history to diagnose drug-induced aseptic meningitis.
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Affiliation(s)
| | - Linda C Klumpp
- Internal Medicine, Citrus Memorial Hospital, Inverness, USA
| | - Cynthia A Mayer
- Infectious Disease, Citrus Memorial Hospital, Inverness, USA
| | - Jeffrey Jordan
- Internal Medicine, Citrus Memorial Hospital, Inverness, USA
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10
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Rathe JA, Poole N, Melvin A. Atypical Severe Shock-like Reactions in Adolescents After Trimethoprim-Sulfamethoxazole Therapy. J Pediatric Infect Dis Soc 2021; 10:382-385. [PMID: 32955095 DOI: 10.1093/jpids/piaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/18/2020] [Indexed: 11/14/2022]
Abstract
Severe drug hypersensitivity reactions to antibiotics are rare but trimethoprim-sulfamethoxazole (TMP-SMX) is uniquely associated with numerous and varied manifestations including a reaction resembling septic shock, first observed in human immunodeficiency virus (HIV)/AIDS patients. Over the past 25 years about 20 cases have been reported and an association with the virus and related immune system dysregulation was assumed. However, recent reports in adults have recognized similar shock-like reactions in non-HIV infected individuals. Here we review severe TMP-SMX hypersensitivity reactions and within the context of these known reactions, describe three non-HIV infected adolescent patients with shock-like reactions to TMP-SMX observed in one institution over 1.5 years.
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Affiliation(s)
- Jennifer A Rathe
- Division of Infectious Disease, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Nicole Poole
- Division of Infectious Disease, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Ann Melvin
- Division of Infectious Disease, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
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11
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Lum J, Echenique I, Athans V, Koval CE. Alternative pneumocystis prophylaxis in solid organ transplant recipients at two large transplant centers. Transpl Infect Dis 2020; 23:e13461. [PMID: 32894607 DOI: 10.1111/tid.13461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/03/2020] [Accepted: 08/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for Pneumocystis jirovecii pneumonia (PJP) prophylaxis and has activity against other opportunistic infections (OIs) after solid organ transplant (SOT). We aimed to describe the incidence, reasons for and outcomes of use of alternative prophylactic agents (APAs) across SOT programs in our high volume centers. METHODS Solid organ transplant recipients (SOTRs) at our centers from 1/2015-12/2016 were identified. Pharmacy records identified APA (pentamidine, atovaquone, or dapsone) use within 1 year. Records were reviewed for allergies, laboratory values at APA initiation, diagnostic tests for TMP-SMX-preventable OIs, and APA side effects. RESULTS An APA was initiated in 105/1173 (8.9%) SOTRs. Of these, 51 (48.6%) were because of sulfonamide allergy recorded pre-SOT, mostly rash/hives (58.8%). The remaining 54 (51.4%) had TMP-SMX discontinued post-SOT, mostly for neutropenia (48%) and renal effects (34%). Differences occurred across programs, with kidney transplant never stopping TMP-SMX for renal issues. Of those changed to APAs post-transplant, 19 (35%) were later successfully re-challenged with TMP-SMX. With thresholds in mind, 67 (64%) received an APA unnecessarily, accounting for up to $100 000/y excess cost. Potential TMP-SMX-preventable OIs occurred in 7 (5 Nocardia; 2 PJP). APA side effects occurred in 14/105 (13.3%). CONCLUSIONS Use of APAs for PJP prophylaxis after SOT is less than previously reported but often unwarranted. Such decisions require scrutiny to avoid TMP-SMX-preventable OIs, cost and important APA side effects. Use of reasonable thresholds for cessation of TMP-SMX and data-driven approaches to re-challenge would substantially reduce APA use.
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Affiliation(s)
- Jessica Lum
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
| | - Ignacio Echenique
- Department of Infectious Diseases, Cleveland Clinic Florida, Weston, FL, USA.,Teva Pharmaceuticals, Miramar, FL, USA
| | - Vasilios Athans
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Christine E Koval
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA
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Kalmi G, Javeri F, Vanjak A, Kirren Q, Green A, Jarrin I, Lloret-Linares C. Drug-induced meningitis: A review of the literature and comparison with an historical cohort of viral meningitis cases. Therapie 2020; 75:605-615. [PMID: 33187718 DOI: 10.1016/j.therap.2020.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/27/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Drug-induced aseptic meningitis (DIAM) is potentially insufficiently considered by clinician, being of rare etiology, with there being no previously published exhaustive study describing its clinical and biological features. METHODS Two independent academic clinicians searched all the case reports of DIAM from 1995 until 15th April, 2017. The search was limited to studies performed in humans, published in English or French. Clinical and biological data of subjects were compared with those of patients with documented viral meningitis. RESULTS One hundred and fifty-one case reports fulfilled our inclusion criteria. Non-steroidal anti-inflammatory drugs were the commonest drug cause of AM n=49, followed by antibiotics n=46, biotherapy n=19 and finally immunomodulators n=15. The clinical and biological presentation of DIAM varies according to the causative etiological drug, especially with respect to the interval between exposure and presentation and cerebrospinal fluid (CSF) pleiocytosis. Clinical symptoms associated with meningitis were more prevalent in viral meningitis than in DIAM, except for fever and signs of encephalitis. Cerebrospinal fluid examination in DIAM reveals an increased CSF white cell count and an increased proportion of neutrophils and protein, compared with viral meningitis. DISCUSSION We present an extensive review of the DIAM case reports, and highlight their clinical and biological characteristics according to the drugs involved. While comparing for the first time their characteristics with those of viral meningitis, this review hopes in facilitate earlier diagnosis and management of DIAM in clinical practice.
