Mycophenolate mofetil/prednisolone/tacrolimus
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Mycophenolate mofetil/prednisolone/tacrolimus Chronic osteomyelitis: case report
A 25-month-old boy developed chronic osteomyelitis during treatment with mycophenolate mofetil, prednisolone and tacrolimus as an immunosuppressant therapy [routes, durations of treatments to reactions onset and outcome not stated; not all dosages stated]. The boy presented with pain in the mid shaft of his humerus and he was not using his left arm. A radiographic image showed a mid-diaphyseal fracture. Within 2 weeks, he was able to move his arm normally and had no pain. At the age of 1 month, he had undergone a Kasai procedure due to extrahepatic biliary atresia complicated by cirrhosis and later a Broviac catheter was placed to support his poor nutrition. Ten days after his fracture, he developed bacteremia line from Enterococcus faecalis (E. faecalis). The central venous catheter was replaced, and he was treated with vancomycin and piperacillin/tazobactam for 32 days. Four weeks after his fracture and 3 weeks after his bacteremia, he underwent a liver transplantation. Following the liver transplant, he was placed on prednisolone, tacrolimus 2.25mg and mycophenolate mofetil along with valganciclovir. Seven weeks after his fracture and 3 weeks after his liver transplant, a follow-up radiographs showed a healed mid-diaphyseal fracture in the left humerus but also revealed an infiltrative process proximal to the fracture. Due to suspicion by the radiologist and orthopedist for osteomyelitis an MRI of the left humerus was obtained. His differential diagnosis included chronic osteomyelitis secondary to organisms such as Staphylococcus aureus, Kingella kingae, and Group A Streptococcus. A malignancy was also included in the differential diagnosis. The boy underwent irrigation and debridement of the left humerus with cultures and pathological bone specimens were collected and sent for further analysis. The orthopedic surgeon reported non-suppurative fragmentation of the left humerus. Hence, curettage was performed and collected fragments were sent for culture and histology. Histological analysis of bone fragments showed reactive bone formation with fibrosis and chronic inflammatory infiltrates not consistent with malignancy nor acute osteomyelitis. Pathologic diagnosis was chronic osteomyelitis and cultures, microscopy and stains of the samples were negative for Mycobacterium, fungi, aerobic and anaerobic bacteria including Kingella kingae. Thereafter, a PICC (peripherally inserted central catheter) line was placed and he was started on vancomycin, ceftriaxone and fluconazole. Subsequently, because of technical issues with his PICC line, he was changed to oral linezolid and cefdinir. Antibiotics were continued for 30 days. All cultures remained negative, and his final diagnosis was chronic osteomyelitis. Based on these findings and clinical presentation it was concluded that the immunosuppressant therapy with mycophenolate mofetil, prednisolone and tacrolimus might have contributed in the development of chronic osteomyelitis. Konda M
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