trimethoprim--sulfamethoxazole-drug-combination and Lupus-Erythematosus--Systemic

Severe systemic reactions resembling septic shock have been described following trimethoprim-sulfamethoxazole (TMP-SMX) administration. Nearly all cases described in the literature occurred in HIV-infected patients.. We present a 42-year-old woman with a history of systemic lupus erythematosus (SLE) who was admitted to the Intensive Care Unit (ICU) twice with fever and circulatory shock after taking a dose of TMP-SMX 800-160 mg. She had no respiratory distress, urticarial rash or eosinophilia on presentation. Infectious workup during both admissions was negative and treatment with antibiotics, steroids and vasopressors was de-escalated with clinical improvement. She was found to be HIV negative, however, labs revealed a low CD4+ count.. TMP-SMX can rarely result in a severe, non-anaphylactic circulatory shock; if initially unrecognized, patients may undergo repeat drug exposure with an associated high morbidity risk. While more commonly reported in HIV individuals, this case demonstrates that TMP-SMX related circulatory shock can occur in a HIV negative patient.

Topics: Adult; Anti-Bacterial Agents; Female; HIV Infections; Humans; Lupus Erythematosus, Systemic; Shock; Trimethoprim, Sulfamethoxazole Drug Combination

Use of cyclophosphamide in systemic lupus erythematosus (SLE) is associated with Pneumocystis jirovecii pneumonia (PJP) that has substantial morbidity and mortality. However, the frequency of PJP in these patients is unknown and there are no guidelines for prophylactic antibiotics.. The objectives of this study are to evaluate the frequency of PJP and the need for prophylactic antibiotics in these patients.. We estimated incidence of PJP and use of prophylactic trimethoprim-sulfamethoxazole in these patients by a literature search and an e-mail survey of US rheumatologists.. We identified 18 manuscripts dealing with infections in SLE patients treated with cyclophosphamide. In these manuscripts, 121 cases of PJP were identified in 76,156 SLE patients with a frequency of 15.88 per 10,000 patients.Of 264 rheumatologists surveyed, 133 (50.37%) were using prophylactic antibiotics in these patients. One hundred thirty-one (49.63%) respondents did not use prophylactic antibiotics. 5,174 SLE patients received cyclophosphamide in last 5 years with 19.6 +/- 30.6 (mean +/- SD) patients per rheumatologist. 32 cases of PJP were reported. The total cumulative experience of 264 rheumatologists was 4742 years [(17.96 +/- 10.35) (mean +/- SD)] with a PJP rate of 67.48 per 10,000 years of practice.. The frequency of PJP in SLE patients on cyclophosphamide remains low (0.1588%). Therefore, routine use of trimethoprim-sulfamethoxazole for PJP prophylaxis in SLE patients on cyclophosphamide does not appear to be substantiated by this study, except in those with elevated risk, ie, with severe leucopenia, lymphopenia, high dose corticosteroids, hypocomplementemia, active renal disease, and higher mean SLEDAI score. There is a need for consensus guidelines addressing prophylactic antibiotics in these patients.

Topics: Anti-Infective Agents; Antibiotic Prophylaxis; Antirheumatic Agents; Comorbidity; Cyclophosphamide; Health Care Surveys; Humans; Lupus Erythematosus, Systemic; Pneumocystis carinii; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination

To investigate the clinical features and prognosis of nocardiosis complicated by connective tissue diseases (CTDs).. We examined patients with CTDs who were diagnosed with nocardiosis from October 2004 to 2019. We retrospectively investigated patient characteristics and therapeutic outcomes. We then performed a comparison between survivors and non-survivors.. Fourteen patients were examined. Underlying CTDs were systemic lupus erythematosus (28.6%), vasculitis syndrome (28.6%), rheumatoid arthritis (21.4%), adult Still disease (14.3%) and dermatomyositis (7.1%). Infected organs were lung (85.7%), brain (42.9%), skin/cutaneous lesions (28.6%) and muscle (7.1%). Disseminated infections were seen in nine patients (64.3%). At the onset of nocardiosis, all patients were given prednisolone (23.2 ± 11.9 mg/day). Only two patients (14.3%) were given TMP-SMX for prophylaxis of pneumocystis pneumonia. Relapse occurred in one patient (7.1%) and four patients (28.6%) died from nocardiosis for a cumulative survival rate at 52 weeks of 76.9%. In a comparison of survivors (71.4%) and non-survivors (28.6%), cutaneous lesions were significantly more frequent in the latter (10 vs 75%,. Cutaneous lesions as a result of dissemination might be a risk factor for nocardiosis mortality in patients with CTDs.

