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Donnan M, Siemienowicz M, Tay HS, McLean C, Philpot S, Mason C, Snell G, Glaspole I, Stirling RG. Trimethoprim-sulfamethoxazole acute respiratory distress syndrome requiring lung transplantation. Respirol Case Rep 2024; 12:e01434. [PMID: 39015482 PMCID: PMC11250387 DOI: 10.1002/rcr2.1434] [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: 03/21/2024] [Accepted: 07/05/2024] [Indexed: 07/18/2024] Open
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) acute respiratory distress syndrome (ARDS) is a rare, but severe complication of a commonly prescribed antibiotic. TMP-SMX typically affects young, otherwise well patients with a specific human leukocyte antigen type (HLA-B*07:02 and HLA-C*07:02). The condition is poorly understood with a unique pathological appearance and mechanism that remains unclear. Mortality rate is greater than one third. We describe the case of a previously well 18-year-old woman treated with a prolonged course of TMP-SMX for a complex urinary tract infection who developed rapidly progressive respiratory failure requiring prolonged intensive care admission, extra-corporeal membranous oxygenation, and eventual lung transplantation. No targeted treatment exists, further research is required to better understand disease pathogenetic mechanisms and potential therapeutic interventions.
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Affiliation(s)
- Matthew Donnan
- Department of Respiratory MedicineAlfred HealthMelbourneVictoriaAustralia
| | - Miranda Siemienowicz
- Department of RadiologyAlfred HealthMelbourneVictoriaAustralia
- Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Hui Sien Tay
- Department of Anatomical PathologyAlfred HealthMelbourneVictoriaAustralia
| | - Catriona McLean
- Department of Anatomical PathologyAlfred HealthMelbourneVictoriaAustralia
| | - Steve Philpot
- Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
- Intensive Care UnitAlfred HealthMelbourneVictoriaAustralia
- Intensive Care UnitCabrini HealthMelbourneVictoriaAustralia
| | - Chris Mason
- Intensive Care UnitAlfred HealthMelbourneVictoriaAustralia
| | - Greg Snell
- Department of Respiratory MedicineAlfred HealthMelbourneVictoriaAustralia
- Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Ian Glaspole
- Department of Respiratory MedicineAlfred HealthMelbourneVictoriaAustralia
- Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | - Rob G. Stirling
- Department of Respiratory MedicineAlfred HealthMelbourneVictoriaAustralia
- Central Clinical School, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
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Miller J, Khan H, Mino-Kenudson M, Taylor M, Shih A, Goldman J. Definition and Clinical Evaluation for Trimethoprim-Sulfamethoxazole Severe Acute Respiratory Failure. Crit Care Med 2023; 51:e264-e268. [PMID: 37449964 PMCID: PMC10787807 DOI: 10.1097/ccm.0000000000006002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Trimethoprim-sulfamethoxazole (TMP-SMX)-associated severe acute respiratory distress syndrome (ARDS) has gone underrecognized. We propose the first disease definition and clinical evaluation for a novel adverse drug reaction (ADR) based on a series of recently identified rare cases of life-threatening ADRs. DESIGN A retrospective study was conducted. All medical records were evaluated. Available pathology samples were sent to Massachusetts General for clinical consultation. Blood samples from surviving patients were obtained and human leukocyte antigen (HLA) analysis was performed by the Children's Mercy Hospital Genomic Center and Vanderbilt University Medical Center. SETTING U.S. ICUs, 1996-2021. PATIENTS Nineteen young patients (10-37) were identified. Patients were previously healthy, with no preexisting pulmonary disease, no other cause for respiratory failure, and no chronic history of smoking/vaping. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Through our retrospective analysis, we analyzed clinical characteristics associated with TMP-SMX. Pathology samples were reviewed, and HLA analysis was performed on available samples by the study team or as standard of care at treatment hospitals in some cases. In 19 critically ill patients, we identified a pattern of severe respiratory failure requiring ICU admission, mechanical ventilation, and frequent extracorporeal membrane oxygenation use. We describe the first three-part clinical diagnosis and evaluation strategy: 1) Clinical definition: Unexplained severe respiratory failure in a patient receiving greater than or equal to 6 days of TMP-SMX at treatment dose (not prophylaxis). TMP-SMX ARDS is a diagnosis of exclusion. 2) Genetic association: One hundred percent of currently available TMP-SMX respiratory failure patient genomic data, ( n = 11) have been carriers of both HLA-B*07:02 and HLA-C*07:02 alleles. HLA allele evaluation could be considered in patients with suspected TMP-SMX respiratory failure. 3) Lung pathology: A unique pulmonary pathologic pattern of lung injury termed diffuse alveolar injury with delayed epithelialization has been observed in these cases. In suspected cases, surgical lung biopsy early in the clinical course could be considered. CONCLUSIONS TMP-SMX is a commonly prescribed antibiotic. However, we find it imperative to share this relatively rare but life-threatening condition with clinicians as the mortality rate approaches 40%.
