Ceftriaxone
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Fatal acute autoimmune haemolytic anaemia: case report An 82-year-old man developed fatal acute autoimmune haemolytic anaemia during treatment with ceftriaxone for pneumonia. The man was hospitalised with a suspected diagnosis of bilateral community-acquired pneumonia, without positive microbial cultures. He had been treated with amoxicillin for 3 days. Due to persisting symptoms, his amoxicillin was switched to ceftriaxone [route and dosage not stated]. However, within 2 days of ceftriaxone initiation, he developed diffuse, scoter and pruriginous skin lesions. He also showed mottles on his inferior limbs and skin lesions on the abdomen. He did not exhibit haemodynamic failure. He was admitted to the ICU. Upon admission, he was apyretic without signs of haemodynamic, neurological or respiratory failure. His clinical examination showed icterus and diffuse skin lesions without splenomegaly, lymphadenopathy or hepatomegaly. An arterial blood gas exam was consistent with lactic acidosis. He developed septic shock with severe mottles or purpura fulminans, due to possible invasive Neisseria meningitidis or Streptococcus pneumoniae infection, despite the absence of necrotic elements in skin lesions and haemodynamic failure. Due to suspected purpura fulminans, he received a meningeal dose of ceftriaxone. His first blood tests were difficult to analyse owing to clotted blood in the EDTA tube at room temperature. However, intravascular acute haemolytic anaemia, acute renal failure, inflammatory syndrome and hyperfibrinogenaemia were suspected. Due to the clotting, complement or direct anti-globulin tests could not be analysed. However, over the next few hours, he showed significant progression of the skin lesions with major acrocyanosis, haemoglobinuria and neurological and haemodynamic failures. A diagnosis of extensive livedo racemosa was considered due to the net-like pattern of purple large patches visible over his body. Due to suspected livedo racemose associated with haemoglobinuria and acrocyanosis, secondary cold agglutinin syndrome was suspected. A new blood examination confirmed the diagnosis of acute haemolytic anaemia. The man had been undergoing mechanical ventilation alongside treatment with norepinephrine infusion, he also received warmed RBC transfusion and high dose of corticosteroids. His ceftriaxone was switched to spiramycin and piperacillin/tazobactam. However, he developed multiple organ failure leading to death 1 day after ICU admission and 5 days after hospital admission. Autoimmune disease and infection were ruled out as causative factors of autoimmune haemolytic anaemia, thus suggesting ceftriaxone-induced fatal acute autoimmune haemolytic anaemia. Boileve A, et al. Acute and fatal cephalosporin-induced autoimmune haemolytic anaemia. British Journal of Clinical Pharmacology 2020: 19 Oct 2020. Available from: URL: 803516054 http://doi.org/10.1111/bcp.14612
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Reactions 21 Nov 2020 No. 1831
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