Topics: Adult; Anti-Bacterial Agents; Arthritis, Rheumatoid; Female; Humans; Lupus Erythematosus, Systemic; Male; Middle Aged; Nocardia Infections; Prognosis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination; Vasculitis

Prophylactic trimethoprim-sulfamethoxazole (TMP-SMX) prevents pneumocystis jirovecii infection in SLE on immunosuppression. Its role in preventing other major infections in immuno suppressed SLE patients is unknown.. A non-concurrent cohort study was conducted on patients of SLE fulfilling SLICC and/or ACR 1997 criteria, who received tapering dose of steroid starting with ≥0.5 mg/kg/day of prednisolone or equivalent dose of deflazacort and mycophenolate mofetil ≥1 g/day (or equivalent dose of mycophenolate sodium) at least for the preceding 1 year. Interviewing patients & documenting relevant data from hospital electronic Medical records (EMR), followed by comparison of Incidence densities of major infections between those on prophylactic Trimethoprim 160 mg + Sulfamethoxazole 800 mg and those not on it, was done by student 't' test. Multivariate logistic regression was performed for independent risk of any major infection between the two groups.. Of 228 patients, 162 did not receive TMP-SMX prophylaxis, and 66 had received. The incidence density of major infection was found to be significantly lower in TMP-SMX group (1.25 per 100 person year) as compared to those not on TMP-SMX group (11.201 per 100 person year); P < 0.001 (95% CI 0.027 - 0.449) and odds ratio of 0.03 (CI 0 - 0.24).. Cotrimoxazole prophylaxis in SLE patients on immunosuppression prevents major infections.

Topics: Adolescent; Adult; Aged; Female; Humans; Immunosuppressive Agents; Incidence; Infection Control; Infections; Logistic Models; Lupus Erythematosus, Systemic; Male; Middle Aged; Multivariate Analysis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

Trimethoprim-sulfamethoxazole (TMP-SMX), a prophylactic agent against pneumocystis pneumonia (PCP), can cause adverse drug reactions (ADRs), particularly in patients with systemic lupus erythematosus (SLE). However, the risk factors for ADRs remain unclear. Thus, we sought to examine the prevalence of TMP-SMX-related ADRs in patients with SLE and identify specific risk factors for ADR development in these patients.. We retrospectively reviewed data from patients with connective tissue disease (CTD) who were administered TMP-SMX as a PCP prophylactic. The prevalence of ADRs was compared between patients with SLE and those with other CTDs. Univariate and multivariate analyses were conducted to identify risk factors for ADRs in patients with SLE.. Of the 424 patients with CTD included in our study (SLE, n = 162; other CTDs, n = 262), 22 with SLE (13.6%) developed ADRs, and this rate was significantly higher than that observed in patients with non-SLE CTDs (n = 18 [6.9%], p = 0.033). In patients with SLE, univariate analyses revealed direct associations of ADRs with anti-Sm (p < 0.001), anti-RNP (p = 0.02), and anti-Ro/SS-A antibodies (p = 0.042). Multivariate analysis identified a significant association between anti-Sm antibody levels and the development of ADRs (adjusted odds ratio 5.27, 95% confidence interval 1.80-15.40, p = 0.002).. Patients with SLE who are prophylactically administered TMP-SMX are at high risk of ADRs. Among these patients, those who display a positive anti-Sm antibody should be carefully monitored for ADRs.

Topics: Connective Tissue Diseases; Drug-Related Side Effects and Adverse Reactions; Humans; Lupus Erythematosus, Systemic; Pneumonia, Pneumocystis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Anti-Bacterial Agents; Female; Humans; Lupus Erythematosus, Systemic; Trimethoprim, Sulfamethoxazole Drug Combination

