Ceftriaxone/methylprednisolone/tacrolimus

Abstract

Haemophilus influenzae non-type B infection and pancytopenia: case reportA 40-year-old man developed Haemophilus influenzae non-type B infection during treatment with methylprednisolone and tacrolimus for neuropsychiatric systemic lupus erythematosus (NPSLE), and subsequently, he developed pancytopenia during treatment with ceftriaxone for Haemophilus influenzae non-type B infection [not all routes and dosages stated, time to reactions onsets not stated].The man, who was diagnosed with NPSLE at the age of 32 years, started receiving induction therapy with high-dose methylprednisolone and tacrolimus. Following induction therapy, tapering of methylprednisolone was initiated. During the maintenance treatment with methylprednisolone 18 mg/day, he presented to the clinic with symptoms of a runny nose. Subsequently, a diagnosis of acute viral rhinitis was made. Ten days after the clinic visit, he developed a high fever and progressive disorder of consciousness. Hence, he was hospitalised. He had no history of pre-hospitalisation contact with children. On admission, his vital signs were as follows: body temperature: 40.9°Celcius, BP: 142/98mm Hg, pulse: 130 bpm, RR: 32 breaths/min and oxygen saturation: 98% on room air. His Glasgow coma scale score was E4V1M4. Physical examination was normal, except for significant neck stiffness. Neurologic examination revealed eyes with conjugate deviation to the right. Also, involuntary movements on both arms were noted. Laboratory examination showed lymphopenia and thrombocytopenia with mild renal failure. In view of high CRP and procalcitonin levels, severe systemic inflammations like sepsis or SLE complications were suspected. However, stable concentrations of anti-DNA antibodies revealed a low level of SLE activity. Because of significant neck stiffness, meningitis was strongly suspected. Hence, lumbar puncture was performed, and CSF analysis showed polynuclear leucocyte-dominant leucocytosis and remarkably low glucose CSF concentrations as compared with serum level. A latex agglutination test with CSF showed negative results for all antigens. The brain MRI showed high intensities in the right temporal lobe on diffusion-weighted imaging, and high intensities scattered over the sulcus of the cerebral hemisphere on fluid-attenuated inversion recovery, indicative bacterial meningitis. Based on findings, a diagnosis of bacterial meningitis was confirmed.Hence, the man was treated with meropenem, vancomycin and betamethasone. On day 2 of admission, primary smear preparation showed the presence of gram-negative bacilli, and from the blood and CSF culture, Haemophilus influenza was detected. After completion of a 3-day course of betamethasone, he started receiving methylprednisolone as maintenance therapy for SLE. On day 4, treatment with vancomycin was stopped as no Gram-positive cocci were detected. On day 5, the latex agglutination test with blood and CSF confirmed the presence of Haemophilus influenzae type f (Hif). Therefore, he was diagnosed with an invasive Haemophilus influenzae...