Multiple drugs

Abstract

Strongyloides hyperinfection, bacterial infections and lack of efficacy: 3 case reports In a case series of 3 patients (2 men and 1 woman) aged 70–72 years were described, who developed strongyloides hyperinfection, Morganella morganii infection, Streptococcus oralis infection, Granulicatella adiacens infection, vancomycinresistant Enterococcus faecium infection, Citrobacter freundii infection, Streptococcus infection, Haemophilus influenzae infection or Escherichia coli infection during treatment with prednisone, cyclophosphamide, infliximab and benralizumab for acquired haemophilia, Crohn’s disease, or allergic bronchopulmonary aspergillosis in USA. One of them exhibited lack of efficacy with ivermectin, while being treated for strongyloides hyperinfection [dosages, routes, durations of treatments to reaction onsets not stated; all outcomes of ADRs not stated]. Case 1: The 72-year-old woman had been receiving prednisone and cyclophosphamide for factor-8 inhibitor/acquired haemophilia and entecavir for chronic hepatitis B. She was admitted to the emergency department with vaginal bleeding and left lower extremity pain and swelling initially considered as cellulitis. Chest X-ray revealed no infiltrates. Urine culture grew Morganella morganii, which was sensitive to ceftriaxone. Her complete blood count showed Hb 9.9 g/dL and WBC count 6.0 × 103/μL with eosinophil count 0.060 × 103/μL. Blood cultures were drawn, and she received empiric treatment with piperacillin/tazobactam and vancomycin. Blood cultures were found positive for both Streptococcus oralis and Granulicatella adiacens. Her treatment was changed to ceftriaxone and she was continued on vancomycin. Transthoracic echocardiography and transesophageal echocardiogram did not revealed any vegetations. At this time, repeat blood cultures remained negative. On day 12 of hospitalisation, she experienced abdominal pain and fever. New blood cultures were positive for vancomycin-resistant Enterococcus faecium and Citrobacter freundii. Vancomycin was changed to daptomycin, and ceftriaxone was discontinued. A CT scan of the abdomen/pelvis was performed to evaluate abdominal pain, which revealed a 17cm haematoma in the left gluteal region. Subsequently, she developed respiratory failure, sepsis and bacteraemia, and was transferred to ICU. She was intubated for respiratory failure. Repeat chest X-ray revealed new diffuse infiltrates, which possibly due to multifocal pneumonia/acute respiratory distress syndrome. Sputum culture detected Strongyloides species on direct Gram stain. The bacterial infections and strongyloides hyperinfection was attributed to her immunosuppressive therapy. She was started received piperacillin/tazobactam and ivermectin. There was no effect with ivermectin for strongyloides hyperinfection. Eventually, she went into torsade de pointes, then ventricular fibrillation, and died. Case 2: The 71-year-old man with known medical history of Crohn’s disease, was treated with infliximab and unspecified corticosteroids. He was admitted to the emergency department with anorexia, nausea, abdominal pain, and cough, with worsening lower extremity edema and symptomatic hyponatremia. On admission, he was afebrile, tachycardic, and non-tachypnoeic. His lung examinaton showed crackles in lower lung lobes bilaterally and lower extremity oedema. Laboratory investigation showed WBC count of 6.4 × 103/μL with eosinophil count 0.090 × 103/μL, Hb 9.3 g/dL, increased platelets, and sodium level 122 meq/L. Chest Xray was normal, and abdominal X-ray showed dilated bowel loops. On third day of hospitalisation, he was transferred to the ICU due to septic shock. Chest CT revealed multifocal pneumonia with enterococcus bacteremia. Sputum culture detected Streptococcus and Strongyloides stercoralis on Gram stain. Also, urine culture and stool samples for ova and parasite revealed S. stercoralis. Subsequently, he was diagnosed with disseminated Strongyloides with hyperinfection syndrome (pulmonary exacerbation and gastrointestinal manifestations). His Strongyloides immunoglobulin-G antibody titer was 3.0. Another workup revealed negative QuantiFERON gold and HIV testing. The bacterial infections and strongyloides hyperinfection was attributed to his immunosuppressive therapy. He received treatment with ivermectin 14 days. He showed clinical improvement and was discharged to home. He was doing well. Case 3: The 70-year-old man with a history of allergic bronchopulmonary aspergillosis was treated with chronic prednisone therapy and benralizumab monthly infusions. He presented to the ED with worsened dyspnoea. His complete blood count revealed Hb level of 12.1 g/dL and eosinophil count 103 /μL. He started receiving unspecified steroids and nebulization. Sputum cultures showed growth of Haemophilus influenzae, and he was started on doxycycline. Second set of sputum cultures grew Escherichia coli. His treatment changed to amoxicillin/clavulanic acid. Steroids were tapered but minimal clinical improvement was observed. Chest CT revealed new onset scattered ill-defined nodules. On day 9, he developed new haemoptysis. A bronchoscopy and transbronchial biopsy were performed, and bronchoalveolar lavage (BAL) fluid revealed Strongyloides. The BAL cytology showed multiple larvae. Serum Strongyloides antibodies were increased. The bacterial infections and strongyloides hyperinfection was attributed to his immunosuppressive therapy. He received ivermectin for 7 days, and the dose of steroids was reduced. He was discharged on ivermectin with a steroid taper. He was clinically doing well since discharge.