Mycophenolate mofetil/prednisolone/tacrolimus
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Bacterial and fungal infections: case report A 39-year-old man developed recurrent Salmonella enteritidis bacteraemia, Salmonella enteritidis urinary tract infection, refractory lung fungal infection and Klebsiella pneumoniae infection during an immunosuppressant therapy with tacrolimus, prednisolone and mycophenolate mofetil [routes and time to reactions onsets not stated]. The man was hospitalised to the nephrology unit due to fever on 31 August 2007. In April 2007, he had undergone a renal transplantation due to chronic renal failure. He had been receiving tacrolimus 2 x 6mg tablet, prednisolone 20 mg/day and mycophenolate mofetil 2 x 750mg tablet for around 4 months. He had been experiencing fever, chill, shivering, cough and shortness of breath for 1 week. On admission, physical examination revealed the following: body temperature 39.2°C, BP 140/70mm Hg, pulse rate 108 /minute and RR 20 /minute. During auscultation, rales were noted in the middle zone of the right lung. Laboratory investigations revealed the following: haemoglobin 9.1 g/dL, WBC count 5970 /mm3 (90% polymorphonuclear leukocytes, 5% lymphocytes), platelet 170.000 /mm3, blood urea nitrogen 78 mg/dL, creatinine 3.1 mg/dL, sodium 130 mEq, potassium 3.0 mEq, albumin 1.7 g/dL and normal liver function tests. Urine microscopy was unremarkable. On anamnesis, it was found out that he had been initially hospitalised 15 days prior to the current admission for acute gastroenteritis. At that time, stool culture did not reveal any pathogenic bacteria and ciprofloxacin and metronidazole were given over the course of 10 days. At current admission, a thoracic CT was performed for further consideration upon the detection of infiltration in the right upper zone in the posterior to anterior chest x-ray. The thoracic CT demonstrated a high number of cavitary lesions and some nodular lesions in the lung basals. He was initiated on liposomal amphotericin-B considering the fungal pulmonary infection. Due to recurrent fever, a urine microscopy was repeated two days later and showed pyuria and gram-negative bacilli in gram staining. Therefore, meropenem was also added in an assumption of nosocomial urinary tract infection. Both blood and urine culture revealed Salmonella enteritidis. It was found that he had been infected with Salmonella enteritidis (growth seen in blood culture taken during the previous hospitalisation) during the previous hospitalisation (i.e. 15 days prior to the current admission). At the current admission, his fever continued despite treatment with meropenem and liposomal amphotericin B. A repeat thorax CT demonstrated increase in the cavitary lesions when compared to the previous CT. Therefore, liposomal amphotericin B was discontinued. The man was initiated on caspofungin and voricanozole considering a refractory lung fungal infection. On the 4th day of caspofungin and voriconazole initiation, his fever decreased, general condition improved and control blood cultures and urine cultures were found to be negative. Meropenem was stopped on the
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