trimethoprim--sulfamethoxazole-drug-combination and Anemia--Hemolytic

We present magnetic resonance imaging findings of a 5-year-old girl who had a rapidly installing hemolytic anemia crisis induced by trimethoprim-sulfomethoxazole, resulting in cerebral anoxia leading to permanent damage. Magnetic Resonance imaging revealed cortical laminar necrosis in arterial border zones in both cerebral hemispheres, ischemic changes in subcortical white matter of left cerebral hemisphere, and in the left putamen. Although cortical laminar necrosis is a classic entity in adulthood related to conditions of energy depletions, there are few reports available in children. A wide review of the literature is also presented.

Topics: Anemia, Hemolytic; Anti-Infective Agents; Arnold-Chiari Malformation; Brain Ischemia; Cerebral Cortex; Child, Preschool; Epilepsy, Tonic-Clonic; Female; Humans; Hypoxia, Brain; Magnetic Resonance Imaging; Necrosis; Putamen; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination

BACKGROUND Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that commonly occurs in immunocompromised patients, especially those with HIV. Early diagnosis and prompt treatment are important because PJP is a potentially life-threatening infection. However, the diagnosis of PJP in the early stage can be challenging due to various factors. Furthermore, the early presentation of PJP, which includes normal chest radiograph and examination findings along with the subacute presentation of PJP in patients with HIV, makes an early diagnosis of the disease even more challenging for doctors. CASE REPORT In this case report, we present the case of a 39-year-old man who had normal chest X-ray findings during the initial stage of his presentation. Coupled with non-disclosure of HIV status, these led to a delay in PJP diagnosis. The diagnosis of PJP with underlying HIV was later supported by the patient's clinical features, initial blood investigations, and presence of high-risk sexual activity. The diagnosis was confirmed when the PJP polymerase chain reaction test from the respiratory sample was positive. He was successfully treated with oral trimethoprim-sulfamethoxazole. However, he subsequently developed rare adverse effects of drug-induced immune hemolytic anemia, which was diagnosed based on the presence of hemolytic anemia and recent exposure to a new drug. Trimethoprim-sulfamethoxazole was promptly discontinued, which resulted in symptom improvement. CONCLUSIONS This case report aims to create awareness among primary care doctors to be vigilant of the PJP diagnosis and its nonspecific presentations as well as to the rare adverse effects of medications to treat PJP.

Topics: Adult; Anemia, Hemolytic; HIV Infections; Humans; Immunocompromised Host; Male; Pneumocystis carinii; Pneumonia, Pneumocystis; Radiography; Trimethoprim, Sulfamethoxazole Drug Combination

Dapsone may be used for Pneumocystis jirovecii pneumonia (PJP) prophylaxis in hematology patients receiving immunosuppressive therapy or after hematopoietic stem cell transplant (HSCT) in the setting of trimethoprim-sulfamethoxazole (TMP-SMX) adverse drug reaction (ADR) history. Dapsone-induced hematological toxicities such as oxidative hemolysis may limit use in these patients and modern assessments of dapsone allergy cross-reactivity in non-HIV patients with a sulfonamide allergy are largely absent. The aim of this single-centre, retrospective study was to describe dapsone usage in hematology patients requiring PJP prophylaxis, including HSCT recipients, over a 12-month period in terms of indications, incidence of dapsone-attributed oxidative hemolysis, and immune cross-reactivity in those previously labeled with a sulfonamide allergy, as well as describing potential opportunities for first-line TMP-SMX PJP prophylaxis reintroduction. Of 24 patients meeting the study inclusion criteria, 12 (50%) were receiving dapsone PJP prophylaxis post-HSCT. No cases of breakthrough PJP infection were noted. Sixteen patients (67%) were initiated on dapsone to avoid the perceived risk of further myelosuppression with TMP-SMX and five patients (21%) because of prior delayed immune-mediated allergy to TMP-SMX. None experienced rash with dapsone therapy. Six patients (25%) were successfully rechallenged on TMP-SMX, including one patient with prior TMP-SMX-associated rash. Four (17%) patients had confirmed oxidative hemolysis, all resulting in dapsone cessation. Dapsone PJP prophylaxis in hematology patients was effective and safe, with nonlife threatening dapsone-related hemolysis noted in a small number. An absence of sulfonamide allergy cross-reactivity was noted, suggesting greater TMP-SMX rechallenges or desensitization could be considered in those receiving dapsone.

Topics: Aged; Anemia, Hemolytic; Anti-Infective Agents; Antibiotic Prophylaxis; Dapsone; Female; Hematologic Neoplasms; Hematopoietic Stem Cell Transplantation; Hemolysis; Humans; Immunosuppression Therapy; Male; Middle Aged; Oxidative Stress; Pneumocystis carinii; Pneumonia, Pneumocystis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination

Drug-induced immune hemolytic anemia (DIIHA) and drug-induced immune thrombocytopenia (DIIT) are rare but dangerous complications of pharmacotherapy that may be underrecognized in hematopoietic stem cell transplant (HSCT) patients due to overlap of signs and symptoms with those of more common disease processes.. A 61-year-old woman with NK-cell deficiency and GATA-2-associated myelodysplastic syndrome, status post-recent allogeneic HSCT (Day +58), presented with 3 days of acute-onset severe back pain, muscle cramps, and increasingly dark urine. She was found to be anemic, thrombocytopenic, and in acute renal failure. On admission, the direct antiglobulin test was positive for complement (C3) only. After careful review of her medication list, the possibility of DIIHA was raised. She had started taking trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jiroveci pneumonia prophylaxis 24 days prior on a weekend dose schedule. Serologic tests on peripheral blood samples were performed using standard methods. Drug studies were performed at an immunohematology reference laboratory.. The patient's serum showed hemolysis of donor red blood cells in the presence of TMP-SMX and also TMP-SMX-induced platelet antibodies. The patient was treated with transfusions, hemodialysis, and immunosuppressive agents. Her clinical condition improved and she was discharged after 8 days in stable condition.. This case describes the first reported concurrent DIIHA and DIIT due to TMP-SMX-induced antibodies in an HSCT patient. DIIHA and DIIT can present a diagnostic challenge in the setting of intermittent medication dosing.

Topics: Anemia, Hemolytic; Blood Transfusion; Female; Humans; Immunosuppressive Agents; Middle Aged; Renal Dialysis; Thrombocytopenia; Transfusion Reaction; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

To report a case of hemolytic anemia in a patient who received trimethoprim/sulfamethoxazole (TMP-SMX) for a urinary tract infection (UTI).. A 47-year-old woman recently diagnosed with uncomplicated UTI received 3 doses of TMP-SMX. She developed yellowing of the skin and eyes, lethargy, mild abdominal pain, and dry mucous membranes. Laboratory testing demonstrated significant anemia with red blood cells (RBCs) of 1.99, hemoglobin (Hgb) of 6.3 g/dL, and hematocrit (Hct) of 18.1%. TMP-SMX was immediately discontinued. The patient was given methylprednisolone 60 mg intravenously (IV) followed by oral steroids and infused with 3 units of packed RBCs over the course of a 10-day inpatient admission. On discharge, the patient continued oral steroids. Outpatient follow-up indicated Hgb of 11.0 g/dL and Hct of 32.7%, 41 days after hospital discharge. Utilizing the Naranjo adverse drug reaction probability scale, there is a probable association between the patient's hemolytic anemia and TMP-SMX.. We report a case of hemolytic anemia resulting from the use of TMP-SMX. Although this is a rare adverse effect, clinicians should be aware of the signs and symptoms of hemolytic anemia, and so appropriate treatment can be administered should it occur.

Topics: Anemia, Hemolytic; Anti-Infective Agents, Urinary; Female; Humans; Middle Aged; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

Patients with HIV are at risk of both primary and secondary haematological disorders. We report two cases of patients with HIV and cryptococcal meningitis who developed severe haemolytic anaemia, thrombocytopenia, renal failure and lactic acidosis while on treatment with amphotericin B and co-trimoxazole.

Topics: Acidosis, Lactic; Adult; AIDS-Related Opportunistic Infections; Amphotericin B; Anemia, Hemolytic; Antifungal Agents; Cryptococcus neoformans; Drug Therapy, Combination; Female; Humans; Male; Meningitis, Cryptococcal; Renal Insufficiency; Thrombocytopenia; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

The case of a patient who developed aseptic meningitis, hemolytic anemia, hepatitis, and orthostatic hypotension simultaneously during treatment with trimethoprim-sulfamethoxazole is described.. A healthy 37-year-old African- American man was receiving treatment with trimethoprim-sulfamethoxazole double strength. This was the patient's first experience with trimethoprim- sulfamethoxazole, and he was not taking any other medications during the treatment period. He had been taking trimethoprim-sulfamethoxazole for approximately eight days when he revisited his family physician, complaining of headaches, dizziness, difficulty with speech, weakness, and itching on the trunk of his body and legs, where a maculopapular rash was noted. Orthostatic hypotension was also noted at that visit, with a standing blood pressure measurement of 95/80 mm Hg. Based on these findings and since the patient had no signs of infection, his physician instructed him to discontinue the drug. The patient was admitted to the emergency department of a local hospital within two days due to ongoing headache, elevated temperature, and nuchal rigidity, symptoms suggestive of meningitis. Because of the presence of hemolysis, the patient underwent testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency, for which he tested positive. The patient was discharged five days after admission and referred to a hematology clinic for follow-up. The patient has since returned to his routines of daily living and has reported no fatigue or other lingering adverse symptoms.. A 37-year-old African- American man with G6PD deficiency developed hemolytic anemia, hepatitis, orthostatic hypotension, and aseptic meningitis simultaneously after using trimethoprim-sulfamethoxazole.

Topics: Adult; Anemia, Hemolytic; Anti-Infective Agents, Urinary; Chemical and Drug Induced Liver Injury; Glucosephosphate Dehydrogenase Deficiency; Hemolysis; Humans; Hypotension, Orthostatic; Liver Function Tests; Male; Meningitis, Aseptic; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

A 10-year-old male with acute leukemia presented with post-chemotherapy anemia. During red cell transfusion, he developed hemoglobinuria. Transfusion reaction workup was negative. Drug-induced immune hemolytic anemia was suspected because of positive direct antiglobulin test, negative eluate, and microspherocytes on smear pre- and post-transfusion. Drug studies using the indirect antiglobulin test were strongly positive with trimethoprim and trimethoprim-sulfamethoxazole but negative with sulfamethoxazole. The patient recovered after discontinuing the drug, with no recurrence in 2 years. Other causes of anemia should be considered in patients with worse-than-expected anemia after chemotherapy. Furthermore, hemolysis during transfusion is not always a transfusion reaction.

Topics: Anemia, Hemolytic; Anti-Infective Agents, Urinary; Child; Diagnosis, Differential; Humans; Male; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Transfusion Reaction; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination

We report a case of Thrombotic Thrombocytopenic Purpura occurring as an allergic response to trimethoprim-sulfamethoxazole therapy (Bactrim, Septra) in a Jehovah's Witness patient. The patient presented with fulminant microangiopathic hemolytic anemia and thrombocytopenia within 48 hr of initiating therapy with trimethoprim-sulfamethoxazole. Other symptoms of drug hypersensitivity included nausea, vomiting, urticarial rash, and leukopenia. Because of her religious faith, the patient was supported without plasma therapy with use of intravenous immunoglobulin, steroids, rituximab, and erythropoietin.

Topics: Adult; Anemia, Hemolytic; Female; Humans; Jehovah's Witnesses; Purpura, Thrombotic Thrombocytopenic; Trimethoprim, Sulfamethoxazole Drug Combination

A 10-year-old, thoroughbred gelding was administered sulphonamide drugs during surgical treatment of guttural pouch mycosis. The horse became anemic and a diagnosis of immune-mediated hemolytic anemia was made after other causes of anemia had been ruled out. The anemia resolved after the drugs were withdrawn.

Topics: Anemia, Hemolytic; Animals; Anti-Infective Agents; Horse Diseases; Horses; Male; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Anemia, Hemolytic; Ethnicity; Favism; Female; France; Glucosephosphate Dehydrogenase Deficiency; Hemolysis; Humans; Infant; Italy; Jaundice; Male; Metabolic Diseases; Trimethoprim, Sulfamethoxazole Drug Combination; X Chromosome

A 27-year-old white woman developed Heinz-body hemolytic anemia following multiple courses of oral phenazopyridine and trimethoprim-sulfamethoxazole. Her diagnosis was supported by the finding of bite cells on peripheral blood smear. The patient's rapid recovery and reversal of abnormal laboratory parameters were consistent with an acquired hemolytic disorder. This case should sensitize the clinician to the development of drug-induced oxidative hemolysis, its clinical features, and its reversibility. It is also important that the clinician recognize those drugs capable of causing this disorder and appreciate the methods available to establish the diagnosis.

Topics: Administration, Oral; Adult; Aminopyridines; Anemia, Hemolytic; Drug Combinations; Drug Therapy, Combination; Female; Heinz Bodies; Humans; Phenazopyridine; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination