Pentobarbital (PB) contains 40% propylene glycol (PG) and could result in lactic acidosis (LA). Previous reports have indicated PG-induced LA following PB continuous infusion (CI), but there are no reports in young children. A 3-year-old male was admitted for new-onset seizures. After failing conventional therapy, he was initiated on intravenous PB on hospital day (HD) 3. The seizures continued, and he was initiated on a PB CI on HD 5 to achieve burst suppression. His CI was titrated to 10 mg/kg/hr. On HD 15, he developed hypotension with a mean arterial pressure (MAP) in the 40's and venous lactate of 3.01 mmol/L (normal range: 0.4?2.0 mmol/L). He received epinephrine, and his PB was decreased to 8 mg/kg/hr. Over the next few weeks, he continued to have subclinical seizures and PB was increased to 10 mg/kg/hr. On HD 37, he developed hypotension with a lactate of 6.28 and osmolar gap of 20.4 mOsm/kg. He received a fluid bolus, sodium bicarbonate, and his PB was decreased to 5 mg/kg/hr. His PB was tapered off, and the decision was made to treat clinical seizures only. The World Health Organization recommends a maximum of 25 mg/kg of PG. On HD 15 and 37, our patient received more than this threshold, 1398 and 1604 mg/kg, respectively. The Naranjo probability scale supports a high-probable drug-related adverse event. Practitioners should be aware of this potential adverse event with medications containing PG. Routine monitoring of osmolar gap should be performed for patients with prolonged use or higher PB doses.

cause of morbidity and mortality in immunocompromised children with highest incidence found in children with Wiskott-Aldrich syndrome and a very low incidence of 0.6% in children with ALL. Aspergillus fumigatus is the most common cause of IA followed by aspergillus flavus, aspergillus niger, aspergillus terreus. Clinical practice guidelines of the Infectious disease society of America does not recommend empirical therapy in shorter duration of neutropenia <10days unless there are findings of invasive fungal infections. Our patient presented with hyperleukocytosis and likely had dysfunctional neutrophil function thus predisposing him to IA. He also progressed to absolute neutropenia in rapid fashion within 3days of initiation of chemotherapy. The most significant risk factor contributing to his development of IA may have been his home environment. The family lived and worked in Avondale Pennsylvania, a suburb of Philadelphia in chester County with close proximity to Kennet Square and its large mushroom farming industry. Kennet Square is noted as "The Mushroom Capital of the World" supplying over 51% of the nation's mushroom crop. Mushrooms as with other fungi, thrive in warm moist dark environment and are frequently fertilized with a soil/ manure compost that is frequently rotated by heavy equipment. This compost rotation releases spores into the air that are harmless when inhaled by immunocompetent individuals. Our patient living in this endemic area was likely exposed to high spore content of pathogenic Aspergillus species environmentally and so rapidly developed brain abscess when chemotherapy was initiated. Our case is unique as he had very rapid onset of CNS aspergillosis, with history of agricultural exposure in the setting of Pre B cell ALL. Given our hospital's geographic location, questions remain whether consideration should be given to initiate empirical antifungal therapy at treatment doses with initiation of chemotherapy.

Objectives To describe a case of successful treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with ceftaroline fosamil after failure with vancomycin and daptomycin. Case Summary A 53-year-old female with a past medical history of cancer (unknown source/type) and hypothyroidism was admitted to the hospital with cervical and paravertebral abscess with suspected sepsis. In the emergency department (ED), magnetic resonance imaging (MRI) revealed possible spinal abscess and narrowing of the spinal canal. The patient was initiated on vancomycin 1,250 mg (~15 mg/kg) every 12 hours and cefepime 2 g every 8 hours empirically. On hospital day 4, blood and wound cultures revealed MRSA susceptible to vancomycin, but with a vancomycin minimum inhibitory concentration (MIC) of 2. Repeat blood cultures were also positive on hospital days 2 and 4. Per infectious disease team consult, therapy was converted to daptomycin 8 mg/kg/day. Although the patient responded well, acute kidney injury (AKI) on hospital day 15 prompted a change in therapy to ceftaroline fosamil 400 mg intravenous every 8 hours. For the remainder of the hospital stay, blood cultures were negative and white blood cell count was within normal limits. On day 20, the patient was discharged to a long-term care facility for continued ceftaroline treatment. Discussion The management of MRSA bacteremia remains challenging due to increasing antimicrobial resistance. Although the standard therapy for serious MRSA infections is vancomycin, treatment failures are becoming common in clinical practice due to increasing MICs (≥2 μg/mL). Other therapies may include daptomycin and off-label treatment with telavancin, quinupristin/dalfopristin, or ceftaroline fosamil. This report describes a patient with paravertebral abscess and MRSA bacteremia failing 3 days of vancomycin therapy due to MIC greater than or equal to 2 μg/mL and persistent bacteremia. Treatment with ceftaroline fosamil was well tolerated and resulted in continued clinical improvement. Based on this case report, ceftaroline fosamil may be a reasonable alternative for invasive MRSA infections. Conclusions This case report describes successful treatment of MRSA bacteremia with ceftaroline in a patient who responded poorly to conventional therapy, specifically vancomycin due to an elevated MIC (2 μg/mL).