BRIEF CLINICAL OBSERVATIONS
ATRIAL NATRIURETIC PEPTIDE IN THE RECOVERY FROM HIGHOUTPUT CONGESTIVE HEART FAILURE Large a r t e r i o v e n o u s f i s t u l a s (AVFs) increase venous return, preload, and cardiac output and may eventually lead to congestive heart failure (CHF) with severe fluid and sodium retention [1]. Closure of an AVF induces a characteristic diuretic and natriuretic response in experimental animals as well as reversal of the clinical signs of CHF in patients. The mechanism of this response is poorly understood, although involvement of the renin-angiotensin system and the renal sympathetic nerves has been proposed [2]. The potential role of atrial natriuretic peptide (ANP) in the natriuresis following closure of a fistula and in the recovery from CHF has not been studied previously. We report here the plasma levels of ANP in two patients with CHF due to a large AVF, both before and after surgical repair, and in two patients with small AVFs, for comparison. A 67-year-old patient was referred with a large iatrogenic femoral AVF. He exhibited dyspnea on exertion, distended jugular veins, enlarged liver, marked peripheral edema, a pulsating mass in his right groin, and oliguria. Plasma ANP concentration was increased to 407 pg/mL (versus 32 4- 5 pg/mL in 10 controls, measured by radioimmunoassay). Surgical closure of the fistula by lateral repair of the femoral artery and vein was followed by a polyuric phase and gradual improvement in the signs of heart failure. Plasma ANP levels remained high immediately after surgery (390 pg/mL), then decreased gradually and returned to normal over a week (283, 205, and 23 pg/mL at 2, 4, and 6 days postoperatively, respectively). Another 70-year-old patient presented with a spontaneous large AVF between an atherosclerotic iliac aneurysm and the inferior vena cava. He had severe congestive heart failure, dyspnea, engorged jugular veins, enlarged liver, a pulsating abdominal mass, peripheral edema, hypotension, and oliguria that progressed to anuria. Plasma
ANP levels were increased about 300% (91 pg/mL). He underwent urgent operation, the AVF was repaired, and the aneurysm was resected and grafted. ANP levels remained high immediately after and 1 day after surgery (82 and 78 pg/ mL, respectively). The patient did not recover from surgery and later died of multisystem organ failure. In contrast to these two patients with large AVFs, in two young patients with small AVFs caused by shrapnel wounds (one femoral and one brachial), and with no signs of heart failure or renal failure, plasma ANP levels were normal both before (5 and 23 pg/mL) and 1 day after surgery (13 and 26 pg/mL, respectively). These data demonstrate marked increases in plasma ANP levels in patients with high-output CHF caused by large fistulas, similar to that reported in other forms of CHF [3] as well as in animal models of AVF [4]. Moreover, a rather slow decrease in plasma ANP levels over several days after surgical closure of a large AVF was observed, in contrast to reportedly immediate decreases in ANP levels after repair of mitral stenosis [5]. Circulating levels of ANP were very high even after surgical closure of an AVF, and were associated with polyuria and a reduction in the signs of CHF. Similar results were recently obtained in an experimental correlate of an aortocaval fistula model in rats [6]. The natriuresis that follows relief of bilateral ureteral obstruction or supraventricular tachycardia has been attributed to ANP [7,8]. Similarly, the pattern of plasma ANP changes in our patients suggests that ANP is not only a marker of the severity of fluid retention [9], but may also play a role in the recovery from CHF by facilitating diuresis and natriuresis after the primary cause of CHF is removed. AARON HOFFMAN, M.D. JOSEPH WINA VER, M.D. R a m b a m Medical Center and The Technion Haifa, Israel A VIAD HARAMATI, Ph.D. Georgetown University Washington, D.C. 1. Alexander JJ, Imbembo AL: Aorta-vena cava fistula. Surgery 1989; 105: 1-12.
2. Humphreys MH, AI-Bander H, EneasJF, Schambelan M: Factors determining electrolyte excretion and renin secretion after closure of an arteriovenous fistula in the dog. J Lab Clin Med 1981; 98: 89-98. 3. Burnett JC, Kao PC, Hu DC, etahAtrial natriuretic peptide in congestive heart failure in the human. Science 1986;231: 1145-1147. 4.Winaver J, Hoffman A, Burnett JC, Haramati A: Hormonal determinants of sodium excretion in rats with experimental high-output heart failure. Am J Physiol 1988; 254: R776-R784. 5. Ishikura F, Nagata S, Hirata Y, et ak Rapid reduction of plasma atrial natriuretic peptide levels during percutaneous mitral commissurotomy. Circulation 1989; 79: 47-50. 6. Hoffman A, Grossman E, Keiser HR: Role of atrial natriuretic peptide in the natriuresis after closure of a large arteriovenous fistula (abstr). Circulation 1989; 80 (suppl): 11-361. 7. Purkerson ML, Blaine EH, Stokes TJ, Klahr S: Role of atrial peptide in the natriuresis and diuresis that follows relief of obstruction in rat. Am J Physio11989; 256: F583-F598. 8. Yamaji T, Ishibashi M, Nakaoka H, Imataka K, Amano M, Fujii J: Possible role for atrial natriuretic peptide in polyuria associated with paroxysmal atrial arrhythmias. Lancet 1985; 1: 1211. 9. Singer DR, Shore AC, Markandu AD, eta/.' Atrial natriuretic peptide levels in treated congestive heart failure. Lancet 1986; 1: 851. Submitted November 29, 1989, and accepted December 6, 1989
ACUTE TUMOR LYSIS SYNDROME IN PROLYMPHOCYTIC LEUKEMIA Chemotherapeutic treatment of large volume, rapidly proliferating tumors may result in acute tumor lysis syndrome (TLS) [1,2]. This occurs most commonly after combination chemotherapy of Burkitt's lymphoma. Prolymphocytic leukemia (PL), a B-cell neoplasm that is relatively nonresponsive to agents with activity against other lymphoproliferative malignancies, has been associated with TLS after combination chemotherapy in one report [3]. We describe a case of TLS developing in a patient treated with dexamethasone alone. A 70-year-old man presented to an outside hospital with fatigue, lassitude, and hepatosplenomegaly. Examination of the peripheral blood smear revealed a lymphocytosis with 30% prolymphocytes. He received three courses of cyclophosphamide, vincristine, and daunomycin with short-lived responses, and subsequently was transferred to our facility. On admission, the following values were noted: white blood cell count (WBC) 71,200/#L with 41% pro-
May1990 TheAmericanJournalof Medicine Volume88
547
BRIEF CLINICAL OBSERVATIONS
lymphocytes, hemoglobin 11.2 g/ dL, platelets 82,000/#L, potassium 3.2 mmol/L, bicarbonate 22 mmol/ L, uric acid 22.2 mg/dL, lactate dehydrogenase (LDH) 12,360 IU/L, calcium 10.6 mg/dL, and phosphorus 1.3 mg/dL. Bone m a r r o w e x a m i n a t i o n showed the marrow to be packed with prolymphocytes. An abdominal computed tomographic (CT) scan revealed impressive hepatos p l e n o m e g a l y and p e r i a o r t i c lymphadenopathy. We initiated t r e a t m e n t with VAD, a regimen consisting of vincristine 0.4 mg/day by a 4-day continuous intravenous infusion, AdriamycinTM (doxorubicin) 15 mg/ day by a 4-day continuous intravenous infusion, and dexamethasone 40 mg orally daily for 4 days. Because of a clinical error, the patient received only dexamethasone for 2 days. Within 2 days the organomegaly was no longer detectable, and the following values were noted: WBC 7,800/#L, platelets 48,000/ #L, bicarbonate 15 mg/dL, uric acid 1.8 mg/dL, LDH 313 IU/L, and calcium 5.8 mg/dL. Over the same period the potassium, phosphorus, and creatinine levels rose to 5.6 mmol/L, 10.0 mg/dL, and 1.6 mg/dL, respectively. Over the ensuing 2 weeks, tumor progression was again noted with recurrent hepatosplenomegaly, a WBC of 82,000/#L, LDH of 3,541 IU/L, calcium of 9.4 mg/dL, and phosphorus of 5.6 mmol/L. Subsequent abdominal CT scan demonstrated hepatosplenomegaly without adenopathy, and he received a full course of VAD chemotherapy with gratifying response and no further complications. There are several unique aspects to this case. PL is a slow-growing B-cell neoplasm with a large tumor burden, and rapid changes in tumor burden with therapy are not characteristic. This case involved rapid tumor progression and impressive therapeutic responses, a pattern typical of more aggressive acute leukemias. Although it is established that steroids demonstrate activity against other lymphoproliferative malignancies [1,2], this is the first time to our knowledge that PL has responded to dexamethasone alone. The previously reported case of TLS associated with PL [3] involved therapy with vincristine and high-dose prednisone. It was not possible from that report to as548
examination revealed neck stiffness. A lumbar puncture yielded cloudy fluid; glucose was undetectable, the protein value was 258 mg/ dL, the red blood cell count was 91/ mm 3, the white blood cell count was 21/mm 3, and Gram-stained smear revealed large numbers of gram-positive diplococci. Culture grew S. pneumoniae of the same serotype as the blood isolate. Treatment was changed to ampicillin and the patient ultimately ROY E. SMITH, M.D. made a complete recovery. Both isolates of S. pneumoniae THOMAS R. STOIBER, M.D. The Medical College of Wisconsin were susceptible to ciprofloxacin Milwaukee, Wisconsin by Kirby-Bauer disk diffusion; the minimal inhibitory concentration 1. Cadman EC, Lundber WB, Bertino JR: Hyperphoswas 2 #g/mL using an agar dilution phatemia and hypocalcemia accompanying rapid cell lysis in a patient with Burkitt's lymphoma and Burmethod. The activity of ciprofloxakitt's cell leukemia. Am J Med 1977; 62: 283-290. cin against S. pneumoniae is only 2. Gomez GA, Stutzman L, Chu TM: Xanthine nemoderate; a concentration of 2 #g/ phropathy during chemotherapy in deficiency of hymL is needed to inhibit 90% of isopoxanthine:guanine phosphoribosyltransferase. Arch Intern Med 1978; 138: 1017-1019. lates [1]. Nevertheless, response 3. Gomez GA, Han T: Acute tumor lysis syndrome in rates for chronic bronchitis and prolymphocytic leukemia. Arch Intern Med 1987; pneumonia range from 70% to 90%, 147: 375-376. although persistence of the organ4. Livingston RB, Carter SK: Single agents in cancer chemotherapy. New York: IFJ/Plenum, 1970; 337ism has been reported [2]. Spinal 358. fluid concentrations in the range of 0.35 to 0.56 #g/mL [3] discourage Submitted September 11, 1989, and accepted in revised form November 10, ],989 ciprofloxacin use if pneumococcal meningitis is suspected. Intravenous ciprofloxacin therapy would be expected to effectively control bacteremia. Meningeal PNEUMOCOCCAL MENINGITIS seeding in this setting is very DURING INTRAVENOUS alarming. Use of oral ciprofloxacin CIPROFLOXACIN THERAPY for the empiric treatment of comCooper and Lawlor (Am J Med munity-acquired pneumonia is 1989; 87: 475) report a case of pneu- probably unwise. mococcal bacteremia occurring JULIE RIGHTER, M.D., F.R.C.PoC. during oral therapy with ciprofloxToronto East General and Orthopaedic Hospital acin. I wish to report an even more Toronto, Canada alarming clinical case in which pneumococcal meningitis devel- 1. Davies BI, Maesen FPV: Quinolones in chest infecoped during treatment with intra- tions. J Antimicrob Chemother 1986; 18: 296-299. 2. Ball AP: Overview of clinical experience with ciprovenous ciprofloxacin. Eur J Clin Microbiol 1986; 5: 214-219. A 77-year-old woman was admit- floxacin. 3. Wolff M, Boutron L, Singlas E, Clair B, Decazes JM, ted in septic shock. Chest radiogra- Regnier B: Penetration of ciprofloxacin into cerebrophy showed left lobe consolidation spinal fluid of patients with bacterial meningitis. Antiand a large pleural effusion. Re- microb Agents Chemother 1987; 31: 899-902. sults of neurologic examination Submitted November 29, 1989, and accepted Dewere normal. The patient was adcember 6, 1989 mitted to the intensive care unit and resuscitated, and underwent ventilation. Past medical history included mild hypertension requir- DESENSITIZATION TO ing no treatment, and polymyalgia SULFONAMIDES IN PATIENTS rheumatica for which she received WITH HIV INFECTION prednisone 5 mg daily. As part of an open trial, she was treated with Sulfonamides are the agents most ciprofloxacin 200 mg intravenously frequently incriminated in the deevery 12 hours. Clinical improve- velopment of a variety of presumed ment was rapid and she was extu- immunologic skin reactions [1]. Albated on Day 3. Multiple blood cul- though these eruptions may be a tures taken on admission grew source of considerable morbidity Streptococcus pneumoniae. Two and occasional mortality, withdays later she became obtunded; holding the offending agent and alcertain the role of prednisone alone, as both agents have antitumor activity [4]. In this case, the total dexamethasone delivered had one fourth the glucocorticoid activity reported in the previously cited prednisonevincristine combination, yet resulted in biochemical changes consistent with acute TLS. Therefore, the use of dexamethasone alone i n this disease should be cautiously approached.
May 1990 The American Journal of Medicine
Volume 88
ATRIAL NATRIURETIC PEPTIDE IN THE RECOVERY FROM HIGHOUTPUT CONGESTIVE HEART FAILURE Large a r t e r i o v e n o u s f i s t u l a s (AVFs) increase venous return, preload, and cardiac output and may eventually lead to congestive heart failure (CHF) with severe fluid and sodium retention [1]. Closure of an AVF induces a characteristic diuretic and natriuretic response in experimental animals as well as reversal of the clinical signs of CHF in patients. The mechanism of this response is poorly understood, although involvement of the renin-angiotensin system and the renal sympathetic nerves has been proposed [2]. The potential role of atrial natriuretic peptide (ANP) in the natriuresis following closure of a fistula and in the recovery from CHF has not been studied previously. We report here the plasma levels of ANP in two patients with CHF due to a large AVF, both before and after surgical repair, and in two patients with small AVFs, for comparison. A 67-year-old patient was referred with a large iatrogenic femoral AVF. He exhibited dyspnea on exertion, distended jugular veins, enlarged liver, marked peripheral edema, a pulsating mass in his right groin, and oliguria. Plasma ANP concentration was increased to 407 pg/mL (versus 32 4- 5 pg/mL in 10 controls, measured by radioimmunoassay). Surgical closure of the fistula by lateral repair of the femoral artery and vein was followed by a polyuric phase and gradual improvement in the signs of heart failure. Plasma ANP levels remained high immediately after surgery (390 pg/mL), then decreased gradually and returned to normal over a week (283, 205, and 23 pg/mL at 2, 4, and 6 days postoperatively, respectively). Another 70-year-old patient presented with a spontaneous large AVF between an atherosclerotic iliac aneurysm and the inferior vena cava. He had severe congestive heart failure, dyspnea, engorged jugular veins, enlarged liver, a pulsating abdominal mass, peripheral edema, hypotension, and oliguria that progressed to anuria. Plasma
ANP levels were increased about 300% (91 pg/mL). He underwent urgent operation, the AVF was repaired, and the aneurysm was resected and grafted. ANP levels remained high immediately after and 1 day after surgery (82 and 78 pg/ mL, respectively). The patient did not recover from surgery and later died of multisystem organ failure. In contrast to these two patients with large AVFs, in two young patients with small AVFs caused by shrapnel wounds (one femoral and one brachial), and with no signs of heart failure or renal failure, plasma ANP levels were normal both before (5 and 23 pg/mL) and 1 day after surgery (13 and 26 pg/mL, respectively). These data demonstrate marked increases in plasma ANP levels in patients with high-output CHF caused by large fistulas, similar to that reported in other forms of CHF [3] as well as in animal models of AVF [4]. Moreover, a rather slow decrease in plasma ANP levels over several days after surgical closure of a large AVF was observed, in contrast to reportedly immediate decreases in ANP levels after repair of mitral stenosis [5]. Circulating levels of ANP were very high even after surgical closure of an AVF, and were associated with polyuria and a reduction in the signs of CHF. Similar results were recently obtained in an experimental correlate of an aortocaval fistula model in rats [6]. The natriuresis that follows relief of bilateral ureteral obstruction or supraventricular tachycardia has been attributed to ANP [7,8]. Similarly, the pattern of plasma ANP changes in our patients suggests that ANP is not only a marker of the severity of fluid retention [9], but may also play a role in the recovery from CHF by facilitating diuresis and natriuresis after the primary cause of CHF is removed. AARON HOFFMAN, M.D. JOSEPH WINA VER, M.D. R a m b a m Medical Center and The Technion Haifa, Israel A VIAD HARAMATI, Ph.D. Georgetown University Washington, D.C. 1. Alexander JJ, Imbembo AL: Aorta-vena cava fistula. Surgery 1989; 105: 1-12.
2. Humphreys MH, AI-Bander H, EneasJF, Schambelan M: Factors determining electrolyte excretion and renin secretion after closure of an arteriovenous fistula in the dog. J Lab Clin Med 1981; 98: 89-98. 3. Burnett JC, Kao PC, Hu DC, etahAtrial natriuretic peptide in congestive heart failure in the human. Science 1986;231: 1145-1147. 4.Winaver J, Hoffman A, Burnett JC, Haramati A: Hormonal determinants of sodium excretion in rats with experimental high-output heart failure. Am J Physiol 1988; 254: R776-R784. 5. Ishikura F, Nagata S, Hirata Y, et ak Rapid reduction of plasma atrial natriuretic peptide levels during percutaneous mitral commissurotomy. Circulation 1989; 79: 47-50. 6. Hoffman A, Grossman E, Keiser HR: Role of atrial natriuretic peptide in the natriuresis after closure of a large arteriovenous fistula (abstr). Circulation 1989; 80 (suppl): 11-361. 7. Purkerson ML, Blaine EH, Stokes TJ, Klahr S: Role of atrial peptide in the natriuresis and diuresis that follows relief of obstruction in rat. Am J Physio11989; 256: F583-F598. 8. Yamaji T, Ishibashi M, Nakaoka H, Imataka K, Amano M, Fujii J: Possible role for atrial natriuretic peptide in polyuria associated with paroxysmal atrial arrhythmias. Lancet 1985; 1: 1211. 9. Singer DR, Shore AC, Markandu AD, eta/.' Atrial natriuretic peptide levels in treated congestive heart failure. Lancet 1986; 1: 851. Submitted November 29, 1989, and accepted December 6, 1989
ACUTE TUMOR LYSIS SYNDROME IN PROLYMPHOCYTIC LEUKEMIA Chemotherapeutic treatment of large volume, rapidly proliferating tumors may result in acute tumor lysis syndrome (TLS) [1,2]. This occurs most commonly after combination chemotherapy of Burkitt's lymphoma. Prolymphocytic leukemia (PL), a B-cell neoplasm that is relatively nonresponsive to agents with activity against other lymphoproliferative malignancies, has been associated with TLS after combination chemotherapy in one report [3]. We describe a case of TLS developing in a patient treated with dexamethasone alone. A 70-year-old man presented to an outside hospital with fatigue, lassitude, and hepatosplenomegaly. Examination of the peripheral blood smear revealed a lymphocytosis with 30% prolymphocytes. He received three courses of cyclophosphamide, vincristine, and daunomycin with short-lived responses, and subsequently was transferred to our facility. On admission, the following values were noted: white blood cell count (WBC) 71,200/#L with 41% pro-
May1990 TheAmericanJournalof Medicine Volume88
547
BRIEF CLINICAL OBSERVATIONS
lymphocytes, hemoglobin 11.2 g/ dL, platelets 82,000/#L, potassium 3.2 mmol/L, bicarbonate 22 mmol/ L, uric acid 22.2 mg/dL, lactate dehydrogenase (LDH) 12,360 IU/L, calcium 10.6 mg/dL, and phosphorus 1.3 mg/dL. Bone m a r r o w e x a m i n a t i o n showed the marrow to be packed with prolymphocytes. An abdominal computed tomographic (CT) scan revealed impressive hepatos p l e n o m e g a l y and p e r i a o r t i c lymphadenopathy. We initiated t r e a t m e n t with VAD, a regimen consisting of vincristine 0.4 mg/day by a 4-day continuous intravenous infusion, AdriamycinTM (doxorubicin) 15 mg/ day by a 4-day continuous intravenous infusion, and dexamethasone 40 mg orally daily for 4 days. Because of a clinical error, the patient received only dexamethasone for 2 days. Within 2 days the organomegaly was no longer detectable, and the following values were noted: WBC 7,800/#L, platelets 48,000/ #L, bicarbonate 15 mg/dL, uric acid 1.8 mg/dL, LDH 313 IU/L, and calcium 5.8 mg/dL. Over the same period the potassium, phosphorus, and creatinine levels rose to 5.6 mmol/L, 10.0 mg/dL, and 1.6 mg/dL, respectively. Over the ensuing 2 weeks, tumor progression was again noted with recurrent hepatosplenomegaly, a WBC of 82,000/#L, LDH of 3,541 IU/L, calcium of 9.4 mg/dL, and phosphorus of 5.6 mmol/L. Subsequent abdominal CT scan demonstrated hepatosplenomegaly without adenopathy, and he received a full course of VAD chemotherapy with gratifying response and no further complications. There are several unique aspects to this case. PL is a slow-growing B-cell neoplasm with a large tumor burden, and rapid changes in tumor burden with therapy are not characteristic. This case involved rapid tumor progression and impressive therapeutic responses, a pattern typical of more aggressive acute leukemias. Although it is established that steroids demonstrate activity against other lymphoproliferative malignancies [1,2], this is the first time to our knowledge that PL has responded to dexamethasone alone. The previously reported case of TLS associated with PL [3] involved therapy with vincristine and high-dose prednisone. It was not possible from that report to as548
examination revealed neck stiffness. A lumbar puncture yielded cloudy fluid; glucose was undetectable, the protein value was 258 mg/ dL, the red blood cell count was 91/ mm 3, the white blood cell count was 21/mm 3, and Gram-stained smear revealed large numbers of gram-positive diplococci. Culture grew S. pneumoniae of the same serotype as the blood isolate. Treatment was changed to ampicillin and the patient ultimately ROY E. SMITH, M.D. made a complete recovery. Both isolates of S. pneumoniae THOMAS R. STOIBER, M.D. The Medical College of Wisconsin were susceptible to ciprofloxacin Milwaukee, Wisconsin by Kirby-Bauer disk diffusion; the minimal inhibitory concentration 1. Cadman EC, Lundber WB, Bertino JR: Hyperphoswas 2 #g/mL using an agar dilution phatemia and hypocalcemia accompanying rapid cell lysis in a patient with Burkitt's lymphoma and Burmethod. The activity of ciprofloxakitt's cell leukemia. Am J Med 1977; 62: 283-290. cin against S. pneumoniae is only 2. Gomez GA, Stutzman L, Chu TM: Xanthine nemoderate; a concentration of 2 #g/ phropathy during chemotherapy in deficiency of hymL is needed to inhibit 90% of isopoxanthine:guanine phosphoribosyltransferase. Arch Intern Med 1978; 138: 1017-1019. lates [1]. Nevertheless, response 3. Gomez GA, Han T: Acute tumor lysis syndrome in rates for chronic bronchitis and prolymphocytic leukemia. Arch Intern Med 1987; pneumonia range from 70% to 90%, 147: 375-376. although persistence of the organ4. Livingston RB, Carter SK: Single agents in cancer chemotherapy. New York: IFJ/Plenum, 1970; 337ism has been reported [2]. Spinal 358. fluid concentrations in the range of 0.35 to 0.56 #g/mL [3] discourage Submitted September 11, 1989, and accepted in revised form November 10, ],989 ciprofloxacin use if pneumococcal meningitis is suspected. Intravenous ciprofloxacin therapy would be expected to effectively control bacteremia. Meningeal PNEUMOCOCCAL MENINGITIS seeding in this setting is very DURING INTRAVENOUS alarming. Use of oral ciprofloxacin CIPROFLOXACIN THERAPY for the empiric treatment of comCooper and Lawlor (Am J Med munity-acquired pneumonia is 1989; 87: 475) report a case of pneu- probably unwise. mococcal bacteremia occurring JULIE RIGHTER, M.D., F.R.C.PoC. during oral therapy with ciprofloxToronto East General and Orthopaedic Hospital acin. I wish to report an even more Toronto, Canada alarming clinical case in which pneumococcal meningitis devel- 1. Davies BI, Maesen FPV: Quinolones in chest infecoped during treatment with intra- tions. J Antimicrob Chemother 1986; 18: 296-299. 2. Ball AP: Overview of clinical experience with ciprovenous ciprofloxacin. Eur J Clin Microbiol 1986; 5: 214-219. A 77-year-old woman was admit- floxacin. 3. Wolff M, Boutron L, Singlas E, Clair B, Decazes JM, ted in septic shock. Chest radiogra- Regnier B: Penetration of ciprofloxacin into cerebrophy showed left lobe consolidation spinal fluid of patients with bacterial meningitis. Antiand a large pleural effusion. Re- microb Agents Chemother 1987; 31: 899-902. sults of neurologic examination Submitted November 29, 1989, and accepted Dewere normal. The patient was adcember 6, 1989 mitted to the intensive care unit and resuscitated, and underwent ventilation. Past medical history included mild hypertension requir- DESENSITIZATION TO ing no treatment, and polymyalgia SULFONAMIDES IN PATIENTS rheumatica for which she received WITH HIV INFECTION prednisone 5 mg daily. As part of an open trial, she was treated with Sulfonamides are the agents most ciprofloxacin 200 mg intravenously frequently incriminated in the deevery 12 hours. Clinical improve- velopment of a variety of presumed ment was rapid and she was extu- immunologic skin reactions [1]. Albated on Day 3. Multiple blood cul- though these eruptions may be a tures taken on admission grew source of considerable morbidity Streptococcus pneumoniae. Two and occasional mortality, withdays later she became obtunded; holding the offending agent and alcertain the role of prednisone alone, as both agents have antitumor activity [4]. In this case, the total dexamethasone delivered had one fourth the glucocorticoid activity reported in the previously cited prednisonevincristine combination, yet resulted in biochemical changes consistent with acute TLS. Therefore, the use of dexamethasone alone i n this disease should be cautiously approached.
May 1990 The American Journal of Medicine
Volume 88