This study aimed to investigate the risk factors of hydroxychloroquine (HCQ)-induced hypersensitivity in patients with systemic lupus erythematosus (SLE) and to propose a simple dose-escalation regimen in cases of mild HCQ-induced hypersensitivity.. We identified patients with SLE who started HCQ between 2009 and 2018 and cases of HCQ-induced hypersensitivity by reviewing the electronic medical charts. A simple dose-escalation regimen, starting at 40 mg/day with weekly increments of 40 mg/day to 200 mg/day, was used in patients with HCQ-induced hypersensitivity who did not require hospitalization or systemic steroid therapy. We then compared the clinical parameters of patients with and without HCQ-induced hypersensitivity and evaluated the success of our dose-escalation regimen.. We enrolled 302 patients with SLE and identified 25 cases of HCQ-induced eruption (8.3%). The mean Naranjo score of these patients was 5.1 ± 1.4 (min 3, max 8), and all 25 patients received a 'possible' (9) or 'probable' (16) score. A mild, generalized, maculopapular rash occurred in 24 patients, and urticaria occurred in one patient at 24 days (interquartile range 15-40 days) after the start of treatment. The proportion of cyclophosphamide use, glucocorticoid consisting of prednisolone 20 mg/day or more, and initiation of SMX-TMP within 28 days were higher in patients with skin eruptions. On multivariate analysis, only cyclophosphamide use was identified as a risk factor of HCQ-induced hypersensitivity (odds ratio = 12.3 (95% confidential interval 1.4-14.3)). Thirteen of the 14 patients on the dose-escalation regimen (92.9%) tolerated continued HCQ treatment. One patient re-experienced eruptions on day 10 day after starting HCQ.. Mild late reactions are common in HCQ-induced hypersensitivity. A simpler dose-escalation regimen enables safe and easier reintroduction of HCQ but should not be applied to patients with immediate reactions or moderate late reactions.

Topics: Adult; Anti-Bacterial Agents; Antirheumatic Agents; Clinical Protocols; Cyclophosphamide; Dose-Response Relationship, Drug; Drug Hypersensitivity; Drug Therapy, Combination; Female; Glucocorticoids; Humans; Hydroxychloroquine; Immunosuppressive Agents; Japan; Lupus Erythematosus, Systemic; Male; Middle Aged; Prednisolone; Retrospective Studies; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination

Systemic lupus erythematosus (SLE) complicated with Pneumocystis jiroveci pneumonia (PCP) is a clinical complex with unsatisfying treatment efficacy and poor prognosis which is difficult to be diagnosed at early stage. The present study aimed to investigate the clinical features of SLE with PCP, recognize the early onset indicating factors, and evaluate the treatment efficacy of combined caspofungin and trimethoprim/sulfamethoxazole (coSMZ).We reviewed data of 9 patients admitted with SLE-PCP and treated with caspofungin combined with coSMZ at Tangshan Gongren Hospital from January 2013 to December 2017. Patients' clinical manifestation and laboratory data [leucocyte, lymphocyte, cluster of differentiation 4 (CD4)T cell, lactate dehydrogenase (LDH), blood gas, etc] were compared before and after treatments. And the early onset factors of SLE-PCP, treatment efficacy of combined caspofungin and CoSMZ were analyzed.Among these 9 patients, 8 patients suffered renal impairment, and all of them had been taking prednisone in the past 3 months at an average dose of 29.4 ± 13.6 mg/day. In addition, they had taken at least one kind of immunosuppressants. Laboratory data (leucocyte, lymphocyte, CD4T cell, PaO2, LDH) were remarkably abnormal at hospital admission, but they were improved significantly after 2 weeks of treatment, which is also statistically significant (P < .05), except that leukocyte had no significance change to the value at admission (P = .973). In addition, none of the studied patients died.The results of the study indicated that long-term use of glucocorticoids and immunosuppressants, low CD4T cell count, and renal impairment are the early-onset factors for SLE-PCP, caspofungin, when combined with CoSMZ, it could be a promising and effective strategy to treat SLE with PCP.

Topics: Adult; Anti-Infective Agents; Caspofungin; Drug Therapy, Combination; Female; Humans; Lupus Erythematosus, Systemic; Middle Aged; Pneumocystis carinii; Pneumonia, Pneumocystis; Retrospective Studies; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

We report a case of drug-induced lupus erythematosus (DILE) secondary to trimethoprim/sulfamethoxazole (TMP/SMX) in a patient with underlying inflammatory bowel disease (IBD). The initial presentation was with febrile pleural and pericardial effusions followed by cardiac tamponade. The patient was treated with a short course of corticosteroids with complete resolution of symptoms. To our knowledge this is the first reported case of TMP/SMX-induced DILE presenting with life-threatening serositis. When confronted with sterile exudative effusions, clinicians should strongly consider non-infectious etiologies.

