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His finger had become sore and then progressively more painful and swollen.
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During the 7-year study period, 909 elderly patients receiving glyburide were admitted with a diagnosis of hypoglycemia. In the primary analysis, those patients admitted for hypoglycemia were more than 6 times as likely to have been treated with co-trimoxazole in the previous week (adjusted odds ratio, 6.6; 95% confidence interval, 4.5-9.7). Patients admitted with digoxin toxicity (n = 1051) were about 12 times more likely to have been treated with clarithromycin (adjusted odds ratio, 11.7; 95% confidence interval, 7.5-18.2) in the previous week, and patients treated with ACE inhibitors admitted with a diagnosis of hyperkalemia (n = 523) were about 20 times more likely to have been treated with a potassium-sparing diuretic (adjusted odds ratio, 20.3; 95% confidence interval, 13.4-30.7) in the previous week. No increased risk of drug toxicity was found for drugs with similar indications but no known interactions (amoxicillin, cefuroxime, and indapamide, respectively).
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From 1982 to 1988, 20 patients with pulmonary nocardiosis were diagnosed at the Department of Medicine, Chulalongkorn Hospital University. The infection was found to be common in immuno-compromised hosts particularly in patients who were suffering from lymphoreticular malignancy, systemic lupus erythematosus, nephrotic syndrome, pulmonary alveolar proteinosis and in patients who were receiving corticosteroids. The clinical manifestations were usually nonspecific. Diagnosis of pulmonary nocardiosis in cases who presented with a short duration of fever and productive cough was often delayed because they were considered to have acute bacterial pneumonia. The findings on chest roentgenogram were nonspecific as nonhomogeneous airspace infiltrates, cavitary lesions, nodule, or miliary infiltrates. The complete blood count frequently showed leukocytosis and neutrophilia. The diagnosis of nocardiosis was suspected if the staining of specimens obtained from the lesions showed typically weakly gram-positive and modified acid-fast branching filament organism and the diagnosis was confirmed by culture. The skin and the central nervous system were the most common hematogenous disseminations. Sulfamethoxazole and trimethoprim in combination were the drugs of choice. The treatment for a minimum of 6 months was appropriate in order to prevent relapse. Poor prognostic factors in nocardiosis were acute infection, Cushing's disease; and disseminated infection involving the central nervous system.
This study was conducted between June 28, 2010, and September 25, 2013. 400 infants were enrolled and 393 randomized at 6 mo of age to no chemoprevention, monthly sulfadoxine-pyrimethamine (SP), daily trimethoprim-sulfamethoxazole (TS), or monthly dihydroartemisinin-piperaquine (DP). Study drugs were administered at home without supervision. Piperaquine (PQ) levels were used as a measure of compliance in the DP arm. Participants were given insecticide-treated bednets, and caregivers were encouraged to bring their child to a study clinic whenever they were ill. Chemoprevention was stopped at 24 mo of age, and participants followed-up an additional year. Primary outcome was the incidence of malaria during the intervention period. During the intervention, the incidence of malaria in the no chemoprevention arm was 6.95 episodes per person-year at risk. Protective efficacy was 58% (95% CI, 45%-67%, p<0.001) for DP, 28% (95% CI, 7%-44%, p = 0.01) for TS, and 7% for SP (95% CI, -19% to 28%, p = 0.57). PQ levels were below the detection limit 52% of the time when malaria was diagnosed in the DP arm, suggesting non-adherence. There were no differences between the study arms in the incidence of serious adverse events during the intervention and the incidence of malaria during the 1-y period after the intervention was stopped.
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A 38-yr-old male with acquired immunodeficiency syndrome developed neck pain in association with mild hyperthyroidism and a diffusely enlarged thyroid gland. Radioactive iodine scanning was consistent with thyroiditis, and biopsy of the thyroid demonstrated the presence of pneumocystis carinii in thyroid tissue. Treatment with pentamidine followed by trimethoprim sulfamethoxazole led to rapid normalization of thyroid size in association with the development of hypothyroidism. This case illustrates the natural history of pneumocystis carinii thyroiditis and suggests that thyroid disease be added to the spectrum of human immunodeficiency virus-associated endocrine dysfunction.
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One hundred sixty-one patients were enrolled, with 12 lost to follow-up. The failure rates were 5.3% (n=4/76) and 4.1% (n=3/73) in the placebo and antibiotic groups, respectively, yielding a difference of 1.2%, with a 1-sided 95% confidence interval (CI) (-infinity to 6.8%). Noninferiority was established with an equivalence threshold of 7%. New lesions occurred at the 10-day follow-up: 19 on placebo (26.4%) and 9 on antibiotics (12.9%), yielding a difference of 13.5%, with 95% 1-sided CI (-infinity to 24.3%). At the 3-month follow-up, 15 of 52 (28.8%) in the placebo group and 13 of 46 (28.3%) in the antibiotic group developed new lesions. The difference was 0.5%, with 95% 1-sided CI (-infinity to 15.6%).
In children with urinary tract infection in vitro susceptibility to trimethoprim was comparable to that to trimethoprim/sulfamethoxazole and significantly higher than to sulfamethoxazole. This finding was similar at all sites. Adding sulfamethoxazole appears unnecessary and may represent a risk to patients. Trimethoprim can be used as an alternative to trimethoprim/sulfamethoxazole based on in vitro antibacterial susceptibility. Routine trimethoprim/sulfamethoxazole use for urinary tract infection should be carefully reevaluated.
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Systemic lupus erythematosus (SLE) induced by drugs, primarily hydralazine and procainamide, is reviewed and compared with idiopathic SLE, and the use of these drugs in patients with idiopathic SLE is discussed. The etiology of SLE is unclear, but genetic predisposition is an important factor. Although more than 25 drugs have been suggested as causes of SLE, the majority of confirmed cases of drug-induced SLE involve hydralazine or procainamide. Parts of these chemical compounds apparently interact with nucleoproteins, causing stimulation of antinuclear antibody (ANA) production. The average age of patients with drug-induced SLE is nearly twice that of patients with idiopathic SLE. Approximately half the patients with drug-induced SLE are women, compared with 92% of patients with idiopathic SLE. For SLE induced by hydralazine or procainamide, musculoskeletal symptoms (especially arthritis in the hands and wrists) are the most common clinical manifestation. In patients with SLE induced by these drugs, ANAs and LE cells are present, erythrocyte sedimentation rate is often elevated, and a false-positive serologic test for syphilis is seen more frequently than in idiopathic SLE. Baseline ANA status should be determined before therapy with these drugs, and patients should be observed carefully for signs and symptoms of SLE. Hydralazine-induced SLE may be dose related; limiting the daily dose to 200 mg is recommended. Some drugs have been shown to exacerbate idiopathic SLE; these include estrogen-containing oral contraceptives and ibuprofen. Hydralazine and procainamide are probably safe for use in patients with idiopathic SLE, but alternative therapy should be considered. The clinical and laboratory manifestations of drug-induced SLE are similar to those of idiopathic SLE, but central nervous system and renal involvement are rare in drug-induced SLE.
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Rats which were immunosuppressed with adrenal corticosteroids then transtracheally inoculated with Pneumocystis carinii were evaluated as models for study of drug efficacy. Trimethoprim/sulfamethoxazole, known to be effective against Pneumocystis, was given in therapeutic and prophylactic regimens and its long-term effectiveness determined by a protocol to study relapse. Untreated animals uniformly developed severe infection with differences in numbers of organisms between untreated and treated animals being greater than two logs. Therapy of prophylaxis studies could be completed in 6 to 7 weeks. Animals given prophylaxis or therapy with trimethoprim/sulfamethoxazole had few organisms detected in lungs. Numbers of organisms did not increase during the 4 weeks when the animals were continued on immunosuppression after discontinuing treatment as long as reinfection was prevented. These models are useful for evaluating anti-Pneumocystis activity of antimicrobials. Relapse study data suggest that reinfection may have an important role in development of recurrent Pneumocystis pneumonia.
A patient with a yearlong fever of unknown origin responded to trimethoprim-sulfamethoxazole and was discovered to have culture-proved Nocardia asteroides sinusitis, with absence of detectable disease in other organs. An inhalational route is postulated as the mode of entry of the organism, with localization in the maxillary sinus.