[PAGID] CGD patient

[Nacho Gonzalez]

Dear Donald, I agree with you. InhA gene mutations are associated with
cross-resistance to INH and ethionamide/Prothinamide, but it represents the
minority of cases of INH resistance (two thirds are caused by mdr gene
mutations) and this mutation is mainly reported in Southest Asia

Luis I Gonzalez Granado. Hospital 12 octubre. Immunodeficiencies and
Pediatric Infectious Diseases Division. Madrid.


2009/8/19, Vinh, Donald (NIH/NIAID) [F] <vinhd at niaid.nih.gov>:

>

> I think the levofloxacin is an interesting point. I guess it depends what

> you believe is going on here.

>

> The 'standard 4-drug' regimen (isoniazid, rifampin, pyrazinamide,

> ethambutol) is recommended during the intensive phase for tuberculous

> meningitis due to M. tuberculosis. If you think that this is BCG/M. bovis,

> though, clearly the PZA is not necessary.

>

> Additionally, the recommendation to use 4 drugs is based on the possibility

> of drug resistance (especially if the prevalence of drug-resistance is 4% or

> more, although local guidelines may vary). So while 4-drugs is safest for M.

> tuberculosis, I am not aware that the commercial BCG strains (which would be

> the most likely source here, if this is BCG meningitis) have demonstrated

> acquired resistance (a few strains have low level in vitro resistance to INH

> and ethionamide, but I don't know what that means clinically).

>

> It is hard to comment from a distance on whether or not to continue

> amphotericin. Is there evidence of yeast disease (e.g. Candida) elsewhere

> (e.g. blood, retinal spots)? If there evidence of mould (e.g. sinus images).

> Is there anything that could be biopsied to give you an answer? Waiting for

> CSF cultures may not yield much. Even in true TB meningitis, a good volume

> of CSF (e.g. 5 mL) is usually required to make a diagnosis by culture - a

> volume typically hard to get, especially in children. For molds, the best

> sample is tissue.

>

>

> Donald C. Vinh, MD

> Infectious Disease specialist & Medical Microbiologist

> Visiting Post-doctoral Fellow, LCID

> NIH / NIAID

> 9000 Rockville Pike

> Bldg 10CRC, Rm B3-4141

> Bethesda, MD     USA

> 20892

> Ph: 301-496-2473

> Fax: 301-480-4507

> e-mail: vinhd at niaid.nih.gov<mailto:vinhd at niaid.nih.gov>

>

>

> ********************************************************************************************

>

> Disclaimer:

>

> The information in this e-mail and any of its attachments is confidential

> and may contain sensitive information.  It should not be used by anyone who

> is not the original intended recipient.  If you have received this e-mail in

> error please inform the sender and delete it from your mailbox or any other

> storage devices.  The National Institute of Allergy and Infectious Diseases

> (NIAID)  shall not accept liability for any statement made that are the

> sender's own and not expressly made on behalf of the NIAID by one of its

> representatives.

>

>

> ******************************************************************************************************************************************

>

> ________________________________

> From: pagid-bounces at list.clinimmsoc.org [pagid-bounces at list.clinimmsoc.org]

> On Behalf Of Nacho Gonzalez [nachgonzalez at gmail.com]

> Sent: Wednesday, August 19, 2009 6:12 AM

> To: pagid at list.clinimmsoc.org

> Subject: Re: [PAGID] CGD patient

>

> Why not add levofloxacin? It has a blood brain barrier penetration and

> antiTB efficacy may be considered as first line therapy. Furthermore, 4

> antiTB drugs is a standard regimen in tuberculous meningitis

>

> Luis Ignacio Gonzalez Granado. Immunodeficiencies and Pediatric infectious

> diseases division. Hospital 12 octubre. Madrid.

>

> 2009/8/19 <grumach at usp.br<mailto:grumach at usp.br>>

> Dear Donald,

>

> Thanks for your comment. My first hypothesis is BCG meningitis but should I

> leave without antifungal drugs? Dexamethasone was used for one week just

> after the seizures. Should i introduce it again with ethambutol?

>

> Anete S Grumach

>

> Citando "Vinh, Donald (NIH/NIAID) [F]" <vinhd at niaid.nih.gov<mailto:

> vinhd at niaid.nih.gov>>:

>

>

> If you believe this is BCG meningitis, then the pyrazinamide will  not be

> useful since M. bovis/BCG produces pyraziminidase and is  intrinsically

> resistant to pyrazinamide. Ethambutol has decent blood  brain barrier

> penetration. Streptomycin does not. If there is  paradoxical worsening on

> treatment, you may consider concomitant  dexamethasone.

>

> Donald C. Vinh, MD

> Infectious Disease specialist & Medical Microbiologist

> Visiting Post-doctoral Fellow, LCID

> NIH / NIAID

> 9000 Rockville Pike

> Bldg 10CRC, Rm B3-4141

> Bethesda, MD     USA

> 20892

> Ph: 301-496-2473

> Fax: 301-480-4507

> e-mail: vinhd at niaid.nih.gov<mailto:vinhd at niaid.nih.gov>

>

>

> ********************************************************************************************

>

> Disclaimer:

>

> The information in this e-mail and any of its attachments is  confidential

> and may contain sensitive information.  It should not  be used by anyone who

> is not the original intended recipient.  If  you have received this e-mail

> in error please inform the sender and  delete it from your mailbox or any

> other storage devices.  The  National Institute of Allergy and Infectious

> Diseases (NIAID)  shall  not accept liability for any statement made that

> are the sender's  own and not expressly made on behalf of the NIAID by one

> of its  representatives.

>

>

> ******************************************************************************************************************************************

> ________________________________________

> From: pagid-bounces at list.clinimmsoc.org<mailto:

> pagid-bounces at list.clinimmsoc.org>  [pagid-bounces at list.clinimmsoc.org

> <mailto:pagid-bounces at list.clinimmsoc.org>] On Behalf Of grumach at usp.br

> <mailto:grumach at usp.br>  [grumach at usp.br<mailto:grumach at usp.br>]

> Sent: Tuesday, August 18, 2009 9:10 PM

> To: pagid at list.clinimmsoc.org<mailto:pagid at list.clinimmsoc.org>

> Subject: [PAGID] CGD patient

>

> Dear

>

>

> I have just diagnosed CGD in a 3 month old male. He had prolonged

> fever with unknown origin and BCG vaccination was not looking well. He

> developed seizures and liquor showed about 600 cells, predominantly

> lymphomono, high protein and low sugar. No positivity was obtained in

> the cultures (for BCG still going on).

> He received drugs for all possibilities: Amphotericin, Isoniazide,

> Pirazinamide, ryphampicin, co-trimoxazole and antibiotics. The fever

> and seizures disapeared after the 3rd day. BCG lesion is still present

> (same aspect). The cerebrospinal fluid (after 30 days) presents 73

> cells, lymphomono, high protein, low glucose and a previous positive

> ADA.

> I would suggest to change pirazinamide for ethambutol.

> Do you have any suggestion?

>

> Thanks a lot

>

> Best regards

>

> Anete S Grumach, MD, PhD

> Outpatient group of Primary Immunodeficiencies,

> Dept of Dermatology, University of São Paulo

> Dept of Immunization, Adverse Events, Secretary of Health, São Paulo

>

>

>

>

>

>

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://seven.pairlist.net/mailman/private/pagid/attachments/20090819/5b7fc546/attachment.htm>