Topics: Adrenal Cortex Hormones; Cardiac Tamponade; Female; Humans; Inflammatory Bowel Diseases; Lupus Erythematosus, Systemic; Middle Aged; Pleural Effusion; Serositis; Tomography, X-Ray Computed; Trimethoprim, Sulfamethoxazole Drug Combination

Trimethoprim-sulfamethoxazole (TMP/SMX) is effective as prophylaxis against many infections in immunocompromised patients. However, it is not commonly prescribed for patients with systemic lupus erythematous (SLE) due to the risk of adverse reactions (ADRs). An upfront graded administration protocol for TMP/SMX was adopted, and its safety and efficacy were assessed.. Data from 59 patients with SLE patients who received prophylactic TMP/SMX were retrospectively analyzed. The incidence and risk factors for ADRs in patients who received TMP/SMX before and after the introduction of graded administration were assessed.. The incidence of ADRs was 41.9% in the non-graded administration group, vs. 10.7% in the graded administration group (p = 0.009). The rate of high fever, liver function test (LFT) abnormality, shortness of breath, and hospitalization were reduced in upfront graded administration group. In addition, a higher rate of anti-Ro/SS-A positivity was found in patients experienced ADRs (46.2% in reactors vs. 5.6% in non-reactors; p = 0.012) in the non-graded administration group.. Upfront graded administration of TMP/SMX reduces the incidence and severity of ADRs in SLE patients. The high incidence of TMP/SMX ADRs in SLE patients was also confirmed, especially when anti-Ro/SS-A antibody is present.

Topics: Adult; Anti-Bacterial Agents; Bacterial Infections; Cohort Studies; Drug-Related Side Effects and Adverse Reactions; Female; Hospitalization; Humans; Immunocompromised Host; Incidence; Japan; Lupus Erythematosus, Systemic; Male; Middle Aged; Retrospective Studies; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

We report the case of a 35-year-old male, who was diagnosed with systemic lupus erythematosus (SLE) in 2010 based on the presence of articular, serous, renal, immune, and hematologic involvement. He also had secondary antiphospholipid syndrome (APS). He was treated with prednisone 10 mg per day, hydroxychloroquine 200 mg per day, methotrexate 12.5 mg per week, leflunomide 20 mg per day, and oral anticoagulation previous to the present event. He presented to emergency room with a 7 day disease duration characterized by pain in the left thigh, which increased with physical activity, resulting in claudication; he also had malaise and fever. The X-ray films showed periostitis of the lower half of the left femur with bone marrow narrowing; the scintigraphy showed marked increased uptake in the middle and distal thirds of the left femur, and magnetic resonance imaging (MRI) showed thickening and hyperintensity of the cortex of the diaphysis and distal epiphysis of the femur and endosteal irregularity. Empirical treatment was started with vancomycin for 3 weeks. Femur biopsy and cultures were performed, isolating Salmonella spp. group "D" Vi (-); treatment with cotrimoxazole and ceftazidime for 4 weeks followed by doxycycline and cotrimoxazole for 4 months were given with a favorable functional outcome. This is an unusual case of a young adult with Garre's sclerosing osteomyelitis associated to SLE and caused by salmonella. The literature is reviewed and the clinical conditions predisposing to this infection are discussed, particularly in patients with SLE.

Topics: Adult; Anti-Bacterial Agents; Antiphospholipid Syndrome; Ceftazidime; Doxycycline; Femur; Humans; Hydroxychloroquine; Immunosuppressive Agents; Isoxazoles; Leflunomide; Lupus Erythematosus, Systemic; Male; Methotrexate; Osteomyelitis; Prednisone; Salmonella Infections; Sclerosis; Trimethoprim, Sulfamethoxazole Drug Combination

We herein report on a 69-year-old male who developed lung nocardiosis and brain abscessation. In April 2011, he was diagnosed as having systemic lupus erythematosus complicated by peripheral neuropathy. Immunosuppressive therapy with high-dose prednisolone was begun. In November 2011, he developed cryptococcal pneumonia and meningitis, which was treated with liposomal amphotericin and flucytosine for 4 weeks and was maintained with fluconazole. In April 2012, consolidation and peripheral atelectasis in the right middle lobe appeared. Bronchoscopy revealed edematous mucosa in the right middle bronchus and occlusive change of the right B4 and B5, but biopsy and culture results provided no etiological information. In late June, he developed an intermittent fever, and obstructive pneumonia of the right middle lobe was suspected. Nocardia species were detected from the sputum culture and were thought to be the causative pathogen. Brain CT and MRI revealed a contrast-enhanced lesion in the right cerebellar hemisphere. The patient was diagnosed as having lung nocardiosis and brain abscessation. Considering that the nocardiosis had developed under prophylaxis for Pneumocystis jirovecii pneumonia using one tablet per day of a sulfamethoxazole-trimethoprim combination, meropenem and amikacin were administered in addition to the sulfamethoxazole-trimethoprim combination for 6 and 4 weeks, respectively. After N. elegans had been identified from the sputum, antibiotics were switched to a sulfamethoxazole-trimethoprim combination and clarithromycin based on the susceptibility results. The patient's clinical and radiological findings were improved and have been well sustained.

