Sirolimus
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Pyogenic periungual infection: case report An 18-year-old male renal transplant recipient developed chronic pyogenic periungual infection during treatment with sirolimus. The boy presented with a 1-day history of fever and chills; 3 years earlier he had undergone renal transplantation, after which he had started receiving sirolimus 5 mg/day, prednisone and tacrolimus. Several months before presentation, he had been diagnosed with paronychia and had received oral antibacterials unsuccessfully until 2 weeks before presentation. On presentation, he reported increasing pain and swelling of his left thumb and part of his hand [time to reaction onset not clearly stated]. On examination, he had a diffusely swollen left hand with an erythematous, warm and exquisitely tender first digit; he had a periungual suppurative ulceration and could not extend or flex his thumb. A culture of the pus from the ulcer grew Staphylococcus aureus, Streptococcus milleri and Peptostreptococcus anaerobius. His serum C-reactive protein level and sedimentation rate were 18 mg/L and 20 mm/h, respectively. Bone scan findings indicated soft tissue cellulitis or tenosynovitis. X-ray showed an early periosteal reaction of the anterolateral region of the distal shaft of his proximal phalanx. The boy underwent surgical debridement of his thumb and started receiving IV ticarcillin/clavulanic acid. Sirolimus was tapered and then replaced by mycophenolate mofetil. Over 1–2 weeks, his ulcerations healed and the swelling and erythema of his thumb gradually improved; however, pain resolution appeared to take longer. After 4 weeks, the antibacterials were replaced by oral moxifloxacin and he received dressings with silver-coated mesh. [Patient outcome not clearly stated.] Author comment: "Sirolimus is known to have several adverse cutaneous effects . . . presumably by reducing plasma and tissue levels of epidermal and vascular growth factors, which may compromise normal tissue healing. A similar mechanism may have contributed to the protracted course of the infection and the lack of response to previous [antibacterial] treatments." Raju DL, et al. Sirolimus-associated chronic pyogenic periungual infection. Kidney 801072841 International 71: 476, No. 6, Mar 2007 - Canada
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Reactions 5 May 2007 No. 1150
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