[PAGID] CGD patient

[grumach at usp.br]

Dear Donald,

The child does not present any evidence of yeast disease but by the  
time he presented seizures everything was treated!
There is pulmonary lesions and we have tried endobronchial biopsy and  
it didn´t help. We have just asked PCR for Mycobacteria/BCG because as  
you mentioned the volume was limited.
Considering that he received 28 days of Amphotericin, I would keep  
with coverage for yeasts. Which could I use for a 3 month old child?  
Fluconazole?

Thank you very much for your help

Anete


Citando "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:

>

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

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>

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

>

> ________________________________

> 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

>

>

>

>

>

>