e-poster TMP-SMX

The patient did not present any symptoms and the accumulated dose of 185/889 mg of trimetoprim with sulfametoxazol was reached; after 2 hours of.
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Rapid  oral  tolerance induction protocol to  trimetoprim and  sulfametoxazol in  a  patient with HIV

Sandra  Nora  Gonzalez-­‐Diaz,  Alfredo  Arias-­‐Cruz,  Maria  del  Carmen  Zarate-­‐Hernandez, Cindy  Elizabeth  de  Lira-­‐Quezada  ,Olga  Patricia  Monge-­‐Ortega,  Diana  Maria  Rangel-­‐ Gonzalez, Jose  Ignacio  Canseco-­‐Villarreal   Autonomous University of  Nuevo  Leon,  University Hospital  "Dr.  José  Eleuterio  González",  Regional  Center  of  Allergy and  Clinical Immunology,  Monterrey,  Nuevo  León,  México.

INTRODUCTION

The Aquired Immunodeficiency Syndrome (AIDS)  affects the immune system after the infection by HIV-­‐1.  In  2011,  the prevalence of  HIV  in  the 15  to  49  year old group was of  147,137  people.  Trimetoprim and  sulfametoxazol is an essential medicine  used to  prevent pneumonia caused by P.  jirovecii,  so  it is important to  identify hypersensitivity reactions.  

CASE  PRESENTATION

A 56 year old female with HIV/AIDS stage III since April 2016 and pneumonia due to Pneumocystis jirovecii treated with trimetoprim and sulfametoxazol (TMP-­‐SMX) presented a macularpapular exanthema on face, thorax, abdomen and limbs, 30 hours after ingestion of medicine and lasted 48 hours. Partial improvement was seen with clorpheniramine 4 mg every 8 hours for 5 days. A rapid oral tolerance induction protocol was performed preparing 3 dilutions from an original solution 1:1000 (Solution A), 1:100 (Solution B), 1:10 (Solution C) from the TMP-­‐SMX 40mg/200mg/5ml (8/40 mg/ml) presentation and 80/400 mg pills. The patient arrived without symptoms and was not premedicated. Initial vital signs were normal and checked every 30 minutes when solution dose was administered. The protocol consisted of a gradual increase in dose and volume. The patient did not present any symptoms and the accumulated dose of 185/889 mg of trimetoprim with sulfametoxazol was reached; after 2 hours of observations she was discharged. Forty-­‐eight hours later she was still asymptomatic. Time  dose Solution Medicine  dose Concentration Volume Time   Temperature HR BR BP PEF STEP

DISCUSSION

This  result  shows  similarity  with  literature  reports  regarding  the  safety  and   effectiveness  of  desensitization  protocols.  

CONCLUSION

The rapid oral tolerance induction protocol was successful, the patient went on taking the indicated dose by Infectology, without symptoms. It is important to consider desensitization as an option in patients with HIV/AIDS and adverse reactions. Weiss,  M.  E.  et  al. Drug  allergy:  an  updated  practice  parameter.  Ann.  Allergy.  Asthma  Immunol. 105,  259–273  (2010). Ticse et  al.  Síndrome de  hipersensibilidad  por  uso  de  Trimetoprim/sulfametoxazol.  Reporte  de  un  caso.  Rev  Med  Hered 2006;17:109-­‐114 Huerta  LJG  y  cols.  Alergia  a  trimetroprim con  sulfametoxazol en  VIH.  Alergia,  Asma  e  Inmunología Pediátrica  Vol.  16,  Núm.  3  •  Septiembre-­‐Diciembre  2007

REFERENCES

was taken

of  TMP-­‐SMX

of  TMP-­‐ SMX  (ml)

accumulated (minutes)

x  min

°C

x  min

mm  Hg

L/s

1

9:10hr

A

0.2/1  µg

8/40  µg/ml

0.025

0

36.5

80

17

120/80

320/357  (89%)

2

9:40hr

A

0.6/3  µg

8/40  µg/ml

0.075

30

36.2

86

18

120/70

390/357(>100)

3

10:10hr

A

1,8/9  µg

8/40  µg/ml

0.225

60

36.5

87

18

120/80

390/357(>100)

4

10:40hr

A

6/30  µg

8/40  µg/ml

0.75

90

36.5

81

17

120/70

400/357  (>100)

5

11:10hr

A

18/90  µg

8/40  µg/ml

2.25

120

36.0

78

16

130/70

380/357  (>100)

6

11:40hr

A

60/300  µg

8/40  µg/ml

7.5

150

36.2

80

17

120/80

390/357(>100)

7

12:10hr

B

0.2/1  mg

80/400  µg/ml

2.5

180

36.2

78

18

120/80

400/357  (>100)

8

12:40hr

B

0.6/3  mg

80/400  µg/ml

7.5

210

36.4

79

17

130/90

390/357(>100)

9

13:10hr

C

1,8/9  mg

0.8/4  mg/ml

2.25

240

35.8

86

17

130/90

390/357 (>100)

10

13:40hr

Pure solution

6/30  mg

8/40  mg/ml

0.75

270

36

87

18

120/80

390/357 (>100)

11

14:10hr

Pure solution

18/90  mg

8/40  mg/ml

2.25

300

36.5

88

16

130/80

395/357(>100)

12

14:40hr

Pure solution

60/300  mg

8/40  mg/ml

7.5

330

35.9

86

17

120/70

400/357  (>100)

13

15:10hr

1  pill

80/400  mg

80/400  mg

-­‐

360

36.2

88

18

120/70

370/357  (>100)

14

16:10hr

1  pill

80/400  mg

80/400  mg

-­‐

420

36.5

78

18

120/80

360/357  (>100)

15

17:10hr

480

36.4

76

17

120/80

380/357  (>100)

Observation time  for step 14  was of  60  minutes

Total  time:_8  Hours__ Total  dose accumulated:___185/889____mg.