Topics: Aged; Brain Abscess; Clarithromycin; Humans; Lupus Erythematosus, Systemic; Male; Nocardia Infections; Trimethoprim, Sulfamethoxazole Drug Combination

We herein report a case of methemoglobinemia induced by trimethoprim-sulfamethoxazole (TMP/SMX). A 41-year-old woman with systemic lupus erythematosus (SLE) received TMP/SMX for prophylaxis of pneumocystis pneumonia (PCP) on the 7th day of hospitalization. She suddenly developed dyspnea and cyanosis on the 9th day of hospitalization. The level of oxygen saturation (SaO2) decreased, and the concentration of methemoglobin (MetHb) in the blood was elevated. We diagnosed the patient with methemoglobinemia induced by TMP/SMX. Methemoglobinemia should be considered in cases of sudden dyspnea following TMP/SMX administration.

Topics: Adult; Anti-Infective Agents; Female; Humans; Immunosuppressive Agents; Lupus Erythematosus, Systemic; Methemoglobinemia; Pneumonia, Pneumocystis; Trimethoprim, Sulfamethoxazole Drug Combination; Withholding Treatment

To identify the risk factors which will indicate the Pneumocystis carinii (Pc) infection in children with systemic lupus erythematosus (SLE) and investigate the clinical features and to elevate the level to find out the high-risk patients and make early diagnosis and treatment.. The characteristics, clinical features, laboratory examinations, treatment and prognosis of Pneumocystis carinii pneumonia (PCP) in children with SLE under 18 years of age treated in our hospital between January 2000 and January 2013 were prospectively reviewed. A comparison was made with the 26 cases of SLE children without PCP who were matched for gender, age and course, and a literature review was made.. (1) Five cases were enrolled, 3 were male and 2 female. Their age range was 13-17 (14.0 ± 1.6) years. All the children had kidney involvement. The courses were from 3 months to 4.5 years. All patients were receiving daily glucocorticoid therapy and immunosuppressive drugs before the diagnosis of PCP.Four patients were in the inactive phase of SLE (SLEDAI 2-4 points), and the fifth case was in active phase (SLEDAI 8, low complement 2 points, anti-dsDNA antibody positive 2 points, urine-protein 4 points). (2) Besides the clinical manifestations of SLE, most patients had progressive dyspnea, fever and dry cough at onset of PCP. Two children accepted mechanical ventilation because of respiratory failure. The mean duration of the symptoms to diagnosis was 10-30 (17.6 ± 7.8) days. Lactose dehydrogenase (LDH) was elevated more or less, median was (700 ± 263) U/L. Lymphocyte count were (0.3-1.4)×10(9)/L (median 0.5×10(9)/L), and three children had CD4 T lymphocyte count <0.3×10(9)/L. Arterial blood gas analyses showed severe hypoxemia. Chest radiographs showed in all cases diffuse interstitial infiltration. Pc was positive in the sputum. All patients were treated with trimethoprim-sulfamethoxazole and corticosteroids.. When SLE children are treated with corticosteroids and immunosuppressive drugs, low lymphocyte count is the risk factor for Pc infection.It is essential to monitor lymphocyte count.We should pay more attention to fever, dry cough and hypoxemia. Chest radiologic examination may help diagnose the PCP in SLE children.It may be helpful for SLE children whose CD4T lymphocyte was below 0.3×10(9)/L to take trimethoprim-sulfamethoxazole for PCP prophylaxis.

