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.
