Allopurinol
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Various toxicities: case report A 78-year-old man developed aseptic meningitis, drug hypersensitivity, loss of consciousness, confusion, abdominal tenderness, maculopapular lesions, petechiae, purpura and respiratory distress following treatment with allopurinol for gout. On 11 February 2017, the man who had a history of hypertension and gout presented with a 7-day history of generalised itchy rashes, petechiae and purpuric lesions on the limbs. Three days before the presentation, he developed fever and the day before presentation, he developed loss of consciousness. For the gout, he was receiving allopurinol [route and dosage not stated]. His other home medications were indometacin [indomethacin], captopril and gabapentin. Upon presentation, physical examinations showed confusion and he opened his eyes by audio stimulation. During eye examination, his pupils were light sensitive and mydriatic. In the head and neck examination, his neck was stiff and the mucosal membranes were slightly dry. His other vital signs were as follows: RR 32/min, axillary body temperature 38 degree’s centigrade, pulse rate 98 /min and BP 115/100mm Hg. The lung and heart examination showed brief bilateral coarse crackles in the lungs and tachycardia followed by arrhythmia in the heart. Chest X-Ray showed blunt angles in both the sides, consolidation in the right lower lob and bilateral hilar prominence. During abdomen and limbs examination, he was found to have a generalised abdominal tenderness and maculopapular lesions, petechiae and purpura. As he had a loss of consciousness, neck stiffness and leucocytosis with polymorphonuclear dominancy, he was suspected to have a bacterial meningitis. He then received antibacterial therapy. Despite this, his loss of consciousness worsened and he developed respiratory distress with a RR of 38 /min and SpO2 of 75%. He then intubated and moved to the ICU. Under the suspicion of tuberculosis, he received antituberculars. CSF examination and PCR ruled out tuberculosis. Therefore, antituberculars were discontinued. On the next day, high-resolution computed tomography (HRCT) was performed, which showed a bilateral pleural effusion with the dominant left side distribution, bilateral grand glass consolidation, emphysematous changes in the right lower lobe. The pleural fluid examination showed fluid appearance as turbid. Due to negative results of CSF examination and unremarkable findings of HRCT, presence of purpuric lesions, gout and worsening of consciousness while on antibacterial coverage, a possibility of drug hypersensitivity and aseptic meningitis was raised and he was referred for rheumatology consultation. As per the consultation, all medication including allopurinol were discontinued. Three days after the discontinuation, the man’s symptoms gradually improved, skin lesions disappeared and his consciousness returned to normal levels. He was then extubated successfully and surprisingly discharged and transferred to the rheumatology ward. One week later, he was discharged in normal condition and
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