Multiple drugs

Abstract

Methaemoglobinaemia, haemolytic anaemia and hypersensitivity reaction : case report A 22-year-old woman developed methaemoglobinaemia and haemolytic anaemia during treatment with dapsone for multibacillary leprosy. Additionally, she developed hypersensitivity reaction during treatment with amoxicillin/clavulanic acid and doxycycline as melioidosis eradication therapy [routes not stated; duration of treatments to reaction onsets not stated clearly]. The woman presented with multiple copper-colored macules and patches with loss of sensation to pinprick and light touch, dryness and loss of hair. Based on the clinical investigation, multibacillary leprosy was diagnosed. She started receiving standard multidrug therapy (MDT) consisting of dapsone 100 mg/day, clofazimine and rifampicin. However, on day 26 of initiation of MDT therapy, she was hospitalised with dyspnoea and high-grade fever with chills. Upon examination, she was found to have tachypnoea and tachycardia. Her oxygen saturation under room air was 75–78%, and it did not increase following usage of a non-rebreathing mask with 15 L/min oxygen. Additionally, she appeared pale, jaundiced, and cyanotic. Her radial arterial and venous blood was dark colored. Arterial blood gas under room air showed partial pressure of oxygen of 125mm Hg and partial pressure of carbon dioxide of 88mm Hg. Her clinical symptoms were consistent with methaemoglobinaemia. Subsequent laboratory examination showed haemoglobin of 5.4 g/dL, reticulocyte count of 4.1%, lactate dehydrogenase of 1512 U/L, and predominantly indirect hyperbilirubinaemia. Her peripheral blood smear and laboratory findings were consistent with haemolysis with spherocytes. She was diagnosed with haemolytic anaemia. Based on symptoms and investigational findings, she was diagnosed with methaemoglobinaemia and haemolytic anaemia secondary to dapsone. The woman was treated with hydrocortisone, folic acid and packed cell transfusion for haemodynamically significant anaemia. Clofazimine, rifampicin and dapsone were discontinued. Due to the clinical evidence of sepsis, thorough infective screening were performed which returned negative. The melioidosis enzyme-linked immunosorbent assay (ELISA) immunoglobulin (Ig)M antibody titer was 1:640. Abdominal ultrasonography showed multiple splenic micro-abscesses. She was diagnosed with concurrent melioidosis infection. She was treated with methylene blue in addition to hyperhydration, forced alkaline diuresis, and parentrovite containing ascorbic acid for methaemoglobinaemia. She also received ceftazidime for melioidosis. Her haemolysis resolved and SpO2 level gradually improved. Subsequently, she was discharged on amoxicillin/clavulanic acid 1250mg 3 times daily and doxycycline 100mg twice daily as melioidosis eradication therapy. However, after few days, she developed hypersensitivity reaction, manifesting as pruritic, erythrodermic-like skin rashes which was attributed to amoxicillin/clavulanic acid and doxycycline. Her antibiotic therapy was withheld. She received treatment with topical emollient and unspecified steroid and antihistamine. Thereafter,hypersensitivity reaction completely resolved. Her antibiotic therapy was switched to cotrimoxazole which she received for total 12 weeks. Repeat serum melioidosis ELISA results were negative with complete resolution of splenic micro-abscesses. However, after 4 weeks of full-dose cotrimoxazole and 5 months of MDT, she developed erythematous nodular skin lesions over her face and bilateral upper and lower limbs. She was diagnosed with type II lepra reaction. She was treated with prednisolone, clofazimine and ofloxacin. Thereafter, her symptoms improved. Prednisolone was tapered off over a 6 month period. After 12 months of leprosy treatment, her skin lesions resolved.