Colistin
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Myasthenic syndrome: case report A 59-year-old woman developed myasthenia syndrome during treatment with colistin for Klebsiella-related urosepsis. The woman, who had hypertension and chronic renal failure, hospitalised with advanced azotemic symptoms, confusional state, lethargy, decreased urine output and febrile illness. Following examination, she was diagnosed with mutidrug resistant strain of Klebsiella pneumonia. She started receiving treatment with IV colistin with loading dose of 6 million unit followed by 2 million units three times daily along with cotrimoxazole. Thereafter, her fever started to remit and her symptoms improved. On day 4 after initiation of colistin, she was found unresponsive in bed with labored breathing and desaturation. Her heart rate was 114/min and BP was 160/90mm Hg. Then, she was transferred to intensive therapeutic unit. Her arterial blood gas was drawn and was intubated, and T-piece oxygenation was given. Her arterial blood gas analysis showed partial pressure of carbon dioxide of 59.6mm Hg, partial pressure of oxygen of 68mm Hg, base excess 1.8 mmol/L and pH of 7.29. Then, she was put on mechanical ventilation with CO2 wash out. Following resuscitation, she became conscious, but she was failing continuous positive airway pressure test. Then, another session of haemodialysis was given with continued positive pressure ventilation mode of ventilation. It showed that she developed weakness of four limbs with cranial nerve and respiratory muscle involvement. Neurological examination revealed grade 2/5 power in lower limbs and grade 3/5 power upper limbs with preserved deep tendon reflexes. After one day, she developed ptosis, oculobulbar weakness, swallowing and diminished gag reflux. Antibody against P/Q type calcium channels found negative. She had been receiving clonidine, pantoprazole, prazosin and cilnidipine which were unknown to contribute such signs and symptoms. Nerve conduction study and electromyogram revealed progressive diminution in amplitude. However, there was a lack of an incremental response with high-rate repetitive nerve stimulation. The woman’s treatment with colistin was discontinued due to probability of colistin-induced neurotoxicity. Subsequently, she started receiving treatment with cefoperazone, and cotrimoxazole was continued. Based on her clinical conditions, intermittent haemodialysis was given. In the 48 hours of discontinuation of colistin, her muscle weakness improved. Her BP stabilised gradually with improvement in muscle power. Then, she was extubated. Her neurological and respiratory status remained stable in the following days of hospitalisation. Nerve conduction study performed 72 hours after discontinuation of colistin revealed normal conduction velocities and normal electromyogram of lower and upper limbs. Hence, a diagnosis of colistin-induced myasthenia was confirmed. Then, she was discharged in a stable condition with cefuroxime along with nitrofurantoin, unspecified diuretics, multivitamins and antihypertensive medications. Author com
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