Methylprednisolone
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Bacterial infections and worsening of scabies: case report An 81-year-old man developed hospital-acquired pneumonia due to multi-drug resistant Pseudomonas aeruginosa, superinfection by Staphylococcus aureus and worsening of classic scabies to crusted scabies during treatment with methylprednisolone for presumed DRESS syndrome. The man presented to the emergency department in late August 2019 with more than 1-year history of multiple crusted lesions, which were extremely itchy and unresponsive to multiple topical and systemic therapy. Since September 2018, he had been suffering with an itchy dermatitis. Initially, the lesions were itchy, erythematous papules, almost located at genitals and interdigital areas of the fingers, which subsequently extended to the whole body. He had consulted multiple dermatologist and received multiple cycles of unspecified topical antihistaminic and steroidal therapies without benefits. From March 2019 to May 2019, he was hospitalised for 41 days due to congestive heart failure and infective spondylodiscitis [aetiologies not stated]. During the hospitalisation, he exhibited dermatitis and high absolute eosinophil count (5270/µL). An allergology specialist misdiagnosed it as DRESS syndrome, which was suspected to be related to concurrent unspecified lipid-lowering medications. He started receiving systemic methylprednisolone 20mg three times daily and topical methylprednisolone [not all dosages stated], which was tapered over weeks. As he had no benefit after a month of steroid therapy, he was referred to a dermatologist. The dermatologist performed a skin punch biopsy, which showed arthropods morphologically similar to scabies mites and lesions were histologically compatible with scabies dermatitis. He was then referred to another dermatologist in the beginning of July 2019, where he was prescribed albendazole 400mg daily for 8 days despite treatment being not recommended by any guideline (off-label use). At current presentation, physical examination showed broad crusted lesions that interested the whole body more prominent on the face, trunk, groin, and limbs. Following scraping of the skin, microbiological examination showed presence of Sarcoptes scabiei. Therefore, a diagnosis of crusted scabies was made. Blood test showed slightly elevated C-reactive protein, LDH, absolute eosinophil count and mild leucocytosis. At presentation, he was still receiving systemic methylprednisolone at a tapered dose of 7.5 mg/day. He was then hospitalised. Subsequent lymphocyte phenotyping showed iatrogenic immunosuppression with CD4+ lymphocyte count of 130 cell/µL [duration of treatment to reaction onset not stated]. The man was treated with permethrin cream and ivermectin, followed by permethrin baths. During hospitalisation, he underwent series of microscopic examinations of skin samples, which showed the presence of live Sarcoptes scabiei mites on days 2, 4 and 10 from the beginning of treatment. On day 15 of the treatment, the skin sample showed negative result. However, his hospitalisation
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