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Ko AWK, Ghaffari-Rafi A, Chan A, Harris WB, Imasa A, Liow KK, Viereck J. A Case Report of Antibiotic-Induced Aseptic Meningitis in Psoriasis. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2021; 80:129-133. [PMID: 34195619 PMCID: PMC8237324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Although frequently prescribed, certain antibiotics such as trimethoprim-sulfamethoxazole carry the risk of a rare yet life-threatening adverse effect, termed drug-induced aseptic meningitis. Morbidity can be avoided if the medication is identified and discontinued. Patients in reported cases tend to be female and have an autoimmune disease or prior adverse reaction to the offending agent. As a rare and poorly characterized condition, the subset of patients using antibiotics at risk for aseptic meningitis remains unclear; hence, cataloging these adverse events remains critical for better elucidating the disease. Here, we report a 62-year-old man with psoriasis and no prior history of sulfa allergy, who presented with a sudden onset of fever, chills, vomiting, and muscle aches 5 hours after taking single doses of trimethoprim-sulfamethoxazole and ciprofloxacin. Common infectious causes were ruled out, and his medications were discontinued. Despite initial symptom resolution with discontinuation, the patient neurologically deteriorated over the next two days before eventually recovering with supportive care. This case highlights the variable presentation of drug-induced aseptic meningitis. In contrast to previous reports of drug-induced aseptic meningitis, our patient was male, older than the median age of 40 years, and did not have a prior adverse reaction to the antibiotic. Furthermore, to the best of our knowledge, we report a possible case of antibiotic-induced aseptic meningitis in a patient with psoriasis. Lastly, the case emphasizes not only the value of a thorough medication history but also the importance of recognizing that patients may deteriorate in the first 48 hours before resolution.
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Affiliation(s)
- Andrew Wai Kei Ko
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Arash Ghaffari-Rafi
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Alvin Chan
- University of California Riverside School of Medicine, Riverside, CA (AC)
| | - William B. Harris
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Arcelita Imasa
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
| | - Kore Kai Liow
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
- Hawai‘i Pacific Neuroscience Institute, Honolulu, HI (KK, JV)
- John A. Burns School of Medicine, Clinical and Translational Research, Department of Quantitative Health Sciences, University of Hawai‘ at Mānoa, Honolulu, HI (KK, JV)
| | - Jason Viereck
- John A. Burns School of Medicine, University of Hawai‘i at Mānoa, Honolulu, HI (AWKK, AG, WBH, AI, KK, JV)
- Hawai‘i Pacific Neuroscience Institute, Honolulu, HI (KK, JV)
- John A. Burns School of Medicine, Clinical and Translational Research, Department of Quantitative Health Sciences, University of Hawai‘ at Mānoa, Honolulu, HI (KK, JV)
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Bruner KE, Coop CA, White KM. Trimethoprim-sulfamethoxazole-induced aseptic meningitis-not just another sulfa allergy. Ann Allergy Asthma Immunol 2014; 113:520-6. [PMID: 25240332 DOI: 10.1016/j.anai.2014.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/06/2014] [Accepted: 08/11/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To review the literature on trimethoprim-sulfamethoxazole (TMP-SMX)-induced aseptic meningitis (TSIAM) and discuss the features, possible mechanisms, evaluation, and treatment options relevant for the allergist. DATA SOURCES A MEDLINE search was performed using the terms aseptic meningitis, trimethoprim-sulfamethoxazole, trimethoprim, and sulfamethoxazole. STUDY SELECTIONS Cases were included that fit the case definition of headache, neck pain, or change in mental status with elevated cerebrospinal fluid white blood cell count or protein attributable to TMP-SMX or either medication alone. RESULTS Forty-one patient cases were reviewed. There was a predominance of female patients and patients with autoimmune disease reported. Fever, headache, neck pain, and altered mental status were the most common findings reported in TSIAM reactions. Severe reactions ranged from hypotension to seizure and unconsciousness or coma. Typical cerebrospinal fluid findings included elevated white blood cell count with neutrophil predominance, elevated protein, and normal glucose. Symptoms quickly remitted with withdrawal of TMP-SMX, typically over 48 to 72 hours. Full recovery was typically experienced, although permanent paraplegia was reported in 1 case. The mechanism of reaction is unknown, although an IgE-mediated reaction is unlikely. Many patients experienced multiple TSIAM reactions before the diagnosis was made. Diagnosis can be confirmed with drug challenge or graded test dosing when necessary. Patients with TSIAM subsequently reacted to TMP and SMX alone and therefore should be advised to avoid these 2 classes of medication after diagnosis. CONCLUSION TMP-SMX is the most common antibiotic to cause drug-induced aseptic meningitis. By being aware of this reaction, allergists are well poised to diagnose TSIAM and prevent future reoccurrences for the patient.
