ro13-9904 and Meningitis--Viral

We report what we believe to be the first two cases of acute interstitial nephritis associated with vancomycin and ceftriaxone therapy in adults. A 40-year-old man with a medical history of traumatic brain injury and tonic-clonic seizure disorder was admitted to the hospital with a seizure episode and temperature of 103 degrees F. He was administered ceftriaxone, vancomycin, and acyclovir for suspected bacterial and/or viral meningitis. On day 4, the patient was noted to have diffuse erythematous plaques on the neck, chest, arms, abdomen, and back, as well as an elevated serum creatinine level of 3.1 mg/dl (baseline 0.9 mg/dl) and an elevated eosinophil count (6%). Dermatology and renal consultations were obtained, and a diagnosis of suspected acute interstitial nephritis was made. After a 3-day course of antibiotic treatment (day 4 of hospitalization), all antibiotics were discontinued and topical triamcinolone 0.1% ointment and hydrocortisone 2.5% cream were begun for the rash. The patient was discharged 5 days later with improvement in the rash, serum creatinine level (1.0 mg/dl), and eosinophil count (0.9%). A 59-year-old woman with a medical history of diabetes mellitus was admitted to the hospital with a serum creatinine level of 3.7 mg/dl, eosinophil count of 8.4%, and fractional excretion of sodium of 2.94%. The patient had been receiving treatment with vancomycin and ceftriaxone for osteomyelitis for 28 days before this hospital admission. Her baseline serum creatinine level (before antibiotic therapy) was 1.0 mg/dl. Renal consultation was obtained, and a diagnosis of probable acute interstitial nephritis was made. Ceftriaxone and vancomycin were discontinued, and her serum creatinine level gradually decreased to 3.3 mg/dl and then further to 1.5 mg/dl over the next 3 months. Use of the Naranjo adverse drug reaction probability scale revealed that the adverse reaction was possible in the first case and probable in the second case. Health care professionals need to be cognizant that drug-induced acute interstitial nephritis can be associated with concomitant administration of ceftriaxone and vancomycin therapy. Early detection of this rare adverse reaction is paramount in order to prevent acute renal insufficiency.

Topics: Acute Disease; Acyclovir; Adult; Anti-Bacterial Agents; Antiviral Agents; Ceftriaxone; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Male; Meningitis, Bacterial; Meningitis, Viral; Middle Aged; Nephritis, Interstitial; Vancomycin

A previously well 11-month-old infant presented with lethargy, a blanching rash, vomiting and diarrhoea. She was diagnosed with suspected gastroenteritis and discharged. The patient deteriorated and re-presented 24 h later with lumbar puncture (LP) confirming Neisseria meningitidis. Following an initial good response to ceftriaxone, the patient then developed a blistering facial rash on day 3 for which topical aciclovir was started with no improvement. She subsequently developed fever and redeveloped a rising C reactive protein (CRP). A CT of the head on day 6 was normal, however a repeat LP on day 7 showed persistently raised cerebrospinal fluid (CSF), white cell count (WCC), high proteins and low CSF glucose. A CSF viral PCR confirmed concurrent herpes simplex virus (HSV) type 1 for which parenteral aciclovir was started. The patient responded well to bacterial and viral anti-infective treatments and was subsequently discharged on day 16 with no neurological sequelae.

Topics: Acyclovir; Anti-Bacterial Agents; Antiviral Agents; Ceftriaxone; Diagnosis, Differential; Drug Therapy, Combination; Female; Herpes Simplex; Humans; Immunocompetence; Infant; Meningitis, Meningococcal; Meningitis, Viral; Neisseria meningitidis; Sepsis; Simplexvirus

A 69-year-old man was admitted to our hospital with severe headache, recurrent episodes of fever and deterioration of general health. He returned from a vacation in Tuscany (Italy) a few days before admission. Physical examination revealed slight nuchal rigidity and an elevated body temperature of 37.8 C but was otherwise unremarkable.. Differential blood count showed a lymphocytopenia. Other abnormal laboratory findings included an elevated blood sedimentation rate and a slightly increased C-reactive protein value. Abdominal sonography demonstrated a marginally enlarged spleen.. A lumbar puncture was performed. Cerebrospinal fluid analysis revealed a lymphocytic meningitis. Serological examination of a blood sample showed specific IgM-antibodies against sandfly fever Naples virus (SFNV), subtype Toscana virus (TOSV). After this diagnosis had been made initially instituted intravenous administration of antibiotics and antiviral medication were discontinued. The patient's symptoms improved rapidly under symptomatic treatment. Slight headaches without episodes of fever persisted for a few weeks without residual neurological symptoms.. A history of travel should always be sought in patients with clinical signs for meningitis. Considering the increasing spread and incidence of SFNV and its subtype Toscana in mediterranean countries, such virus should be kept in mind when treating patients who present such symptoms after returning from those countries during the summer season.

Topics: Acyclovir; Aged; Antiviral Agents; Ceftriaxone; Diagnosis, Differential; Drug Therapy, Combination; Fever of Unknown Origin; Germany; Humans; Male; Meningitis, Viral; Phlebotomus Fever; Sandfly fever Naples virus; Travel

Topics: Adult; Antibodies, Viral; Ceftriaxone; Cranial Nerve Diseases; Diagnosis, Differential; Encephalitis Viruses, Tick-Borne; France; Humans; Immunoglobulin M; Lyme Disease; Male; Meningitis, Viral; Radiculopathy; Vestibulocochlear Nerve

Ampicillin and chloramphenicol have been used for initial empiric therapy of childhood meningitis since the mid-1970s. Problems associated with these drugs include the possibility of chloramphenicol-associated aplastic anemia and the existence of Hemophilus influenzae type b resistance to both ampicillin and chloramphenicol. Several second- and third-generation cephalosporins have been shown to be as effective as ampicillin and chloramphenicol in the treatment of childhood meningitis.

Topics: Adolescent; Ampicillin; Bone Marrow Diseases; Ceftriaxone; Cefuroxime; Cephalosporins; Child; Child, Preschool; Chloramphenicol; Haemophilus influenzae; Humans; Infant; Meningitis; Meningitis, Viral; Penicillin Resistance