Topics: Adolescent; Anti-Infective Agents; Case-Control Studies; Child; Female; Glucocorticoids; Humans; Immunosuppressive Agents; Kidney Diseases; Lung; Lupus Erythematosus, Systemic; Lymphocyte Count; Male; Opportunistic Infections; Pneumonia, Pneumocystis; Prognosis; Retrospective Studies; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination

Listeria monocytogenes infection (LMI) is a rare complication in systemic lupus erythematosus (SLE) patients, and it is associated with nonspecific clinical manifestations and is often mistaken with SLE flares. Several cases of LMI in SLE patients have been reported, with high mortality rates. This article describes five new cases of LMI in patient with SLE in a cohort of 174 patients (2.8%). All patients were women, with a mean age of 19.4 years (range, 5-29 years). Mean duration of SLE before clinical LMI was 2.8 years (range, 2-4 years). Recurrent infection was not evidenced. At the time of LMI, all patients had an inactive disease, receiving steroids and immunosuppressive treatment. Clinical picture of meningitis was present in two patients. All patients were treated with ampicillin, with resolution of clinical manifestations without sequels. In order to eliminate the intracellular forms of L. monocytogenes, trimethoprim-sulfamethoxazole was initiated, and an allergic skin reaction was presented in all but one patient. Our report highlights the unspecific clinical manifestations of LMI and these characteristics are initially challenging and may be interpreted as lupus flares. An accurate diagnosis and an early antibiotic treatment are essential to improve the outcome in these patients.

Topics: Adolescent; Adult; Ampicillin; Anti-Bacterial Agents; Child, Preschool; Cohort Studies; Drug Therapy, Combination; Female; Glucocorticoids; Humans; Immunosuppressive Agents; Listeriosis; Lupus Erythematosus, Systemic; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Here, we describe a patient with disseminated systemic nocardiosis. He had a history of systemic lupus erythematosus and had received oral prednisolone for 7 months. Nocardia farcinica was isolated from the pus. There were neither clinical nor radiologic features of pulmonary nocardiosis. The patient was treated with oral trimethoprim/sulfamethoxazole, intravenous imipenem and surgical drainage with a good clinical response, and there has been no recurrence of the infection.

Topics: Anti-Bacterial Agents; Debridement; Drainage; Humans; Imipenem; Immunocompromised Host; Immunosuppressive Agents; Lupus Erythematosus, Systemic; Male; Middle Aged; Nocardia; Nocardia Infections; Prednisolone; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

We report a 45-year-old woman of systemic lupus erythematosus (SLE) with thoracic empyema that was unusually infected by Mycobacterium tuberculosis (MTB), Nontuberculosis mycobacteria (NTM) concomitant with Nocardia asteroides. After a combined treatment of cotrimoxazole, clarithromycin and anti-tuberculosis drugs with a short-term of intravenous immunoglobulin (IVIG), the patient recovered from the critical illness. On the basis of the results in this case, we recommend a thorough survey of the probably concomitant infections of MTB and NTM in an immunocompromised patient with a known N. asteroid infection. In addition, an adjuvant intravenous immunoglobulin therapy may have beneficial effect in the control of infections in an SLE patient.

Topics: Antitubercular Agents; Clarithromycin; Drug Therapy, Combination; Empyema, Pleural; Empyema, Tuberculous; Female; Humans; Immunocompromised Host; Immunoglobulins, Intravenous; Lupus Erythematosus, Systemic; Middle Aged; Mycobacterium; Nocardia asteroides; Taiwan; Trimethoprim, Sulfamethoxazole Drug Combination

Although co-trimoxazole (trimethoprim-sulphamethoxazole) is an effective drug for prophylaxis against and treatment of Pneumocystis pneumonia, patients often experience adverse events with this combination, even at prophylactic doses. With the aim being to achieve individual optimization of co-trimoxazole therapy in patients with systemic lupus erythematosus (SLE), we investigated genetic polymorphisms in the NAT2 gene (which encodes the metabolizing enzyme of sulphamethoxazole). Of 166 patients with SLE, 54 patients who were hospitalized and who received prophylactic doses of co-trimoxazole were included in the cohort study. Adverse events occurred in 18 patients; only two experienced severe adverse events that lead to discontinuation of the drug. These two patients and three additional ones with severe adverse events (from other institutions) were added to form a cohort sample and were analyzed in a case-control study. Genotype was determined using TaqMan methods, and haplotype was inferred using the maximum-likelihood method. In the cohort study, adverse events occurred more frequently in those without the NAT2*4 haplotype (5/7 [71.4%]) than in those with at least one NAT2*4 haplotype (13/47 [27.7%]; P = 0.034; relative risk = 2.58, 95% confidence interval = 1.34-4.99). In the case-control study the proportion of patients without NAT2*4 was significantly higher among those with severe adverse events (3/5 [60%]) than those without severe adverse events (6/52 [11.5%]; P = 0.024; odds ratio = 11.5, 95% confidence interval = 1.59-73.39). We conclude that lack of NAT2*4 haplotype is associated with adverse events with co-trimoxazole in Japanese patients with SLE.

