trimethoprim--sulfamethoxazole-drug-combination and Rhabdomyolysis

We report a case of rhabdomyolysis associated with the use of trimethoprim-sulfamethoxazole (TMP-SMX) in a newly diagnosed AIDS patient with presumed Pneumocystis jiroveci (formerly named Pneumocystis Carinii) pneumonia. The present case is significant because of the paucity of similar cases in the literature and the relative frequency with which TMP-SMX is used today.

Topics: Acquired Immunodeficiency Syndrome; Adult; AIDS-Related Opportunistic Infections; Anti-Infective Agents; Humans; Male; Pneumonia, Pneumocystis; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination

Hematopoietic cell transplantation (HCT) offers long-term cure against early morbidity and mortality of hemoglobinopathies, such as sickle cell disease (SCD) and beta-thalassemia. Following HCT, sirolimus is an immunosuppressant used to prevent graft-versus-host disease (GVHD) while receiving trimethoprim-sulfamethoxazole (TMP-SMX) for Pneumocystis jirovecii prophylaxis and other antimicrobial agents (including acyclovir). One rare adverse event associated with both drugs is rhabdomyolysis, defined as creatine kinase (CK) elevation at least 5 to 10 times the upper limit of normal. This study was conducted to evaluate the rate of and risk factors for developing rhabdomyolysis in the post-HCT setting. Across 4 haploidentical and matched related donor (MRD) nonmyeloablative protocols, CK levels were prospectively monitored and patients were retrospectively identified for rhabdomyolysis. The rhabdomyolysis was graded based on the severity of CK elevation and other organ injury. At diagnosis, patients were queried for concurrent medication use (ie, sirolimus, TMP-SMX, acyclovir, or statins), sex, age, donor genotype, and time from transplantation. Among 127 patients with mostly SCD, rhabdomyolysis occurred in 22 (17%), including 2 recipients of haploidentical donor HCT and 20 recipients of MRD HCT. The time to the development of rhabdomyolysis was 61 and 73 days for the 2 recipients of haploidentical HCT and a median of 73 days for the MRD HCT recipients. Among the 22 patients who developed rhabdomyolysis, 20 (91%) were receiving sirolimus (2 haploidentical HCT recipients and 18 MRD HCT recipients), and 14 (64%) were also receiving TMP-SMX (all in the MRD HCT group). Seventy-five percent of the haploidentical donors and 69% of the MRDs had sickle cell trait. All but 2 patients with rhabdomyolysis were male. No patients who developed rhabdomyolysis were receiving statins at any point. Higher-than-expected rates of rhabdomyolysis were found post-transplantation for patients with SCD and beta-thalassemia. Contributing risk factors included immunosuppression with sirolimus, TMP-SMX, male sex, and sickle trait donor. These factors differ from the excessive muscle strain or injury, seizures, infections, or HMG-CoA inhibitors typically identified in non-HCT recipients.

Topics: Hematopoietic Stem Cell Transplantation; Humans; Male; Pneumonia, Pneumocystis; Retrospective Studies; Rhabdomyolysis; Sirolimus; Trimethoprim, Sulfamethoxazole Drug Combination

Rhabdomyolysis is a rare phenomenon that may be challenging to recognize in an emergency setting. Drugs are one of the common causes. Trimethoprim-sulfamethoxazole is a commonly used antibiotic effective in the treatment of upper and lower respiratory tract infections as well as renal, urinary, and gastrointestinal tract infections. It has variable side effects, ranging from mild symptoms of fatigue and insomnia to a potentially life-threatening Steven-Johnson syndrome and renal failure. Rhabdomyolysis is a rare complication of therapy with this drug and is commonly seen in immunocompromised patients or those with an allogenic stem cell transplant. In this article, we report a case of rhabdomyolysis in an immunocompetent patient who has undergone treatment with trimethoprim-sulfamethoxazole and a possible drug interaction with nonsteroidal anti-inflammatory drugs, with the latter acting as an aggravating factor of this complication.

