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Amphotericin-b/fluticasone-propionate/prednisolone Various toxicities: 2 case reports

In a case report from Pakistan, a 55-year-old man developed acute kidney injury during treatment with amphotericin-b; a 73-yearold man developed methicillin resistant Staphylococcus aureus (MRSA), Aspergillus infection and Syncephalastrum pneumonia during treatment with fluticasone-propionate and prednisolone, and acute kidney injury during treatment with amphotericin-b [not all routes, dosages and outcomes stated; durations of treatments to reactions onset not stated]. Case 1: The 55-year-old man presented to the hospital with shortness of breath, fever and scanty sputum. He had a significant history of acute myeloid leukaemia and was not receiving any treatment. At the time of current presentation, following various investigations, he was diagnosed with MRSA and Syncephalastrum pneumonia. He also had concurrent hypotension and tachycardia. Hence, treatment with amphotericin-b 1 mg/kg/day [deoxycholate amphotericin B] and vancomycin was initiated leading to an improvement in the WBC count. However, eight days after the therapy initiation, he developed acute kidney injury secondary to amphotericin-b. Additionally, lactic acidosis and hypotension was also observed. Thereafter, the dose of vancomycin was adjusted and amphotericin-b was decreased to 0.5 mg/kg/day according to his creatinine clearance. His condition gradually improved, but subsequently deteriorated with a decrease in the creatinine clearance by day 8. Additionally, the progressive primary disease was considered as an accelerating factor. Thereafter, he developed respiratory and metabolic acidosis leading to intubation on day 12. Also, haemodialysis was planned. However, 12 days following hospitalisation, he died [immediate cause of death not stated]. He had received amphotericin-b and vancomycin for a total duration of 10 days. Case 2: The 73-year-old man, presented to the emergency room with 1 week history of worsening shortness of breath. He had chronic obstructive pulmonary disease and was receiving treatment with prednisolone 5mg tablet for over a month (that was recently tapered from 30 mg/day), fluticasone propionate [fluticasone] inhalation 250mcg and salmeterol for 3 years. At the time of current presentation, mucoid sputum production was noted without fever. His pulse rate was 90 /min, SaO2 was 88% and had low BP. Additionally, bilateral crepitations with wheeze was noted. Chest-CT and X-ray demonstrated infiltrates and cavity formation and total leucocyte count was 18.2 × 109/L. Initially, he received empiric therapy with vancomycin and piperacillin/tazobactam. His culture test showed growth of Aspergillus and Syncephalastrum species. Hence, treatment with piperacillin/tazobactam was switched to amphotericin-b 1 mg/kg/day [deoxycholate amphotericin B] and vancomycin was continued. Microscopic morphological examination showed both Aspergillus flavus and Syncephalastrum spp. On day 5 of hospitalisation, he had borderline serum beta D glucan and serum Asp