trimethoprim--sulfamethoxazole-drug-combination and Lymphopenia

Trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity reaction, ranging from circulatory shock to aseptic meningitis and respiratory failure, is a potentially life-threatening condition with dermatologic relevance.. To describe the mucocutaneous findings and clinical features of TMP-SMX hypersensitivity reaction.. This was a retrospective case series study of 7 patients who developed a characteristic rash, hemodynamic changes, and end-organ dysfunction after treatment with TMP-SMX at a large university hospital system during January 2013 to March 2022.. Treatment with TMP-SMX within 2 weeks of the reaction.. Descriptions of the condition, including the demographic information of the affected population, the reaction timeline, and mucocutaneous and clinical features.. The cohort comprised 7 patients (median [range] age, 20 [15-66] years; 4 female and 3 male). The most common mucocutaneous findings were generalized sunburn-like erythema without scale, conjunctivitis, and mild facial and acral edema. Three patients had previous exposure to TMP-SMX and developed symptoms in 1 day or less, while those without prior exposure presented from 4 to 11 days after drug initiation. Among the 7 patients, 6 had fever, 7 had hypotension, and 7 had tachycardia. All patients had lymphopenia and evidence of end-organ dysfunction with either kidney or liver involvement. Median (range) time to resolution was 72 (48-96) hours.. This retrospective case series indicates that SCoRCH (sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes) should be considered in the differential diagnosis of patients presenting with acute generalized sunburn-like erythema, conjunctivitis, systemic symptoms, and hemodynamic changes in the setting of recent TMP-SMX use.

Topics: Adult; Exanthema; Female; Humans; Hypersensitivity; Lymphopenia; Male; Multiple Organ Failure; Retrospective Studies; Sunburn; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

Sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes (SCoRCH) is a recently described hypersensitivity reaction to trimethoprim-sulfamethoxazole. To date, only 1 case of histologic findings in SCoRCH has been reported, revealing a superficial perivascular dermatitis. In this article, we present a 53-year-old woman with a four-day history of a widespread, confluent, erythematous, and dusky rash after exposure to trimethoprim-sulfamethoxazole. Histologic examination revealed a vacuolar interface dermatitis with several apoptotic keratinocytes at multiple levels of the epidermis, similar to an erythema multiforme-like presentation. As described in SCoRCH, our patient's clinical findings rapidly improved within 48 hours of presentation without treatment. This case adds to the current literature by identifying a newly described histopathological presentation of SCoRCH.

Topics: Conjunctivitis; Dermatitis; Exanthema; Female; Humans; Lymphopenia; Middle Aged; Thrombocytopenia; Trimethoprim, Sulfamethoxazole Drug Combination

Nocardia infections are rare opportunistic infections in SOT recipients, with few reported pediatric cases. Pediatric patients with single ventricle congenital heart defects requiring HT may be more susceptible to opportunistic infections due to a decreased T-cell repertoire from early thymectomy and potential immunodeficiencies related to their congenital heart disease. Other risk factors in SOT recipients include the use of immunosuppressive medications and the development of persistent lymphopenia, delayed count recovery and/or lymphocyte dysfunction.. We report the case of a patient with hypoplastic left heart syndrome who underwent neonatal congenital heart surgery (with thymectomy) prior to palliative surgery and 2 HTs.. After developing respiratory and neurological symptoms, the patient was found to be positive for Nocardia farcinica by BAL culture and cerebrospinal fluid PCR. Immune cell phenotyping demonstrated an attenuated T and B-cell repertoire. Despite antibiotic and immunoglobulin therapy, his symptoms worsened and he was subsequently discharged with hospice care.. Pediatric patients with a history of congenital heart defects who undergo neonatal thymectomy prior to heart transplantation and a long-term history of immunosuppression should undergo routine immune system profiling to evaluate for T- and B-cell deficiency as risk factors for opportunistic infection. Such patients could benefit from long-term therapy with TMP/SMX for optimal antimicrobial prophylaxis, with desensitization as needed for allergies. Disseminated nocardiosis should be considered when evaluating acutely ill SOT recipients, especially those with persistent lymphopenia and known or suspected secondary immunodeficiencies.