Topics: Alanine Transaminase; Anti-Infective Agents; Arylamine N-Acetyltransferase; Asian People; Aspartate Aminotransferases; Case-Control Studies; Cohort Studies; Haplotypes; Humans; Immunocompromised Host; Lupus Erythematosus, Systemic; Pneumonia, Pneumocystis; Polymerase Chain Reaction; Polymorphism, Single Nucleotide; Trimethoprim, Sulfamethoxazole Drug Combination

A 46-year-old man had been given 40mg prednisolone daily for systemic lupus erythematosus. He complained of fever and general fatigue and chest computed tomography revealed wide-spread consolidation with multiple cavity formation in his left lung. Pulmonary nocardiosis was clinically suspected because we detected nocardia from Gram staining of sputum. He was cured by sulfamethoxazole-trimethoprim, Imipenem/Cilastatin, although a cavity with a slightly thickened wall in the left lung remained. Nocardia asteroides was cultured from sputum and pulmonary nocardiosis was diagnosed. The present case was pulmonary nocardiosis that spread with multiple and extensive cavity formation. A good outcome was obtained by early treatment with sulfamethoxazole-trimethoprim.

Topics: Anti-Infective Agents; Humans; Lung Diseases; Lupus Erythematosus, Systemic; Lupus Nephritis; Male; Middle Aged; Nocardia Infections; Opportunistic Infections; Prednisolone; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardiosis has become a significant opportunistic infection over the last two decades as the number of immunocompromised individuals has grown worldwide. We present two patients with nocardial brain abscess. The first patient was a 39-year-old woman with systemic lupus erythematosus. A left temporoparietal abscess was detected and aspirated through a burr-hole. Nocardia farcinica infection was diagnosed. The patient had an accompanying pulmonary infection and was thus treated with imipenem and amikacine for 3 weeks. She received oral minocycline for 1 year. The second patient was a 43-year-old man who was being treated with corticosteroids for glomerulonephritis. He was diagnosed with a ring-enhancing multiloculated abscess in the left cerebellar hemisphere, with an additional two small supratentorial lesions and triventricular hydrocephalus. Gross total excision of the cerebellar abscess was performed via a left suboccipital craniectomy. Culture revealed Nocardia asteroides, and the patient was successfully treated with intravenous ceftriaxone, then oral trimethoprime-sulfamethoxazole for 1 year. The clinical course, radiological findings, and management of nocardial brain abscess are discussed in light of the relevant literature, and current clinical management is reviewed through examination of the cases presented here.

Topics: Adult; Anti-Bacterial Agents; Brain Abscess; Ceftriaxone; Female; Humans; Lupus Erythematosus, Systemic; Magnetic Resonance Imaging; Male; Nocardia Infections; Trimethoprim, Sulfamethoxazole Drug Combination

To report a case of subretinal abscess due to Nocardia farcinica resistant to trimethoprim-sulfamethoxazole in a patient with systemic lupus erythematosus on immunosuppressive therapy.. Observational case report.. We retrospectively studied the medical record of a patient with nocardiosis.. The microorganism disseminated from the lungs (pneumonia) to the eye and brain. The ocular lesion appeared to be a yellowish, lobulated subretinal abscess with irregular surface and superficial retinal hemorrhages. As it was not responding to empiric therapy for nocardia, pars plana vitrectomy and aspiration of the subretinal material was performed to confirm the etiology.. In an immunocompromised patient with pulmonary involvement and a subretinal abscess with a characteristic aspect, one should consider nocardia as a possible etiology taking into account its possible antibiotic resistances.

Topics: Abscess; Adult; Anti-Bacterial Agents; Ciprofloxacin; Combined Modality Therapy; Eye Infections, Bacterial; Female; Humans; Lupus Erythematosus, Systemic; Nocardia; Nocardia Infections; Retinal Diseases; Retrospective Studies; Trimethoprim Resistance; Trimethoprim, Sulfamethoxazole Drug Combination; Vitrectomy

Kikuchi-Fujimoto disease is a rare benign cervical lymphadenopathy, which often affects young adult women. Its etiology and pathogenesis are unknown. We present the case of Kikuchi-Fujimoto disease in the Polish population and analyse the difficulties in differentiating this disease from the systemic lupus erythematosus.

