Antibacterials/pembrolizumab

Abstract

Clostridium difficile infection and hypothyroidism: case report A 59-year-old man developed hypothyroidism during treatment with pembrolizumab. Later, he developed Clostridium difficile infection secondary to amoxicillin/clavulanic-acid, cefuroxime and clarithromycin. The man was diagnosed with lung cancer in April 2019. He had several co-morbidities including acute appendicitis, squamous cell carcinoma of the lower jaw, depressive syndrome and renal insufficiency stage II. He underwent regional chemotherapy with paclitaxel, adjuvant radiotherapy with cisplatin. In May 2019, disease progression was noted, and he was referred to other clinic for treatment. Then, he was noted to have lung cancer stage IVA (T4N0M1b). His performance status was good except for mild fatigue, loss of appetite and burning sensation in the chest. He started receiving pembrolizumab from June 2019. After 5 cycles (September 2019), sub-complete regression was noted. Further, pembrolizumab treatment was continued. Before the administration of the seventh cycle of pembrolizumab (October 2019), he developed myalgia, arthralgia stage I–II, dyspeptic problems with vomiting, low fever with chills and sweating. Laboratory investigations showed increased of CRP, creatinine and uric acid. He was also noted to have decreased TSH. Then, he was orally rehydrated and received paracetamol and cefuroxime. Subsequently, his condition started improving. In November 2019 (pembrolizumab cycle 9), he developed dyspepsia with vomiting. He was more tired, sleeping, and developed arthralgia stage I. Laboratory investigation again showed a slight increase in CRP, creatinine and decrease in fT4 (free thyroxine) and TSH. The immunotherapy was continued due to the assumed immune origin of thyroid disease. The man was treated with unspecified hormone replacement therapy and prednisone. Eventually, a clinical improvement was noted. In February 2020, he was hospitalised due to fever, increased CRP and leucocytes. Thus, he started receiving a combination of amoxicillin/clavulanic acid [Amoxiclav] and clarithromycin [Klacid]. At the time of discharge, his CRP decreased without clinical improvement. His sub-febrile stage persists, and was noted to have unsystematic vertigo, slurred speech, new and watery green diarrhoea. Thus, he received unspecified probiotics; however no effect was noted. At a follow-up, his condition was noted to be worse. Thus, he was admitted and received metronidazole for possible Clostridium difficile infections. His condition started improving but he was subsequently hospitalised in the follow-up care facility for 4 weeks due to persistent malcondition. During a follow-up in March 2020, he lost 20kg during the entire course of the complaints. He was also treated with megestrol [megestrol acetate]. In April 2020, his condition improved significantly. He continued pembrolizumab therapy and increased unspecified hormone replacement therapy. Currently, after the 17 cycles of treatment, his clinical condition was good. Later, it was confirmed that the hypothyroidism was associated with pembrolizumab, and the Clostridium difficile infection was caused due to antibacterial therapy with amoxicillin/clavulanic acid, cefuroxime and clarithromycin.