trimethoprim--sulfamethoxazole-drug-combination and Brain-Neoplasms

We report a case of acute interstitial nephritis with associated nephrogenic diabetes insipidus in a patient treated with temozolomide and sulfamethoxazole-trimethoprim for glioblastoma multiforme. Kidney biopsy demonstrated focal tubulointerstitial change with tubular dilatation, epithelial change and interstitial inflammation. The patient's kidney function improved with cessation of sulfamethoxazole-trimethoprim and treatment with hydrochlorothiazide for nephrogenic diabetes insipidus. Recommencement of temozolomide did not result in further deterioration in kidney function. In this case report, we discuss the novel association between sulfamethoxazole-trimethoprim-induced acute interstitial nephritis and nephrogenic diabetes insipidus, and suggest possible mechanisms involved.

Topics: Acute Kidney Injury; Anti-Bacterial Agents; Antineoplastic Agents, Alkylating; Brain Neoplasms; Diabetes Insipidus, Nephrogenic; Glioblastoma; Humans; Hydrochlorothiazide; Kidney Function Tests; Male; Middle Aged; Nephritis, Interstitial; Sodium Chloride Symporter Inhibitors; Temozolomide; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

This report presents the case of a 67-year-old woman affected by glioblastoma. After a few days of adjuvant therapy with temozolomide and prophylaxis with trimetrophin-sulfamethoxazolo to prevent Pneumocystis Jiroveci, she had progressive and rapid worsening of symptoms with weakness, dyspnea and orthopnea. She had peripheral edema and proximal hyposthenia of the lower limbs. Chest CT showed bilateral ground-glass opacities and laboratory exams revealed hypoxemia and hypocapnia, an initial reduction in platelet and white blood cells, and an elevation of LDH, AST, ALT, and active urinary sediment. Blood cultures, bronchoalveolar lavage (BAL) data and transbronchial biopsy showed no infections, and in particular no evidence of Pneumocystis Jiroveci pneumonia. Histological examination revealed a typical pattern of AIP. She was treated with broad-spectrum antibiotics and high-dose steroids. The symptoms worsened and respiratory failure required mechanical ventilation. The pneumonia was not responsive to medical or invasive care. She died after ten days of hospitalization. At present very little can be found in the literature about lung toxicity caused by temozolomide. This case can be added as a new report describing this risk. The combination therapy with temozolamide and trimetophin-sulfamethoxazolo could have a synergistic action inducing various forms of pulmonary toxicity. ESTABLISHED FACTS: Acute interstitial pneumonia is a common manifestation of lung toxicity caused by drugs. The clinical course is favorable with a good response to corticosteroids. NOVEL INSIGHT: This is the first fatal case of lung toxicity caused by Temozolomide. Clinicians must be aware that a combination therapy including trimetophin-sulfamethoxazolo could have a synergistic action in inducing pulmonary toxicity.

Topics: Aged; Antineoplastic Agents, Alkylating; Blood Gas Analysis; Brain Neoplasms; Bronchoalveolar Lavage Fluid; Dacarbazine; Electrocardiography; Fatal Outcome; Female; Glioblastoma; Humans; Lung; Lung Diseases, Interstitial; Physical Examination; Pneumocystis carinii; Pneumonia, Pneumocystis; Temozolomide; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Aged; Anti-Bacterial Agents; Antineoplastic Combined Chemotherapy Protocols; Brain Neoplasms; Carcinoma, Small Cell; Ceftriaxone; Cisplatin; Combined Modality Therapy; Cranial Irradiation; Etoposide; Fatal Outcome; Female; Humans; Immunocompromised Host; Lung Neoplasms; Opportunistic Infections; Pneumonia, Pneumocystis; Pneumonia, Staphylococcal; Staphylococcus aureus; Trimethoprim, Sulfamethoxazole Drug Combination

