Carbamazepine
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Agammaglobulinaemia and diffuse panbronchiolitis: case report A 61-year-old man developed agammaglobulinaemia and diffuse panbronchiolitis during treatment with carbamazepine for seizures. The man’s medical history was notable for removal of a meningioma and surgery for a postoperative epidural abscess 2 years prior to admission with respiratory symptoms. He had experienced several seizures perioperatively and carbamazepine had been started with excellent seizure control [dosage and route not stated]. He presented with a 3-month history of exertional dyspnoea and productive cough. Physical examination revealed a BP of 136/67mm Hg, a pulse of 110/min, fever (38.3°C) and coarse crackles bilaterally on chest auscultation. Investigations detected marked decreases in serum immunoglobulin levels (IgG, IgA and IgM 46, < 5 and < 5 mg/dL, respectively), CD4 T cell lymphopenia, an abnormal CD4:CB8 T cell ratio and a complete absence of CD19 B cells. His carbamazepine concentration was in the therapeutic range. Lung and brain CT showed multiple centrilobular lesions and maxillary sinusitis, respectively. Sputum cultures grew Haemophilus influenzae. Arterial blood gas analysis showed PCO2 and PO2 values of 37.4 and 74.6mm Hg, respectively, and lung function testing showed an obstructive pattern. Diffuse panbronchiolitis was diagnosed. Valproic acid was substituted for carbamazepine, which was considered the most likely cause of agammaglobulinaemia. The man received gammaglobulin supplementation (targeting a serum IgG level > 500 mg/dL) as well as a 10-day course of cefotaxime. He was afebrile by hospital day 8 and was discharged on day 28. Long-term therapy with clarithromycin was started on completing the cefotaxime course and supplemental gammaglobulin was continued. His serum IgG normalised while his IgA and IgM levels remained low 5 months after stopping carbamazepine. Six months postdiscontinuation, repeat lung CT showed resolution of the centrilobular lesions. Author comment: "In the present case, humoral immunodeficiency could have increased susceptibility to the H influenza infection responsible for inflammation centred on the respiratory bronchiole and adjacent centrilobular regions." Hoshino C, et al. Carbamazepine-induced agammagloblinaemia clinically mimicking diffuse panbronchiolitis. BMJ Case Reports : 2011. Available from: 803055469 URL: http://dx.doi.org/10.1136/bcr.11.2010.3535 - Japan
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Reactions 11 Jun 2011 No. 1355
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