Multiple drugs

Abstract

Multiple drugs Pneumatosis intestinalis: case report A 73-year-old man developed pneumatosis intestinalis (PI) during immunosuppressive treatment with prednisone and mycophenolate mofetil and antibacterial treatment with vancomycin, azithromycin and piperacillin/tazobactam for bacterial pneumonia [routes not stated, not all dosages stated]. The man with end-stage renal disease underwent deceased donor renal transplant in 2013. Thereafter, he started receiving immunosuppressive maintenance therapy with tacrolimus, prednisone and mycophenolate mofetil. Mycophenolate mofetil was later discontinued and dose of prednisone was increased. On 15 February 2020, he presented with shortness of breath to an outside hospital. On presentation, he was afebrile, hypertensive and tachypnoeic. He was clinically fluid overloaded and in atrial fibrillation with rapid ventricular response. He also had an acute kidney injury. On admission, a chest X-ray revealed bilateral interstitial opacities, suggesting multifocal pneumonia. Laboratory test showed white cell count (WCC) 16.7 k/mm 3 , LDH 525 U/L and ALT 34 U/L. He was admitted to the ICU and was intubated on day 2 of admission for acute respiratory failure. As per the outside hospital records, he was treated for a provisional diagnosis of Pneumocystis jiroveci pneumonia (PJP). Though, he was on chronic immunosuppression and his findings of bilateral interstitial opacities were consistent with multifocal pneumonia. Initially, he was started on cotrimoxazole [trimethoprim/sulfamethoxazole], which was quickly switched to clindamycin and primaquine due to hyperkalaemia. Additionally, he was started on high dose prednisone with taper as part of PJP treatment protocol. PJP polymerase chain reaction (PCR) tested negative. Subsequently, the presumptive diagnosis of PJP was changed to bacterial pneumonia. He was started on broad spectrum antibiotics, which included vancomycin, azithromycin and piperacillin/tazobactam for bacterial pneumonia. On 18 February 2020, a transoesophageal echocardiogram was negative for endocarditis and valvular dysfunction. Ventilator requirements increased. Serial chest X-ray findings were concerning for multifocal pneumonia and suggestive of acute respiratory distress syndrome (ARDS). On 26 February 2020, a CT scan of the chest, abdomen and pelvis confirmed diffuse lung opacities and small pleural effusions with no intra-abdominal findings. The presumptive diagnosis of bacterial pneumonia remained and he completed an extended course of antibiotics. On 02 March 2020, he was finally extubated. His remainder course was uncomplicated. He was discharged to inpatient rehabilitation facility (IRF). On 04 March 2020, the level ferritin was 966 ng/mL. No other inflammatory markers were obtained throughout the duration of the his stay. On arrival at the IRF, he was afebrile and hypertensive. He had a regular HR and RR with appropriate oxygen saturation on room air. Laboratory test showed WCC was 12.6 k/mm 3 , normal ALT and elevated ferritin. On day 9, LDH and CRP were sl...