Temozolomide (TMZ) is a cytotoxic agent of the imidazotetrazine class, chemically related to dacarbazine. Its use poses higher risks of lymphopenia and opportunistic infections. Prophylaxis for Pneumocystis jiroveci must be considered up to 12 months after treatment discontinuation. The due literature (MEDLINE) makes no mention of a possible connection between the use of TMZ and tuberculosis (TB). A female patient, aged 59, featuring glioblastoma multiforme and having undergone solely a brain biopsy, was submitted to TMZ along with radiotherapy. After the first TMZ maintenance cycle, the referred patient was admitted displaying a background of a 40-day afternoon fever and productive coughing. She was thus submitted to a bronchoscopy and LBA, which resulted BAAR 1+/4+. TMZ was then suspended, and rifampicin, isoniazid, and pyrazinamide introduced. Considerations on prophylaxis with isoniazide in cancer patients are long-lived and scarce. Some subgroups are likely to benefit from the prophylactic administration of isoniazide during TMZ treatment, such as those patients under high doses of corticoids, patients with past medical history of TB, the malnourished, patients from endemic regions, and patients with highly reactive tuberculinic tests. That, nevertheless, must not restrict the administration of TMZ, but, rather, stand for a warning about its possible toxicity, and thus mitigate complications.

Topics: Anti-Infective Agents; Anti-Inflammatory Agents; Anti-Ulcer Agents; Antibiotics, Antitubercular; Anticholesteremic Agents; Anticonvulsants; Antineoplastic Agents, Alkylating; Atorvastatin; Brain Neoplasms; Combined Modality Therapy; Cyclosporine; Dacarbazine; Dexamethasone; Female; Fluoxetine; Glioblastoma; Heptanoic Acids; Humans; Immunosuppressive Agents; Isoniazid; Middle Aged; Omeprazole; Phenobarbital; Prednisone; Pyrazinamide; Pyrroles; Radiotherapy; Red-Cell Aplasia, Pure; Rifampin; Temozolomide; Trimethoprim, Sulfamethoxazole Drug Combination; Tuberculosis, Pulmonary

Isolated Whipple disease of the central nervous system is a rare occurrence. Migratory arthralgias and gastrointestinal problems, including malabsorption, abdominal pain, diarrhea, and weight loss, are common presenting symptoms.. For those patients with systemic signs and symptoms of Whipple disease, 6% to 43% will have clinically manifested CNS involvement that may include alterations in personality, ataxia, and dementia. We report our experience with a patient, who was successfully treated for Whipple disease 12 years prior to presentation and had a magnetic resonance image of the brain that revealed two solitary lesions resembling a tumor upon presentation.

Topics: Anti-Infective Agents; Brain Neoplasms; Chronic Disease; Consciousness Disorders; Diagnosis, Differential; Diagnostic Errors; Encephalitis; Headache; Humans; Hypothalamus; Magnetic Resonance Imaging; Male; Middle Aged; Neurosurgical Procedures; Temporal Lobe; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Tropheryma; Whipple Disease

We report a 62-year-old woman presenting with nocardia brain abscess that mimics metastatic brain tumor. Six months before admission to our hospital, she presented with persistent hemoptysis, and a friable endobronchial mass was detected at another hospital. However, a definite diagnosis had not been made, and then she presented with hemianopia. Her laboratory analysis results showed that she had no immunological abnormalities. T1-weighted magnetic resonance images of the brain with Gd-DTPA revealed hyperintensive multiple masses with surrounding edema. We suspected this case as metastatic brain tumor of unknown origin, and the patient underwent biopsy of the supraclavicular lymph node. Histopathology results indicated abscess, and gram staining of material obtained from the abscess showed Gram-variable rods, which were determined upon culture as acid-fast Gram-positive branching rods and identified as Nocardia asteroides. Accordingly, we diagnosed the patient as having nocardia brain abscess, and she was treated with an oral antibiotic (TMP-SMX). Four months later, the abscesses disappeared. The patient recovered after prolonged TMP-SMX therapy with no recurrence in over 9 months.

Topics: Administration, Oral; Anti-Infective Agents; Brain Abscess; Brain Neoplasms; Diagnosis, Differential; Female; Humans; Middle Aged; Nocardia asteroides; Nocardia Infections; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardia asteroides cerebral abscesses are rare but challenging intracranial lesions. Early diagnosis, institution of appropriate antimicrobial therapy, lack of underlying systemic disease and limited intracranial disease are recognized factors leading to good outcome. However, the optimal treatment approach has not been established and nocardial brain abscesses have been managed either conservatively, with steroetactic aspirations or with open craniotomy and enucleation. We present three cases of Nocardia asteroides cerebral abscesses cured only after neurosurgical enucleation, and discuss the current management alternatives and conclude that a more aggressive approach than that currently preferred for this entity may be more effective.

Topics: Adult; Aged; Amikacin; Anti-Bacterial Agents; Brain Abscess; Brain Neoplasms; Cefotaxime; Diagnosis, Differential; Drug Therapy, Combination; Humans; Imipenem; Magnetic Resonance Imaging; Male; Nocardia asteroides; Nocardia Infections; Sulfadiazine; Tomography, X-Ray Computed; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Administration, Inhalation; Brain Neoplasms; Drug Therapy, Combination; Female; Humans; Infant; Methemoglobinemia; Neuroblastoma; Nitric Oxide; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Acute Disease; Adult; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Brain Neoplasms; Consciousness Disorders; Disease Susceptibility; Fatal Outcome; Hallucinations; Humans; Lymphoma, AIDS-Related; Male; Pneumonia, Pneumocystis; Psychoses, Substance-Induced; Sulfadiazine; Toxoplasmosis, Cerebral; Trimethoprim, Sulfamethoxazole Drug Combination

In France, where 70% of adults are latently infected by toxoplasma, from 20% to 40% of patients with AIDS developed toxoplasmic encephalitis until recently. The prophylactic use of drugs which are active against pneumocystis and toxoplasma has proven to be efficient. These drugs are trimethoprim-sulfamethoxazole or dapsone-pyrimethamine. With the extent of these primary prophylaxis, there is a decrease of risk of toxoplasma encephalitis; thus the rate of toxoplasma encephalitis among opportunistic infections has fallen off from 19% of the patients in 1988 to 6% in 1994, in the department of infectious diseases of the Pitié-Salpêtrière hospital. However, toxoplasmic abscesses occurring despite the prophylaxis are frequently slow growing lesions which can become huge with a moderate mass effect, mimicking the pattern of primary cerebral lymphoma. The rule of antitoxoplasmic trial treatment must be strictly followed, even under prophylaxis.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Antiprotozoal Agents; Brain Abscess; Brain Neoplasms; Chemoprevention; Dapsone; Diagnosis, Differential; Drug Combinations; Encephalitis; France; Humans; Lymphoma, AIDS-Related; Pyrimethamine; Toxoplasmosis, Cerebral; Trimethoprim, Sulfamethoxazole Drug Combination

All histologically documented episodes of Pneumocystis carinii pneumonia in adult patients with primary brain tumors treated at Memorial Sloan-Kettering Cancer Center, New York, NY, since 1981, were retrospectively reviewed. Pneumocystis carinii pneumonia was histologically documented 11 times in 10 patients. During the same 8-year interval, approximately 587 adults were seen at the center for a brain tumor, 90% of whom received ongoing therapy. Therefore, in at least 1.7% (10/587) of our patients with brain tumors, P carinii pneumonia developed. The median duration of dexamethasone therapy at the onset of P carinii pneumonia symptoms was 2.75 months. Symptoms began during tapering of steroid therapy in eight episodes. Bronchoscopy was diagnostic in the eight cases in which it was performed. Four episodes (40%) were fatal. Trimethoprim-sulfamethoxazole prophylaxis may be indicated in some patients with brain tumors, especially during tapering of steroid therapy.

Topics: Adult; Brain Neoplasms; Bronchoscopy; Dexamethasone; Humans; Opportunistic Infections; Pneumonia, Pneumocystis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination