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Trimethoprim-sulfamethoxazole induced aseptic meningitis case report
Giulia Pata1, Marco Montagna1, Emanuele Bosi1,2
1Vita-Salute San Raffaele University, Milan, Italy.
Rationale:
Drug-induced aseptic meningitis (DIAM) is an uncommon meningitis and trimethoprim with or without sulfamethoxazole is the most involved antibiotic. Although DIAM is easily treated with the discontinuation of the causative drug, the diagnosis is a big challenge for physicians, as it remains a diagnosis of exclusion. Here, we present a case report of trimethoprim-sulfamethoxazole induced aseptic meningitis in a woman with acute osteomyelitis.
Patient Concerns:
A 52-year-old woman was admitted to the hospital for septic shock and acute osteomyelitis of the right homerus. She was started on antibiotic therapy with oxacillin and daptomycin, then oxacillin was replaced with cotrimoxazole, due to its excellent tissue penetration, including bone tissue. During cotrimoxazole therapy, the patient developed a fluent aphasia with ideomotor apraxia and muscle hypertonus.
Diagnosis And Interventions:
Having excluded infectious, epileptic and vascular causes of the acute neurologic syndrome of our patient, given the improvement and full recovery after discontinuation of cotrimoxazole, we hypothesized a DIAM.
Outcomes:
After discontinuation of cotrimoxazole, in 48 hours the patient had a full recovery.
Lessons:
Although DIAM can be easily managed with the withdrawal of the causative drug, it can be difficult to recognize if it is not included in the differential diagnosis. An antimicrobial stewardship program with a strict monitoring of patients by infectious disease specialists is essential, not only to optimize the appropriate use of antimicrobials, but also to improve patient outcomes and reduce the likelihood of adverse events.
Insights
Drug-induced aseptic meningitis (DIAM) from trimethoprim-sulfamethoxazole is challenging to diagnose but resolves quickly after drug withdrawal. Prompt recognition and management are key to preventing adverse events.
Area of Science:
- Neurology
- Infectious Diseases
- Pharmacology
Background:
- Drug-induced aseptic meningitis (DIAM) is an uncommon adverse drug reaction.
- Trimethoprim-sulfamethoxazole is frequently implicated in DIAM.
- DIAM is a diagnosis of exclusion, posing a diagnostic challenge for clinicians.
Observation:
- A patient with acute osteomyelitis developed neurological symptoms including aphasia and muscle hypertonus during treatment with trimethoprim-sulfamethoxazole.
- Infectious, epileptic, and vascular causes were ruled out.
- Neurological symptoms resolved within 48 hours of discontinuing trimethoprim-sulfamethoxazole.
Findings:
- The patient experienced a full recovery after the cessation of trimethoprim-sulfamethoxazole.
- This case supports trimethoprim-sulfamethoxazole as a potential cause of DIAM.
- Early recognition and drug withdrawal are crucial for managing DIAM.
Implications:
- DIAM should be considered in the differential diagnosis of meningitis, especially with implicated antibiotic use.
- Antimicrobial stewardship programs and specialist monitoring are essential for optimizing antibiotic use and patient outcomes.
- Vigilance for DIAM can reduce adverse drug events and improve patient safety.
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