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Affiliation(s)
- Karen E Bruner
- Department of Allergy/Immunology, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas.
| | - Christopher A Coop
- Department of Allergy/Immunology, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas
| | - Kevin M White
- Department of Allergy/Immunology, Wilford Hall Ambulatory Surgical Center, San Antonio, Texas
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Naitoh T, Yamamoto M, Kawakami K, Suzuki C, Naishiro Y, Yamamoto H, Takahashi H, Shinomura Y. [Case of systemic lupus erythematosus repeated with various allergic reactions by trimethoprim-sulfamethoxazole]. ACTA ACUST UNITED AC 2010; 32:492-8. [PMID: 20046017 DOI: 10.2177/jsci.32.492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 23-year-old Japanese woman was diagnosed with lupus nephritis on May 2007. The patient was prescribed 30 mg/day of prednisolone, but developed a pulmonary abscess and was admitted to Sapporo Medical University Hospital in March 2008. Antibiotics improved the symptoms. We prescribed trimethoprim-sulfamethoxazole as prophylaxis for pneumocystis pneumonia; however, the patient developed fever and thrombocytopenia with hyperferritinemia after a week of this prophylaxis. We considered that she was developing hemophagocytic syndrome, and administered methylprednisolone pulse therapy. The clinical findings soon improved. However, when the prophylaxis was restarted, the patient developed fever, headache, and anaphylaxis the same day. Symptomatic therapy resolved these symptoms after three days, but they recurred on recommencing trimethoprim-sulfamethoxazole. Analysis of the cerebrospinal fluid revealed aseptic meningitis. These episodes were thought to be induced by trimethoprim-sulfamethoxazole. As trimethoprim-sulfamethoxazole is frequently used as prophylaxis for pneumocystis infection in immunosuppressed patients, clinicians should be vigilant regarding the complications of this treatment, particularly the rare occurrence of aseptic meningitis and anaphylaxis.
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Affiliation(s)
- Takafumi Naitoh
- First Department of Internal Medicine, Sapporo Medical University School of Medicine
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Abstract
Drug-induced aseptic meningitis (DIAM) has been reported as an uncommon adverse reaction with numerous agents. It is a diagnosis of exclusion, and clinical signs and CSF findings vary greatly. The body of evidence regarding DIAM is largely in the form of anecdotal case reports and must be interpreted carefully bearing this in mind. The major categories of causative agents are nonsteroidal anti-inflammatory drugs, antimicrobials, intravenous immunoglobulin, intrathecal agents, vaccines and a number of other less frequently reported agents. There appears to be an association between DIAM and connective tissue disease, particularly systemic lupus erythematosus, and ibuprofen. There are 2 major proposed mechanisms for DIAM. The first involves direct irritation of the meninges by intrathecal administration of the drug, and the second involves immunological hypersensitivity to the drug, most likely type III and type IV hypersensitivity. Recognition and diagnosis of DIAM is important, as it is treatable by withdrawal of the drug and recurrence is prevented. The outcome of DIAM is generally good, usually without long term sequelae. This article describes the case reports of DIAM in the current literature and discusses the diagnosis and management of this rare complication.
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Affiliation(s)
- S Jolles
- Division of Cellular Immunology, National Institute for Medical Research, London, England.
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