Reactions 1680, p174 - 2 Dec 2017 Various toxicities: case report An 8-year-old boy developed urinary tract infection, rhinovirus infection, during treatment with antithymocyte globulin, prednisone, tacrolimus, sirolimus, methylprednisolone, betamethasone dipropionate and mycophenolate mofetil; he also developed mouth ulcers and hyperlipidaemia due to sirolimus and acute kidney injury with dehydration and neutropenia due to tacrolimus [not all dosages and routes stated; durations of treatments to reactions onsets not stated]. At the age of 2 years, the boy had a history of contracted staphylococcal sepsis with systemic ischaemic injury, which led to quadrimembral amputation and kidney failure. At the age of 4 years, he had undergone living-related kidney transplantation. At that time, he was administered immunosuppressive regimen for induction and was maintained on a steroid-free protocol with mycophenolate mofetil 270 mg/m2 per dose and tacrolimus (trough levels 4 6 ng/mL). At the 6 years of age, he presented for seeking lower extremity prosthetics, which was unsuccessful. He was then referred for the vascularised composite allotransplantation (VCA) programme, for assessment as an upper extremity transplant candidate. He successfully underwent VCA procedure. Post-transplantation surveillance included daily physical examination of the limbs and pulse oximetry to monitor tissue perfusion. Weekly skin biopsies were also performed. Seven weeks later, he was discharged. Postoperatively, he received treatment with antithymocyte globulin 1.5 mg/kg for 4 days with IV methylprednisolone 10 mg/kg, mycophenolate mofetil 600 mg/m per dose and tacrolimus 0 03% ointment. Later, methylprednisolone was administered at 15 mg/kg for one day, followed by 1.5 mg/kg for three days. At week 3, he had his first rejection episode, which improved following treatment with IV methylprednisolone, topical betamethasone dipropionate 0.05% ointment and topical tacrolimus. A month later, bilateral grade I rejection recurred but responded to betamethasone treatment. His serum creatinine level increased from 0 5 g/dL to 0 7 g/dL. The creatinine level increase was presumed to be secondary to tacrolimus. Therefore, sirolimus was added to the treatment to enable reduction in tacrolimus. He had serious rejection episodes in month four and seven, for which he received topicl tacrolimus, topical betamethasone and IV methylprednisolone. The dose of oral prednisone was tapered gradually depending on the timing of the resolution of the rejection episode. He further developed several episodes of rejection which were cleared by adjusting tacrolimus or sirolimus doses. He developed several adverse events during the first year of therapy, which included urinary tract infection, rhinovirus infection, two episodes of acute kidney injury associated with dehydration and neutropenia. All these responded well to granulocyte-colony stimulating factor therapy. He also developed sirolimus related mouth ulcers and hyperlipidaemia, which were treated with triamcinolone and statin, respectively [not all outcomes stated]. Author comment: "This child. . .was already exposed to immunosuppression and the associated risks of systemic complications, such as diabetes, infections, and malignancy." "[T]he serum creatinine concentration increased. . .presumed to be secondary to tacrolimus". "[T]he patient is likely to have incurred some degree of chronic renal injury with persistent increase in creatinine". "Related to the sirolimus, the patient experienced mouth ulcers. . .and hyperlipidaemia". Amaral S, et al. 18-month outcomes of heterologous bilateral hand transplantation in a child: a case report. The Lancet Child and Adolescent Health 1: 35-44, No. 1, Sep 2017. Available from: URL: http://doi.org/10.1016/ S2352-4642%2817%2930012-3 - USA 803285137 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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