Topics: Anti-Infective Agents, Urinary; Diagnosis, Differential; Emergency Service, Hospital; Humans; Kidney Function Tests; Male; Middle Aged; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

A 24-year-old active duty soldier was evacuated from Afghanistan to the United States after persistent upper respiratory tract infection. His course was complicated by an exfoliative rash, diffuse muscle aches, and elevated creatine kinase following trimethoprim-sulfamethoxazole exposure that persisted despite withdrawal of the medication. Dermatomyositis was strongly considered, but the patient had a negative muscle biopsy and had positive serologies for acute Epstein-Barr virus infection. We present a case of acute Epstein-Barr virus infection and possible trimethoprim-sulfamethoxazole reaction mimicking dermatomyositis.

Topics: Afghan Campaign 2001-; Anti-Infective Agents; Creatine Kinase; Dermatomyositis; Diagnosis, Differential; Drug Eruptions; Exanthema; Humans; Infectious Mononucleosis; Male; Military Personnel; Myalgia; Pharyngitis; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination; United States; Young Adult

We describe a case of rhabdomyolysis associated with trimethoprim-sulphamethoxazole (TMP-SMZ) in a HIV-infected patient. A 33-year-old African American man with newly diagnosed AIDS initially presented with persistent, high-grade fevers suspected to be TMP-SMZ-related drug fever. The antibiotic was discontinued while in the hospital, but the patient was restarted on TMP-SMZ following discharge. Two days later, he returned to the hospital with severe muscle pain, acute renal failure and a significantly elevated creatine phosphokinase consistent with rhabdomyolysis. The patient gradually improved following discontinuation of TMP-SMZ.

Topics: Adult; Anti-Bacterial Agents; HIV Infections; Humans; Male; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination; Withholding Treatment

Trimethoprim-Rhabdomyolysis is a serious, potentially life-threatening complication diagnosed when creatine phosphokinase levels exceed 1000 U/L. Although many drugs are associated with rhabdomyolysis, the previous reports of trimethoprim-sulfamethoxazole (TMP/SMX)-induced rhabdomyolysis have involved patients with human immunodeficiency virus/acquired immunodeficiency syndrome. This is the first report, to our knowledge, of TMP/SMX-induced rhabdomyolysis in an allogeneic stem cell transplant patient.

Topics: Adult; Anti-Infective Agents; Creatine Kinase; Female; Hematopoietic Stem Cell Transplantation; Humans; Pneumocystis carinii; Pneumonia, Pneumocystis; Rhabdomyolysis; Transplantation, Homologous; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; Anti-Infective Agents; HIV Infections; Humans; Male; Middle Aged; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination

Adverse drug reactions to trimethoprim-sulfamethoxazole (TMP/SMX) are common in HIV-positive patients. However, only one case of TMP/SMX-related rhabdomyolysis has been reported, so far. We report a 55-year old-man with asymptomatic rhabdomyolysis after oral high-dose TMP/SMX for suspected PCP. Laboratory changes settled after discontinuation of the drug.

Topics: AIDS-Related Opportunistic Infections; Anti-Infective Agents; Humans; Male; Middle Aged; Pneumonia, Pneumocystis; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Adult; AIDS-Related Opportunistic Infections; HIV; HIV Seropositivity; Humans; Male; Pneumocystis Infections; Rhabdomyolysis; Trimethoprim, Sulfamethoxazole Drug Combination

A patient with acquired immunodeficiency syndrome (AIDS) developed rash, fever, neutropenia, and elevated liver function tests during an initial course of trimethoprim-sulfamethoxazole (TMP-SMX) therapy. Upon reexposure to the drug, the patient experienced a severe anaphylactoid reaction associated with pulmonary edema and rhabdomyolysis. Reactions associated with TMP-SMX rechallenge in this patient population have been previously reported but have not been associated with this degree of severity. TMP-SMX therapy should be instituted with extreme caution in patients with AIDS who have demonstrated a prior hypersensitivity reaction to the drug.

Topics: Acquired Immunodeficiency Syndrome; Adult; Dermatitis, Exfoliative; Drug Combinations; Drug Hypersensitivity; Fever; Humans; Hypersensitivity, Delayed; Male; Pneumonia, Pneumocystis; Pulmonary Edema; Rhabdomyolysis; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination

Topics: Acute Disease; Acute Kidney Injury; Adult; Brucellosis; Doxycycline; Drug Combinations; Humans; Male; Rhabdomyolysis; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination