Cotrimoxazole

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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 32-year-old man developed Stevens-Johnson syndrome during empiric treatment with cotrimoxazole for suspected acanthamoebic encephalitis.

The man was diagnosed with moderate COVID-19 and received off label treatment methylprednisolone for 5 days. He also received oxygen supplementation along with other supportive measures. He remained asymptomatic for 6 weeks. Later, he just missed an accident while driving because he was unable to estimate the distance to a nearby vehicle. Three days later, he developed facial deviation to the left and a weakness of the right side of the body. Over the following days, he additionally developed left hemi-paresis, followed by severe diffuse headache, vomiting, and a sensorial decline. Urgent decompressive craniectomy was performed. Investigations raised suspicion of amoebic infection. While awaiting the confirmation for the presence of specific free-living amoeba, he started receiving empiric treatment with a six-drug regimen comprising amphotericin-B-liposomal [liposomal amphotericin B], cotrimoxazole [trimethoprim-sulfamethoxazole; route and dosage not stated] 160mg/800mg per day, fluconazole, albendazole, azithromycin and rifampicin. However, he developed Stevens-Johnson syndrome due to cotrimoxazole [duration of treatment to reaction onset not stated].

Therefore, cotrimoxazole was stopped. Additionally, flucytosine was added. The man was treated with midazolam and up-titration of anti-epileptics due to the detection of features consistent with nonconvulsive status epilepticus on continuous electroencephalogram. Aspiration of the scalp swelling showed acanthamoeba cysts detected by lactophenol cotton blue staining. PCR for 18S ribosomal deoxyribonucleic acid (DNA) with the JDP primer confirmed the diagnosis of acanthamoebic encephalitis. Thereafter, amphotericin-B-liposomal was stopped and miltefosine was added to treatment regimen for 4 weeks. Later, he underwent surgical procedure to excise organizing abscess within central necrotic tissue. After debridement, the sensorium improved. After 15 weeks of hospitalisation, he was discharged in a haemodynamically stable tracheostomized state on five anti-amoebic drug regimen comprising flucytosine, fluconazole, rifampicin, azithromycin and albendazole. He was doing well at home 8 weeks after the discharge [outcome of ADR not stated].