Prednisolone
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Genitourinary melioidosis and diabetes mellitus: case report A 38-year-old man developed diabetes mellitus (DM) and genitourinary melioidosis during treatment with prednisolone. The man presented with a 3-day history of increased urine frequency, swelling of the scrotum, dysuria, pain and fever. Six weeks prior to this presentation, he had been assessed for proteinuria and generalised oedema. At that time, he was nondiabetic. Two weeks before, he had received a course of ciprofloxacin for a presumed urinary infection, which showed symptomatic improvement. Six days after completion of the antibiotics, he developed severe systemic symptoms. He was subsequently diagnosed with IgA nephropathy and started receiving treatment with oral prednisolone 60 mg/day (1 mg/kg/day). He continued taking prednisolone but missed his follow-up visits. Due to increased symptoms, he was admitted to a hospital in Bangladesh for further management (the current presentation). Upon admission, examinations revealed a body temperature of 101°F. He also showed minimal bipedal oedema and appeared pale. His inguinal lymph nodes were not palpable and the scrotum was tender and swollen. Urine examinations showed proteinuria and glycosuria. Additionally, capillary blood glucose level was noted to be 24 mmol/L. Subsequent laboratory tests were significant for neutrophil leucocytosis, low serum sodium, elevated levels of ESR, HbA1c and serum creatinine. He was diagnosed with DM, and the DM was determined to be induced by prednisolone (steroid-induced DM). Multiple pus and red cells were seen in the urine. Slight thickening of bilateral scrotal walls, enlarged and non-homogeneous tail of the right epididymis and testes, mild ascites, small pleural effusions and small loculated collection in the left tunica vaginalis were observed on an ultrasonogram. Examinations for HIV serology were negative, but urine culture was positive for B. pseudomallei. Hence, based on the clinical presentation and investigational findings, he was diagnosed with genitourinary tract infection due to B. pseudomallei epididymo-orchitis (genitourinary melioidosis). Risk factors for genitourinary melioidosis included steroid therapy with prednisolone and IgA nephropathy. The man was therefore treated with ceftriaxone, which was later changed to ceftazidime, cotrimoxazole and doxycycline. His DM was treated with insulin. He also received various other medications as supportive therapy. Over the next 12 months, he was followed-up and his prednisolone was gradually tapered off. He showed significant improvement at a visit 2 years after diagnosis of IgA nephropathy. His total protein and serum creatinine were found to be normal, without requiring anti-diabetic therapy. The melioidosis did not recur. Author comment: "Genitourinary Melioidosis in a Bangladeshi Farmer with IgA Nephropathy Complicated by Steroid-induced Diabetes Mellitus." "Other underlying conditions that have been associated with genitourinary melioidosis include alcoholism, renal transplantation, steroid therapy,
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