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Affiliation(s)
- Galith Kalmi
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France
| | - Florian Javeri
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France
| | - Anthony Vanjak
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France
| | - Quentin Kirren
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France
| | - Andrew Green
- Yorkleigh surgery, Saint Georges Round, Cheltenham, Gloucestershire GL50 3ED, United Kingdom
| | - Irène Jarrin
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France
| | - Célia Lloret-Linares
- Assistance publique-hôpitaux de Paris, hôpital Lariboisière, therapeutic research unit, department of internal medicine, 75010 Paris, France.
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Bianchi L, Marietti R, Hansel K, Tramontana M, Patruno C, Napolitano M, Stingeni L. Drug‐induced aseptic meningitis to ibuprofen: The first case confirmed by positive patch test. Contact Dermatitis 2020; 82:405-406. [DOI: 10.1111/cod.13487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Leonardo Bianchi
- Dermatology Section, Department of MedicineUniversity of Perugia Perugia Italy
| | - Rossella Marietti
- Dermatology Section, Department of MedicineUniversity of Perugia Perugia Italy
| | - Katharina Hansel
- Dermatology Section, Department of MedicineUniversity of Perugia Perugia Italy
| | - Marta Tramontana
- Dermatology Section, Department of MedicineUniversity of Perugia Perugia Italy
| | - Cataldo Patruno
- Section of Dermatology, Department of Health SciencesUniversity Magna Graecia of Catanzaro Catanzaro Italy
| | - Maddalena Napolitano
- Section of Dermatology, Department of Health SciencesUniversity of Molise Campobasso Italy
| | - Luca Stingeni
- Dermatology Section, Department of MedicineUniversity of Perugia Perugia Italy
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Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis: A Rare Presentation of Commonly Used Antibiotic. Case Rep Infect Dis 2019; 2019:4289502. [PMID: 31885958 PMCID: PMC6927022 DOI: 10.1155/2019/4289502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 09/12/2019] [Indexed: 12/30/2022] Open
Abstract
Drug-induced aseptic meningitis is a rare medical condition with trimethoprim-sulfamethoxazole being one of the most common antimicrobial agents associated with it. Here, I report a case of a 56-year-old male who presented to a health care facility with shock and meningitis-like syndrome in two occasions, one year apart following an exposure to trimethoprim-sulfamethoxazole for treatment of skin/soft tissue infection. Investigations did not reveal an infectious etiology in the two presentations. The patient improved with supportive care and withdrawal of the offending agent. In the two admissions, the patient improved following stopping the offending drug in addition to supportive care. The diagnosis of trimethoprim-sulfamethoxazole-induced aseptic meningitis was the most likely explanation for this case. Trimethoprim-sulfamethoxazole-induced aseptic meningitis is rare although it is a life-threatening side effect of TMP/SMX; therefore, the clinicians should keep the diagnosis of drug-induced aseptic meningitis in the differential diagnosis of aseptic meningitis in the appropriate clinical setting as early withdrawal of the culprit drug and supportive measurements will lead to early recovery.
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15
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Khan DA, Knowles SR, Shear NH. Sulfonamide Hypersensitivity: Fact and Fiction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2116-2123. [DOI: 10.1016/j.jaip.2019.05.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/26/2019] [Accepted: 05/29/2019] [Indexed: 02/06/2023]
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16
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Yelehe-Okouma M, Czmil-Garon J, Pape E, Petitpain N, Gillet P. Drug-induced aseptic meningitis: a mini-review. Fundam Clin Pharmacol 2018; 32:252-260. [DOI: 10.1111/fcp.12349] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/12/2017] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Melissa Yelehe-Okouma
- Centre Régional de Pharmacovigilance; CHRU de Nancy; Hôpital Central; 29, avenue du Maréchal de Lattre de Tassigny 60034, 54035 Nancy France
| | - Julie Czmil-Garon
- Centre Régional de Pharmacovigilance; CHRU de Nancy; Hôpital Central; 29, avenue du Maréchal de Lattre de Tassigny 60034, 54035 Nancy France
| | - Elise Pape
- Centre Régional de Pharmacovigilance; CHRU de Nancy; Hôpital Central; 29, avenue du Maréchal de Lattre de Tassigny 60034, 54035 Nancy France
| | - Nadine Petitpain
- Centre Régional de Pharmacovigilance; CHRU de Nancy; Hôpital Central; 29, avenue du Maréchal de Lattre de Tassigny 60034, 54035 Nancy France
| | - Pierre Gillet
- Centre Régional de Pharmacovigilance; CHRU de Nancy; Hôpital Central; 29, avenue du Maréchal de Lattre de Tassigny 60034, 54035 Nancy France
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17
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McNulty CMG, Park MA. Delayed Cutaneous Hypersensitivity Reactions to Antibiotics: Management with Desensitization. Immunol Allergy Clin North Am 2017; 37:751-760. [PMID: 28965638 DOI: 10.1016/j.iac.2017.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Successful desensitization to mild to moderate delayed cutaneous adverse reaction to antibiotics has been described in a limited number of antibiotics and found to be safe. However, there are ample opportunities to standardize protocols for delayed cutaneous adverse reactions to antibiotics.
