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Trimethoprim/sulfamethoxazole-induced tremor in a patient with AIDS
R S Slavik1, M J Rybak, S A Lerner
1College of Pharmacy and Allied Health, Wayne State University, Detroit, MI, USA.
Objective:
To report a case of trimethoprim/sulfamethoxazole (TMP/SMX)-induced tremor responsive to a reduction in dosage.
Case Summary:
A 55-year-old white man with AIDS and Pneumocystis carinii pneumonia (PCP) developed a tremor after receiving 5 days of therapy with TMP/SMX 19.4 mg/kg/d (TMP). The tremor resolved completely 3 days after a dosage reduction to TMP/SMX 15.1 mg/kg/d.
Discussion:
Central nervous system adverse reactions to TMP/SMX have been reported in both the AIDS and non-AIDS populations. To our knowledge, this is the first reported case of TMP/SMX-induced tremor responsive to a reduction in dosage. Pharmacokinetic and clinical data suggest a concentration-dependent etiology for various adverse effects, including tremor. The mechanism of the tremor is unknown; however, toxic metabolites of SMX and disruptions of biogenic amine neurotransmission by TMP have been hypothesized.
Conclusions:
TMP/SMX remains the drug of first choice for treating PCP, but it is clearly not well tolerated by patients with AIDS. Concentration-dependent toxicities such as tremor may lead to premature discontinuation of proven, effective TMP/SMX therapy. Using the lower end of the recommended dosing range for TMP/SMX (TMP 15 mg/kg/d) may reduce the incidence of these toxicities while still achieving acceptable TMP concentrations and antimicrobial efficacy.
Insights
Trimethoprim/sulfamethoxazole (TMP/SMX) can cause tremors, especially in patients with AIDS. Reducing the TMP/SMX dosage can effectively resolve this central nervous system adverse reaction.
Area of Science:
- Pharmacology
- Neurology
- Infectious Diseases
Background:
- Trimethoprim/sulfamethoxazole (TMP/SMX) is a primary treatment for Pneumocystis carinii pneumonia (PCP).
- Central nervous system (CNS) adverse effects of TMP/SMX are known in both acquired immunodeficiency syndrome (AIDS) and non-AIDS populations.
Observation:
- A 55-year-old male patient with AIDS and PCP developed a tremor after five days of TMP/SMX therapy at 19.4 mg/kg/d.
- The tremor resolved within three days following a dosage reduction to 15.1 mg/kg/d.
Findings:
- This case represents the first report of TMP/SMX-induced tremor that responded to a dosage decrease.
- The tremor is hypothesized to be concentration-dependent, potentially linked to SMX toxic metabolites or TMP's disruption of neurotransmission.
Implications:
- TMP/SMX, while effective for PCP, may not be well-tolerated by AIDS patients due to dose-dependent toxicities like tremor.
- Lowering TMP/SMX dosage to the lower end of the recommended range (e.g., 15 mg/kg/d) may mitigate adverse effects while maintaining therapeutic efficacy.