Dexamethasone/prednisone/sodium chloride

Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 22-months-old male infant developed nosocomial legionellosis and invasive aspergillosis while receiving dexamethasone and prednisone. Additionally, invasive aspergillosis was also attributed to exposure to contaminated sodium chloride nasal spray [not all dosages, routes and indications stated].

The infant was diagnosed with acute T-lymphoblastic leukaemia. He was started on prednisone pre-phase followed by dexamethasone 10 mg/m2 for 21 days, then tapering, combined with induction chemotherapy with pegaspargase, daunorubicin, methotrexate and vincristine on day 3 of his hospitalisation. On the day 36 of induction therapy, a laryngoscopy assessment showed a mild inflammation and a pharyngeal swab was positive for coronavirus NL63 and parainfluenza virus Type 3. He was discharged after 39 days of admission good clinical condition. One day later, he was again hospitalised with high fever, tachycardia, tachypnoea, cough, reduced oxygen saturation and low BP. His chest-radiograph showed marked opacification of the right lower lobe and diffuse, fine-nodular pulmonary transparency-reduction. The neutrophil count was 0.3 χ 10⁹/L. He was treated with broad spectrum with gentamicin, meropenem and teicoplanin for pneumonia and suspected sepsis. A bronchoalveolar lavage (BAL) was showed mucosal inflammation and pus in the right airways. Two main pathogens, Legionella pneumophila serotype 1 and Aspergillus fumigatus, were identified in microbiological investigations of the BAL fluid. A urine culture also showed the presence of Legionella pneumophila serotype 1 antigen. An elisa test of serum Aspergillus antigen showed an elevated index.

The infant was treated with IV levofloxacin 20 mg/kg in two single doses for 21 days, followed by azithromycin 10 mg/kg daily for five days, later, 10 mg/kg/day twice a week for six weeks and amphotericin-B liposomal 4 mg/kg daily. Following this treatment, he developed hypokalaemia, which was treated with potassium supplementation. He recovered with infections but was still positive for Legionella pneumophila. A thorax CT scan confirmed severe pneumonia of right lobe. After one month of admission, he developed left sided hemiparesis. An MRI scan showed increased intracranial pressure and at least 4 intracerebral abscesses. Neurosurgery was performed with postoperative external ventricular drains to manage abscesses. An elisa test of serum Aspergillus antigen again showed an elevated index. A biopsy of CNS abscess wall revealed Aspergillus fumigatus. Antifungal treatment was switched to voriconazole to treat CNS aspergillosis. He received IV voriconazole 9 mg/kg twice on day one, followed by 8 mg/kg twice daily. On day 5 of voriconazole treatment, the infant developed acute pancreatitis. Treatment of voriconazole was switched to caspofungin and his acute pancreatitis resolved. Subsequently, CNS aspergillosis was treated with amphotericin-B liposomal 8 mg/kg/days as a 3-hour infusion for 28 days followed by 5 mg/kg/day as a 2-hour infusion for 28 days, then 2.5 mg/kg/day two times a week as secondary prophylaxis. A sub-duroperitonal shunt was also implanted to manage hydrocephalus malresorptivus and subdural hygroma. Later, a follow-up MRI cans and microbiological assessment of the CSF were negative for residual fungal or bacterial CNS disease. His pulmonary and hemiparesis symptoms resolved completely. On further investigation, it was revealed that the infant had received 0.9% sodium chloride nose spray contaminated with the Aspergillus fumigatus.

Author comment: "A sodium chloride nose spray was found to be contaminated with the [Aspergillus fumigatus] isolate of the patient." "Although extraordinary rare, Legionellosis has to be confirmed or excluded in pediatric leukemia patients with fever and pneumonia after prolonged leukopenia and high dose corticosteroid treatment."