Reactions 1871, p138 - 4 Sep 2021

(1)

Reactions 1871, p138 - 4 Sep 2021

Cyclophosphamide/methylprednisolone/prednisolone

S Multiple infections: case report

A 69-year-old woman experienced Enterococcal urinary infection, Covid-19 infection and Acinetobacter infection following immunosuppression therapy with cyclophosphamide, prednisolone and methylprednisolone for antineutrophil cytoplasmatic antibody (ANCA)-associated vasculitis (AAV).

The woman, who had multiple morbidities, presented to hospital with malaise, dry cough and sub-febrile temperatures for 1 month. Multiple analyses were undertaken, and following admission, she developed a rapid increase in creatinine. Nine days following admission, she was transferred to another centre with high suspicion of pulmonary-renal syndrome, acute renal failure requiring haemodialysis and ANCA-AAV. Further analyses were undertaken, which revealed alveolar haemorrhage compatible with autoimmune disease-vasculitis. Immediately following transfer, her oxygen saturation dropped to 70%. Therefore, she started receiving IV methylprednisolone pulse doses 500mg per day for 3 days, followed by oral prednisolone, which was slowly tapered to 60mg per day [initial dose not stated]. She also received an IV drip of cyclophosphamide 500mg for the ANCA-positive AAV, with plasmapheresis for the alveolar haemorrhage, alongside haemodialysis and oxygen support. Thereafter, her oxygen saturation improved to 90%. Subsequent urine cultures revealed Enterococcus spp.

Therefore, the woman started receiving antibacterials. Her inflammatory markers gradually declined; however, after 12 days of treatment and the need to repeat the cycle of cyclophosphamide on day 14, she reported pharyngeal dryness with a drop in haemoglobin to 72 g/L. A nasal swab was found to be positive for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2).

Serological IgG and IgM tests for SARS-COV-2 were found negative. Due to the co-infection with Covid-19, the plasma exchanges were discontinued. As per protocol, she was shifted to a Covid-19 hospital; discharge diagnoses included pulmonary-renal syndrome, acute renal failure stage 3, ANCA-AAV, alveolar haemorrhage, anaemic syndrome, Enterococcal urinary infection and Covid-19 infection. Following transfer, she was diagnosed with Covid-19 pneumonia. Another reverse transcription PCR (RT-PCR) test for SARS-COV-2 taken at the time of admission was also positive. Initial laboratory analyses on admission and revealed persistent anaemia and hypoalbuminaemia. Haemodialysis was continued. CT angiography of the pulmonary truncus revealed bilateral diffuse zones of interstitial consolidation, with multiple lymph nodes being observed in the mediastinum. Visualisation of the pulmonary arteries and main pulmonary truncus showed no endoluminal thrombotic masses and no alterations in the haemodynamic flow. No alterations of the blood flow were noted in the segmental pulmonary branches. Pulmonary X-ray revealed massive zones of parenchymal consolidations in the apical, middle and basal parts of both lungs. Given her general health condition, she was transferred to the ICU, where she was intubated and put on a mechanical ventilator. She had oligoanuria and was under continuous inotrope stimulation. Laboratory analyses identified Acinetobacter spp. in the tracheal aspirate. Hence, she received triple antibiotic therapy with colistin, linezolid and meropenem. She also received off-label tocilizumab, plasma [fresh frozen plasma] and convalescent-anti-SARS-CoV-2-plasma [convalescent plasma], alongside packed RBCs, ozone therapy, unspecified anticoagulants and gastroprotective therapy. However, despite the treatment and measures for cardiopulmonary resuscitation, she passed away on day 33 of her initial admission [immediate cause of death not stated]. The development of the fatal Enterococcal urinary infection, Covid-19 infection and Acinetobacter infection was thus immunosuppression therapy with cyclophosphamide, prednisolone and methylprednisolone [times to reaction onsets not clearly stated].

Gerasimovska-Kitanovska B, et al. Patient with antineutrophil cytoplasmic antibody associated small vessel vasculitis, acute renal failure, and coronavirus disease-19 pneumonia: A diagnostic and therapeutic challenge. Open Access Macedonian Journal of Medical Sciences 8: 542-547, No. 1, 2020. Available from: URL: https://www.id-

press.eu/mjms/article/download/5510/5263 803592798