Amphotericin B
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Anaphylactic response: case report A 45-year-old man developed anaphylactic response following administration of amphotericin B for empiric antifungal treatment. The man was admitted to a hospital in Tanzania with a six-week history of progressive bilateral lower limb swelling associated with aches and occasional cramps while walking. He reported unintentional weight loss (approximately 10kg) in the three months prior to the admission with a two-week history of intermittent fevers and one-day history of sudden onset of difficulty breathing. He had no cough or chest pain. He had received several courses of unspecified antibiotics with little clinical improvement. He was known to be hypertensive for the past five years and had been on losartan and amlodipine. General examination showed an alert, dyspnoeic, desaturating and febrile man with HR 112 beats/min. He appeared moderately pale with scleral jaundice and had bilateral pitting lower limb oedema. An erythematous patch was present on the anterior aspect of the right leg, which was warm and tender to touch. Respiratory system examination revealed normal chest cage with centrally located trachea. Lung auscultation revealed bilateral fine crepitations from the midzone to bases. An abdominal examination showed uniform distension with an everted umbilicus and mild tenderness elicited on deep palpation of the right hypochondrium. Initial blood tests revealed a markedly elevated WBC count, anaemia, an elevated CRP, elevated direct bilirubin, procalcitonin of 61 ng/mL, d-Dimer of 6.74 µg/mL and ESR of 30 mm/hr. He had no HIV and blood serology and stool microscopy was negative for amoeba. A chest x-ray showed parenchymal infiltrates likely of infective aetiology. Subsequently, radiological workup showed metastatic abscesses in the lungs, liver, lower limb muscle and subcutaneous tissue. Additionally, bone marrow changes suggestive of osteomyelitis were noted. An abdominal CT scan showed multiple non-enhancing cystic liver lesions. Doppler ultrasound for both the limbs were suggestive of superficial as well as deep vein thrombosis (DVT). CT-pulmonary angiography exhibited no evidence of pulmonary embolism. A brain CT scan showed only mild cortical atrophy. He was admitted to an ICU. Treatment was started with supplemental oxygen with a non-rebreather mask and broad-spectrum antibiotics such as imipenem/cilastatin and metronidazole. An empirical antifungal therapy was started with amphotericin B [dosage and route not stated]; however, following the first dose of amphotericin B, he developed an anaphylactic response. Consequently, the man’s antifungal therapy with amphotericin B was stopped. For DVT, he was initially treated with enoxaparin sodium [enoxaparin], which was later switched to rivaroxaban. During the hospital stay, he developed endogenous endophthalmitis. His breathlessness acutely worsened, which was attributed to an NSTEMI based on elevated cardiac markers. A 2D echocardiography revealed septal hypertrophy. Eventually, blood cultures grew Klebsiella pneumo
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