A 26-year-old woman presented to the emergency department with new-onset fever, severe headache, blurred vision, photophobia, shortness of breath, and a “racing heart” one hour after taking a dose of trimethoprim/sulfamethoxazole.
Prior to the emergency department visit, she had been seen in the urogynecology clinic for dysuria and urinary retention. An indwelling bladder catheter was placed, and she was prescribed trimethoprim/sulfamethoxazole for a urinary tract infection. She had undergone a vaginal posterior repair, enterocele repair, and retropubic midurethral sling five days prior to that.
The patient was 11 weeks postpartum after vaginal delivery, with subsequent intrauterine device placement for birth control. Her medical history also included depression and a rash associated with penicillin ingestion. In the emergency department, she was tachycardic with a heart rate of 150 bpm in sinus rhythm.
Her blood pressure was 107/53 mm Hg, and her temperature spiked to 103°F. She was admitted to the hospital to receive IV antibiotics, hydration, and a workup for other sites of infection, pulmonary embolus, or fluid collection. The patient was pancultured and empirically placed on ciprofloxacine, cefepime, ceftriaxone, vancomycin, and metronidazole.
On admission, her complete blood count revealed a white blood cell (WBC) count of 4.8 K/uL, hemoglobin level of 14.2 gm/dL, a platelet count of 260 K/uL, with 94% segmental neutrophils, no bands, and 5% lymphocytes. A urinalysis showed specific gravity of 1.020, pH of 5.0 with 0-2 WBCs, 5-10 red blood cells (RBCs), and 5-10 squamous epithelial cells.
Her basic metabolic panel was within normal limits. Her liver function panel showed an elevated aspartate aminotransferase and alanine aminotransferase of 75 U/L and 52 U/L, respectively, and her lactic acid level was elevated at 3.25 mmol/L.
A chest x-ray, along with a CT scan of the head, chest, pelvis, and abdomen, were negative. Cerebrospinal fluid analysis revealed an RBC count of 16 uL, WBC count of 45 uL, 99% segmented neutrophils, 1% lymphocytes, and 0% monocytes. Gram stain and culture were negative. Viral studies and cultures were negative. Urine culture showed 10,000-50,000 col/mL of Escherichia coli. Screening for methicillin-resistant staphylococcus aureus (MRSA) was negative, blood cultures from two sites were negative, and a beta-hemolytic streptococcus culture was negative.
The clinician consulted with an infectious disease specialist, who believed that the patient’s condition was consistent with aseptic meningitis, likely drug related and secondary to trimethoprim/sulfamethoxazole. The patient remained hemodynamically stable. During the hospitalization, she was treated with methylprednisolone sodium succinate, which was tapered to prednisone to be completed a couple of days postdischarge. The patient had an uncomplicated recovery. — KRISTINE ZINKGRAF, APNP, Oconomowoc, Wis. (199-5)
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