Various drugs
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Off-label use, optochiasmatic arachnoiditis as paradoxical reaction: case report A 7-year-old girl developed optochiasmatic arachnoiditis as a paradoxical reaction while receiving treatment with isoniazid, rifampicin, pyrazinamide and moxifloxacin for tuberculosis (TB) meningitis. Thereafter, she received off-label treatment with infliximab for paradoxical reaction [routes not stated]. The girl was hospitalised with a 7 day history of vomiting, fever and headache. Initial findings showed hyponatraemia and lymphopenia with a normal chest radiograph. She was initiated on IV ceftriaxone. Furthermore, chest CT scan showed localised tree-in-bud nodules around a calcific focus in the right middle lobe with calcified right hilar lymph nodes consistent with TB infection. Subsequently, she was initiated on antitubercular treatment with rifampicin 15 mg/kg daily, isoniazid 15 mg/kg daily, moxifloxacin 10 mg/kg daily and pyrazinamide 35 mg/kg daily along with IV dexamethasone 0.15 mg/kg 6 hourly. Eight weeks after initiating treatment, she reported recurrence of headache, nocturnal polyuria and sore eyes. On examination, she had Cushingoid features with normal neurology. A formal ophthalmologic evaluation showed decreased visual acuity of 6/12 bilaterally. The brain MRI revealed a new hyperintense mass lesion in the suprasellar cistern extending into the sella and the anterior recess of the third ventricle. The mass encased the optic chiasm and optic tracts, extending into the Sylvian fissures, consistent with optochiasmatic arachnoiditis. Because of the notable risk of the further vision impairment related to this inflammatory mass, she was reinitiated on IV dexamethasone 0.15 mg/kg 8 hourly with off label infliximab 5 mg/kg. One week after, repeat MRI revealed remarkable reduction in the size of the inflammatory mass and her visual acuity returned to baseline. Further, she received 2 doses of infliximab 5 mg/kg after 2 and 6 weeks and continued on prednisolone for 2 weeks before slow weaning over 8 weeks. At 6 month follow-up, she remained well with no visual symptoms. Abo Y-N, et al. Successful Treatment of a Severe Vision-Threatening Paradoxical Tuberculous Reaction with Infliximab: First Pediatric Use. Pediatric Infectious Disease 803521653 Journal 39: e42-e45, No. 4, Apr 2020. Available from: URL: http://doi.org/10.1097/INF.0000000000002578
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Reactions 19 Dec 2020 No. 1835
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