Reactions 1680, p226 - 2 Dec 2017 Various toxicities: case report A 71-year-old woman developed cystoisosporiasis that led to dehydration, hypotension, acute renal failure, acute decompensated heart failure, cardiogenic shock, macrocytic anaemia and inflammatory syndrome during treatment with methotrexate and prednisone [durations of treatment to reaction onsets and routes not stated] for rheumatoid arthritis (RA). Eventually, she died of cystoisosporiasis and few of the associated complications. The woman, who had chronic renal failure, was admitted to the emergency department due to a 3 day history of fever and severe watery diarrhoea. She had 10 bowel movements a day, impaired general condition with weight loss of 5kg within 3 weeks, and abdominal pain related to food consumption. She had been receiving immunosuppressant treatment with prednisone 6 mg/day and methotrexate 12.5 mg/week for 15 years for RA. Upon admission, she was observed to be undernourished with a BMI of 18 kg/m . A physical examination revealed signs of dehydration with skin fold and dryness of the mucous membranes, mild tachycardia and moderate hypotension. The abdominal palpation was painful. Upon investiagation, the possible cause of infection was consumption of a home cooked noodles dish with imported Asian mushrooms. Her underlined chronic renal failure was acutely exacerbated with uraemia 21.4 µmol/L and creatinine 185 µmol/L. The haemogram showed macrocytic anaemia with haemoglobin of 106 g/L, haematocrit 35% and mean corpuscular volume of 108fL. There was a slight increase in neutrophil cells. Increased CRP showed an inflammatory syndrome. A macroscopic examination of the stool showed bloodless watery and yellowish stools. A direct wet mount parasitological examination of faeces revealed numerous oocysts of Cystoisospora belli, as well as numerous Charcot- Leyden crystals. The fecal concentration methods also showed C. belli oocysts. The findings were consistent with cystoisosporiasis. The woman started receiving treatment with cotrimoxazole [trimethoprime-sulfamethoxazole]. She underwent fluid replacement and was given IV rehydration with sodium chloride solution. The treatment with methotrexate and prednisone was continued. The symptoms of diarrhoea th improved within 3 days. On the 5 day of hospitalisation, she developed a sudden cardiogenic shock and died within an hour despite quick management. Cystoisosporiasis diarrhoeal disease was considered to be directly involved in the death, through dehydration that led to hypotension, acute renal failure, cardiogenic shock and the acute decompensated heart failure in context of an immunocompromised state with methotrexate and prednisone. Author comment: "The cystoisosporiasis diarrheal disease was directly involved in the death of our patient, through dehydration leading to hypotension, acute renal failure and the decompensation of cardiac disorders in an immunocompromised context with [methotrexate and prednisone]." Post L, et al. Uncommon and fatal case of cystoisosporiasis in a non HIV- immunosuppressed patient from a non-endemic country. Parasitology International 67: 1-3, No. 1, Feb 2018. Available from: URL: http://doi.org/10.1016/ j.parint.2017.10.003 - France 803284742 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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