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Affiliation(s)
- Caitlin M G McNulty
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Miguel A Park
- Division of Allergic Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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18
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Abstract
This chapter provides an overview of infectious syndromes, pathogens, and diagnostic testing modalities for central nervous system infections in the immunocompromised host.
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19
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Ni Lochlainn M, Gooi HC, Ogese MO, Naisbitt DJ, Jafar-Mohammadi B. Trimethoprim-induced aseptic meningism. Br J Hosp Med (Lond) 2017; 78:108-109. [PMID: 28165786 DOI: 10.12968/hmed.2017.78.2.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mary Ni Lochlainn
- Foundation Doctor, Department of Geriatric Medicine, King's College Hospital, London SE5 9RS
| | - Hock C Gooi
- Consultant, Department of Immunology, King's College Hospital, London
| | - Monday O Ogese
- Post-doctoral Research Associate, Pathology Sciences, Drug Safety and Metabolism, AstraZeneca R&D, Cambridge Science Park, Cambridge
| | - Dean J Naisbitt
- Reader, Department of Pharmacology, University of Liverpool, Liverpool
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20
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A Rare Complication of Trimethoprim-Sulfamethoxazole: Drug Induced Aseptic Meningitis. Case Rep Infect Dis 2016; 2016:3879406. [PMID: 27579194 PMCID: PMC4992527 DOI: 10.1155/2016/3879406] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022] Open
Abstract
Drug induced aseptic meningitis is a rare but challenging diagnosis, most commonly reported with nonsteroidal anti-inflammatory drugs and antibiotics. Trimethoprim/sulfamethoxazole is a sulfonamide that is widely used in clinical practice for the treatment and prophylaxis of various infections. Drug induced aseptic meningitis, when seen with trimethoprim/sulfamethoxazole, occurs predominantly in patients with some degree of immune compromise and is less commonly seen in immune competent individuals. The patient often exhibits the classic symptoms of meningitis. Early diagnosis is important, since the cessation of the antibiotic leads to rapid clinical improvement. Trimethoprim/sulfamethoxazole induced aseptic meningitis has been underreported to FDA/MED-WATCH program. Here we report two cases of trimethoprim/sulfamethoxazole: an immune competent individual and immune compromised individual, both of which presented with signs of meningitis and a negative infectious workup. Trimethoprim/sulfamethoxazole is an uncommon and mysterious adverse reaction to a commonly used antibiotic. It should be considered in the differential diagnosis of patients presenting with acute signs and symptoms of meningitis especially after infectious causes have been ruled out.
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21
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Scotch AH, Budavari AI. 68-Year-Old Woman With Fever, Headache, Bicytopenia, and Transaminitis. Mayo Clin Proc 2016; 91:941-5. [PMID: 27140540 DOI: 10.1016/j.mayocp.2016.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/24/2016] [Accepted: 02/04/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Allison H Scotch
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Phoenix, AZ
| | - Adriane I Budavari
- Advisor to resident and Consultant in Hospital Internal Medicine, Mayo Clinic, Phoenix, AZ.
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22
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Abstract
Drug-associated headache is a quite common phenomenon, e.g. as a side effect of distinct substances such as nitric oxide or as a result of medication overuse of analgesic drugs. A different drug-associated headache entity is headache in drug-induced aseptic meningitis (DIAM). This is a rare disorder and only described in few case reports or smaller case series. One of the main clinical features of DIAM despite fever is headache. Based on the literature, no typical or even pathognomonical clinical presentation of this headache entity can be described. Sometimes, migrainous features might be present, and treatment response to triptans was reported in single case reports. Headache in DIAM seems to be emerging from sterile meningeal inflammation, which is suggested to represent the underlying pathology in DIAM. Headache in DIAM usually ceases when treated sufficiently, mainly through termination or withdrawal of the causing agent. Migraine as a predisposing factor of DIAM has been discussed previously but remains unproven.
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Affiliation(s)
- Dagny Holle
- Department of Neurology, University of Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Germany,
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