Severe systemic toxicity after intravenous administration of metamizole and ceftriaxone in a splenectomised patient-case report

Abstract

Drug-induced toxicity can have a mild to severe clinical presentation as a life-threatening condition. We presented a case with a general vasculitis and severe multi-organ failure in a splenectomised middle-aged woman, which developed after ceftriaxone and metamizole parenteral administration. A middle-aged woman was treated with IV metamizole and ceftriaxone for a fever and soar throat in a local hospital. She had a post traumatic splenectomy 5 years ago. After metamizole, during ceftriaxone administration she felt burning in her face with maculo-papulose rash which started to conflate, spread to whole body and intensively darkened. She was transferred to the University Toxicology Clinic with а hypotension, hypoxemia, generalized necrotic vasculitis with predominant facial distribution. There was increased values for CRP (250 mg/l), WBC (27x10^9/l) and LDH (1867 U/l) during hospitalisation. She also presented anaemia (Er 2.6x10^12/l, Hgb 88 g/l, Hct 0.24), polyserositis-ascites, pleural effusion and mild pericarditis (high sensitive troponin 107 ng/l), acute pancreatitis (amylase 1048 U/l, lipase 881 U/l), hepatomegaly, acute kidney injury (BUN 36.5 mmol/l, creatinine 528 μmol/l, oliguria), disseminated intravascular coagulation (Plt 23x10^9/l, DD 7658ng/ml, PT 56 sec, aPTT 120 sec), vitreous haemorrhage of the right eye and rhabdomyolysis, CPK 428U/l. Microbiological findings were negative. Immunoserology showed positive p-ANCA. The acute renal failure, ascites and pleural effusions resolved under methylprednisolone, meropenem, LMWH, haemodialysis and symptomatic therapy, with normalization of laboratory parameters. A skin biopsy finding was inconclusive. After 25 days, rheumatologist recommended mycophenolate mofetil PO. She was asymptomatic with prednisolone and mycophenolate mofetil therapy during following two years and maintained stable after their discontinuation. Drug-induced toxicity have potential to induce a severe multiorgan failure with life-threatening complications. Splenectomy may be studied as a potentially risk factor for immunomodulated response to drugs and drugs interactions, especially during infections.