Topics: Anti-Bacterial Agents; Child; Heart Transplantation; Humans; Infant, Newborn; Lymphopenia; Male; Nocardia Infections; Opportunistic Infections; Trimethoprim, Sulfamethoxazole Drug Combination

International guidelines for Pneumocystis jirovecii pneumonia (PJP) prevention recommend prophylaxis for ≥6 months following allogeneic hematopoietic cell transplantation, and longer in patients with graft-versus-host disease (GVHD) or on immunosuppressive therapy (IST). These recommendations are based on cohorts of patients who did not routinely receive anti-thymocyte globulin (ATG) for GVHD prophylaxis.. We performed a retrospective chart review of 649 patients, all of whom received ATG as part of GVHD prophylaxis.. The cumulative incidence of definite PJP was 3.52% at both 3 and 5 years (median follow up, 1648 days for survivors). PJP occurred in 13 non-GVHD patients between days 207 and 508, due in part to low CD4 T-cell counts (<200 CD4 T cells/µL). PJP occurred in eight GVHD patients between days 389 and 792, due in part to non-adherence to PJP prophylaxis guidelines (discontinuation of PJP prophylaxis at <3 months after discontinuation of IST). Breakthrough PJP infection was not observed in patients receiving prophylaxis with cotrimoxazole, dapsone or atovaquone, whereas three cases were observed with inhaled pentamidine.. In conclusion, for non-GVHD patients receiving ATG-containing GVHD prophylaxis, 6 months of PJP prophylaxis is inadequate, particularly if the CD4 T-cell count is <200 cells/µL or if there is a high incidence of PJP in the community. For patients with GVHD receiving ATG-containing GVHD prophylaxis, continuing PJP prophylaxis until ≥3 months post-discontinuation of IST is important. Cotrimoxazole, dapsone and atovaquone are preferred over inhaled pentamidine.

Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Antilymphocyte Serum; Atovaquone; CD4 Lymphocyte Count; Dapsone; Female; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Immunocompromised Host; Immunosuppression Therapy; Incidence; Lymphopenia; Male; Middle Aged; Pentamidine; Pneumocystis carinii; Pneumonia, Pneumocystis; Retrospective Studies; Trimethoprim, Sulfamethoxazole Drug Combination; Young Adult

Topics: Aged; Androstadienes; Antineoplastic Combined Chemotherapy Protocols; Breast Neoplasms; Cyclin-Dependent Kinase 4; Cyclin-Dependent Kinase 6; Fatal Outcome; Female; Humans; Immunocompromised Host; Lymphocyte Count; Lymphopenia; Piperazines; Pneumocystis; Pneumonia, Pneumocystis; Pyridines; Severity of Illness Index; Trimethoprim, Sulfamethoxazole Drug Combination

The case is presented of a 38 year-old patient who was admitted in the Emergency Department due to a severe acute respiratory failure and who was transferred to the Critical Care Unit with a suspected initial diagnosis of community acquired pneumonia caused by an atypical microorganism, which was complicated with an acute respiratory distress syndrome. This was able to be treated with non-invasive mechanical ventilation. At 48 hours after admission, the growth of Gram negative bacilli in the blood culture was reported, which was subsequently identified as Salmonella enteritidis. This information, along with the lymphopenia suffered by the patient, suggested an immunodepressed state, thus serological tests were performed which showed positive for HIV. Antibiotic treatment was started based on the microbiological findings, with a favourable clinical outcome for the patient.