Topics: Anti-Infective Agents; Anti-Inflammatory Agents; Biomarkers; Diagnosis, Differential; Female; Histiocytic Necrotizing Lymphadenitis; Humans; Lupus Erythematosus, Systemic; Lymph Nodes; Middle Aged; Necrosis; Prednisolone; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Anorexia; Anti-Bacterial Agents; Brain Abscess; Combined Modality Therapy; Diagnosis, Differential; Female; Fever; Headache; Humans; Immunocompromised Host; Liver Abscess; Lupus Erythematosus, Systemic; Nocardia asteroides; Nocardia Infections; Opportunistic Infections; Pleural Effusion; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardial infections in an immunocompromised host have been increasingly reported. Nocardial brain abscess, the most common presentation of nocardiosis in the central nervous system, is associated with a high mortality rate because of its delayed diagnosis and its unresponsiveness to the usual antibiotic therapy. We report four patients who experienced a long-term cure of nocardial brain abscess due to treatment by a combination of surgery and postoperative antibiotic therapy; 1 man and 3 women, ages ranging from 43 to 67 years old. Two patients were associated with systemic lupus erythematosus and two with autoimmune hemolytic anemia. Patients underwent surgical aspiration and drainage of brain abscess. Nocardia was identified from the aspirated specimen and postoperative antibiotic therapy for 5-6 weeks was performed using effective antibiotic agents; sulfamethoxazole/trimethoprim (ST), imipenem/cilastatin and minocycline (MINO) in Case 1, ST and MINO in Case 2, erythromycin in Case 3, and panipenem/betamipron and cefotaxime in Case 4. Case 3 and Case 4 with multilobulated brain abscess underwent total excision of the brain abscess. All patients showed successful cure of nocardial brain abscess with no recurrence for the period of 1-8 years. The combination of surgery and postoperative antibiotic therapy provides a good prognosis for nocardial brain abscess.

Topics: Adult; Aged; Anemia, Hemolytic, Autoimmune; Anti-Bacterial Agents; beta-Alanine; Brain Abscess; Cefotaxime; Cilastatin; Cilastatin, Imipenem Drug Combination; Drainage; Drug Combinations; Drug Therapy, Combination; Female; Humans; Imipenem; Immunocompromised Host; Lupus Erythematosus, Systemic; Male; Middle Aged; Minocycline; Nocardia Infections; Postoperative Care; Thienamycins; Trimethoprim, Sulfamethoxazole Drug Combination

Although Pneumocystis carinii pneumonia (PCP) is known to occur in adults with systemic lupus erythematosus (SLE), this infection has rarely been described in childhood SLE. We describe 3 children with SLE who developed PCP and describe risk factors for this complication.. A retrospective case review.. All 3 children had severe active SLE with organ involvement requiring immunosuppressive therapy, but the clinical presentations of PCP differed in each patient. They shared some of the known risk factors for opportunistic infection in adults with SLE, including lymphopenia, but severe lymphopenia (< 0.35 x 10(9)/1) was not seen.. PCP is an uncommon but serious complication of childhood SLE, and should be considered in the presence of respiratory symptoms, however subtle. The role of oral chemoprophylaxis is discussed.

Topics: Adolescent; Anti-Bacterial Agents; Child; Fatal Outcome; Female; Humans; Immunosuppressive Agents; Lung; Lupus Erythematosus, Systemic; Pneumocystis; Pneumonia, Pneumocystis; Retrospective Studies; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Female; Humans; Kidney; Lupus Erythematosus, Systemic; Lupus Nephritis; Pneumonia, Pneumocystis; Remission Induction; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Agranulocytosis; Decision Making; Diagnosis, Differential; Dyspnea; Edema; Female; Granulocyte-Macrophage Colony-Stimulating Factor; Humans; Infant, Newborn; Leukopenia; Lung Diseases; Lupus Erythematosus, Systemic; Pregnancy; Pregnancy Complications; Puerperal Disorders; Trimethoprim, Sulfamethoxazole Drug Combination

Most reports of drug induced meningitis in systemic lupus erythematosus (SLE) have implicated ibuprofen. We describe a 46-year-old woman with SLE who developed aseptic meningitis abruptly after ingesting trimethoprim-sulfamethoxasole (TMP-SMX). This patient had received TMP-SMX twice before; each was associated with increasingly severe reactions, whose relationship with the use of TMP-SMX became apparent only in retrospect. A history of medication use should be sought in all patients with meningitis who have an underlying autoimmune disorder.

Topics: Female; Humans; Lupus Erythematosus, Systemic; Meningitis, Aseptic; Middle Aged; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections