Amphotericin B liposomal/antihyperglycaemics/itraconazole
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Lack of efficacy, acute kidney injury and nausea: case report An 18-year-old woman exhibited lack of efficacy during treatment with insulin lispro and metformin for type 1 diabetes mellitus. Additionally, she developed acute kidney injury during empiric treatment with amphotericin B liposomal, and nausea during treatment with itraconazole for invasive fungal rhinosinusitis (IFRS) [durations of treatments to reactions onsets not stated]. The woman presented to the emergency department with facial discomfort, fever, headache, congestion and blood glucose reading greater than 500 mg/dL. Her anamnesis revealed type 1 diabetes mellitus and a recent toothache. She had been receiving SC insulin lispro 15 units thrice daily before meals and oral metformin 500mg twice daily, however her type 1 diabetes mellitus remained uncontrolled suggestive of ineffectiveness of the antihyperglycaemic agents. Her body mass index was 28.3 kg/m2. She required hospital admission for treatment of fever, hyperosmolar hyperglycaemia and altered mental status changes. Vital signs were stable. CT scan of the facial maxillary region revealed sinus disease with bony erosion. Blood cultures were performed and empiric broad-spectrum antimicrobial therapy including IV amphotericin B liposomal [liposomal amphotericin B] (5 mg/kg) 400mg every 24 hours, piperacillin/tazobactam and vancomycin was initiated. She underwent functional endoscopic sinus surgery (FESS) and a specimen was obtained for pathology examination and microbiology cultures. The findings revealed a irregular, broad, septated and branching filamentous fungal hyphae. Preliminary sinus cultures were found to be negative for fungal elements and positive for coagulase negative staphylococci. Amphotericin B liposomal and piperacillin/tazobactam were withdrawn after four days of therapy. Vancomycin was continued to treat coagulase negative staphylococci and ceftriaxone was initiated to cover common upper respiratory tract infection organisms. Five days after the sample collection, the sinus cultures showed fungal hyphae. Intravenous antibacterials were discontinued. She was discharged on IV amphotericin B liposomal (5mg/kg) 400 mg every 24 hours and cefuroxime was initiated. However three days later, she was re-admitted for the management of acute kidney injury with serum creatinine elevation. Acute kidney injury attributed to amphotericin B liposomal. The woman’s amphotericin B liposomal therapy was stopped. Subsequently, acute kidney injury resolved. Later, amphotericin B liposomal was restarted in the hospital for 3 days. The woman was discharged home on oral itraconazole 200mg capsules twice daily for 6 weeks. Three weeks later, sinus cultures grew Curvularia, but the species was not identified. She was diagnosed with acute IFRS and was advised to follow up with the outpatient clinic 1 week after discharge and until resolution of signs and symptoms. During the second visit, she revealed that she had stopped itraconazole after 3 weeks due to nausea and resolution of sign and symptoms o
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