Topics: Adult; AIDS-Related Opportunistic Infections; Anti-Bacterial Agents; Bacteremia; Bronchoalveolar Lavage Fluid; Ceftriaxone; Cocaine-Related Disorders; Community-Acquired Infections; Diagnosis, Differential; Female; Humans; Lymphopenia; Pneumonia, Bacterial; Pneumonia, Pneumocystis; Respiratory Distress Syndrome; Salmonella enteritidis; Salmonella Infections; Trimethoprim, Sulfamethoxazole Drug Combination

Pneumocystis jiroveci pneumonia (PCP) is an important cause of morbidity and mortality in renal transplant recipients (RTRs). Chemoprophylaxis with trimethoprim/sulphamethoxazole is recommended during the early post-transplantation period, but the optimal duration has not been determined and a main drawback of chemoprophylaxis is the development of resistance of the commensal faecal flora. A cluster outbreak of PCP occurred in our outpatient Renal Transplant Unit. We aimed to investigate risk factors for PCP in RTRs to determine who should receive long-term chemoprophylaxis.. In a case-control study, we investigated common demographic variables and immunological parameters. Nine PCP cases diagnosed between August 2006 and April 2007 were matched with 18 control patients, who did not develop PCP, received their transplant in the same time-period and had a similar follow-up period with a comparable immunosuppressive drug regimen.. The median time from transplantation to PCP was 19 months. We observed no significant differences in gender, age, donor type or number of rejections. In PCP cases, the median lymphocyte count just before PCP diagnosis was 0.49 (0.26-0.68), which was significantly reduced compared to the control patients after a similar follow-up period (median 1.36, 0.59-3.04, P = 0.002). This lymphocytopaenia was chronic and existed in most patients already for many months. CD4(+) T-cell counts were also significantly reduced in the PCP cases. We found no difference in the Th1, Th2 and Th17 subsets between PCP cases and control patients.. Long-term prophylactic therapy for PCP may be indicated for RTR with persistent severe lymphocytopaenia.

Topics: Adult; Aged; Anti-Infective Agents; Case-Control Studies; Female; Follow-Up Studies; Glomerular Filtration Rate; Humans; Immunosuppressive Agents; Kidney Failure, Chronic; Kidney Function Tests; Kidney Transplantation; Lymphocyte Count; Lymphopenia; Male; Middle Aged; Pneumocystis carinii; Pneumocystis Infections; Prognosis; Retrospective Studies; Risk Factors; Trimethoprim, Sulfamethoxazole Drug Combination

Haematological anomalies are frequent during HIV infection, and can be the fact of virus and or bone marrow toxicity of antiretroviral drugs. In order to analyze the evolution of the haematological parameters during HAART this work was carried out in the internal medicine department of the national teaching hospital Yalgado-Ouédraogo in Ouagadougou. So 107 patients receiving for the first time HAART and followed regularly were retained. The immunological efficacy at the end of the first six months was 60, 75% with an average gain of 119 CD4/mm3. The haematological changes at the end of these first six months showed: --an anaemia in 51.4% of the cases at month 6 versus 80.3% at baseline (p=0.0001). The average rate of haemoglobin was 11.8 versus 11.2 g/dl at baseline in the AZT containing HAART regimen (p=0.014) and 12.2 versus 10.7 g/dl at baseline in the group without AZT (p=0.00006). --a neutropenia in 35.5% of the cases at month 6 versus 31.7% at baseline (p=0.6). The average rate of neutrophil was 1908/mm3 versus 2267.1/mm3 at baseline in the AZT containing HAART regimen and 2150.7/mm3 versus 2001.9/mm3 at baseline in the group without AZT These results show that the therapeutic efficacy measured on the immunological answer is accompanied by a reduction of haematological anomalies. They also suggest the necessity to evaluate the cotrimoxazole impact before deciding the interruption of AZT.

Topics: Adolescent; Adult; Anemia; Anti-Infective Agents; Antiretroviral Therapy, Highly Active; Burkina Faso; Female; Follow-Up Studies; Hematologic Diseases; Hemoglobins; HIV Infections; Humans; Lymphopenia; Male; Middle Aged; Neutropenia; Retrospective Studies; Thrombocytopenia; Trimethoprim, Sulfamethoxazole Drug Combination; Zidovudine