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Affiliation(s)
- Jenna Miller
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO
| | - Hason Khan
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO
- Kansas City University of Medicine and Biosciences, Kansas City, MO
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Martin Taylor
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Angela Shih
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Jennifer Goldman
- Department of Pediatrics, Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO
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Huang P, Kam KQ, Tan YH, Lee MP, Chan SWB, Lee JH. Trimethoprim-sulfamethoxazole-induced lung injury: a case report. Transl Pediatr 2023; 12:2062-2073. [PMID: 38130590 PMCID: PMC10730970 DOI: 10.21037/tp-23-383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/22/2023] [Indexed: 12/23/2023] Open
Abstract
Background Trimethoprim-sulfamethoxazole (TMP-SMX) is a commonly used antibiotic. While cutaneous adverse drug reactions associated with TMP-SMX are commonly recognized, lung toxicity induced by TMP-SMX is an unusual condition, with scattered reports of hypersensitivity pneumonitis, acute fibrinous organizing pneumonia, interstitial lung disease and acute respiratory distress syndrome. Reports of TMP-SMX-associated drug-induced lung injury (DLI) are rare in the pediatric population and its pathogenesis is not well understood. Diagnosis of DLI remains a challenge, given the wide range of clinical presentations that overlap with other conditions and the lack of diagnostic tests. In this report, we describe a case of TMP-SMX-induced lung injury in an eight-year-old child. Case Description An eight-year-old girl presented in respiratory failure with acute symptoms of shortness of breath, fever, maculopapular rash and vomiting. This was associated with pneumonitis, pneumothorax, pneumomediastinum and subcutaneous emphysema on imaging. She had been on 25 days of TMP-SMX for treatment of Group D Salmonella bacteremia and osteomyelitis that was diagnosed prior to this current presentation. TMP-SMX was discontinued on admission due to concerns of possible drug reaction. Extensive infective, autoimmune and immunologic workup did not reveal the cause of the respiratory failure. Considering the absence of an alternative explanation for her clinical presentation and similarities in clinical courses to other reported cases, she was eventually diagnosed with TMP-SMX-associated DLI. She received a course of corticosteroids with subsequent clinical improvement and was weaned off home oxygen therapy a few months after her discharge from the hospital. Conclusions Diagnosis of DLI can be challenging. The early identification of DLI and discontinuation of culprit drug is essential in its management. Further understanding of the underlying pathophysiology and risk factors for TMP-SMX-associated DLI is required.
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Affiliation(s)
- Peiqi Huang
- Department of Neonatology, KK Women’s & Children’s Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kai-Qian Kam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Infectious Disease Service, Department of Pediatrics, KK Women’s & Children’s Hospital, Singapore, Singapore
- SingHealth Duke-NUS Pediatrics Academic Clinical Program (ACP), Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Imperial College London, Nanyang Technological University, Singapore, Singapore
| | - Yi Hua Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- SingHealth Duke-NUS Pediatrics Academic Clinical Program (ACP), Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Imperial College London, Nanyang Technological University, Singapore, Singapore
- Respiratory Medicine Service, Department of Pediatrics, KK Women’s & Children’s Hospital, Singapore, Singapore
| | - May Ping Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- SingHealth Duke-NUS Pediatrics Academic Clinical Program (ACP), Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Imperial College London, Nanyang Technological University, Singapore, Singapore
- Allergy Service, Department of Pediatrics, KK Women’s & Children’s Hospital, Singapore, Singapore
| | - Su-Wan Bianca Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- SingHealth Duke-NUS Pediatrics Academic Clinical Program (ACP), Duke-NUS Medical School, Singapore, Singapore
- Lee Kong Chian School of Medicine, Imperial College London, Nanyang Technological University, Singapore, Singapore
- Rheumatology and Immunology Service, Department of Pediatric Subspecialties, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Jan Hau Lee
- SingHealth Duke-NUS Pediatrics Academic Clinical Program (ACP), Duke-NUS Medical School, Singapore, Singapore
- Children’s Intensive Care Unit, KK Women’s & Children’s Hospital, Singapore, Singapore
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