Methylprednisolone
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Methylprednisolone Multidrug-resistant Acinetobacter infection: case report
An 11-year-old girl developed multidrug-resistant Acinetobacter infection during steroid therapy with methylprednisolone. The girl, who was accidentally exposed to chlorine fumes during disinfection in a swimming pool in Colombo, Sri Lanka, was admitted to the ICU. She was previously healthy. On admission, she was found to have severe respiratory distress syndrome, tachycardia, hypotension and widespread rhonchi. Her oxygen saturation, which was 40-50%, increased to 83% with face-mask humidified oxygen. The radiograph showed bilateral haziness of the lung fields. She received methylprednisolone [route and dosage not stated], ceftriaxone and salbutamol. By the second day, multiple inotropes [specific drug not stated] were given to maintain her BP. Her serum troponin levels were elevated but echocardiography was normal. She was severely tachypneic with respiratory rates of 80 breaths per minute. Blood gases showed respiratory acidosis. The chest radiograph showed worsening bilateral shadows. Her CRP was elevated. Meropenem and teicoplanin were added. She had tonic convulsions with opisthotonos managed with midazolam. By the third day, her bronchospasms worsened and salbutamol, magnesium sulfate [magnesium sulphate], ketamine, theophylline, sodium bicarbonate and an unspecified surfactant were added. She had an apnoeic attack. As a result, she was intubated and ventilated. Haemofiltration was started to reduce pulmonary oedema and inflammatory mediators. The ventilator settings were increased. She was hospitalised to another hospital in Sri Lanka for venovenous extracorporeal membrane oxygenation. She underwent venovenous extracorporeal membrane oxygenation. Her condition stabilised rapidly over the following few hours. The ventilator settings were gradually reduced to rest settings. Her haemodynamics were stable without inotropes. She was sedated with morphine and midazolam. Standard heparinization protocols were followed with a target activated clotting time of 180–200 seconds. Over the following 48 hours, chest radiographs improved briefly, but worsened thereafter with fever, neutrophilic leukocytosis and a CRP of 160 mg/L. Multidrug-resistant Acinetobacter species was cultured from endotracheal secretions. A diagnosis of Acinetobacter infection secondary to methylprednisolone therapy was made [duration of treatment to reaction onset not stated]. Based on antibiotic sensitivity, the girl’s antibiotics were changed to cefoperazone/sulbactam and cotrimoxazole and then to tigecycline. On the 6th day, there was surgical emphysema, pneumomediastinum and a right-sided pneumothorax which was surgically drained by thoracostomy. By the 9th day, she was trialled-off and decannulated after 238hours of extracorporeal membrane oxygenation and extubated the following day. Six months later, her chest radiographs and lung function tests were normal. She returned to school, swimming and diving. She was schedule for yearly follow-up. Harischandra T, et
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