Bactrim: “CRAB” Findings in a Patient With Fatigue and Poor Appetite

Possible Answers

Most likely diagnosis: multiple myeloma. Multiple myeloma is defined as a clonal proliferation of aberrant bone marrow plasma cells accompanied by monoclonal protein production and destructive bone lesions.[1]

The most common clinical manifestations of multiple myeloma are summarized by the acronym, "CRAB": hypercalcemia, renal dysfunction (ie, increased serum creatinine concentration), anemia, and lytic bone lesions.[2] The most recent diagnostic criteria for multiple myeloma are summarized in Table 2 .[2]

Although monoclonal protein spikes (M-spikes) are most often seen upon SPE or UPE of serum or urine from patients with a plasma cell dyscrasia, they can also be seen upon SPE of serum and/or urine from patients with lymphoma, carcinoma, chronic infections, solitary and multiple plasmacytomas, plasma cell leukemia, amyloidosis, smoldering (or indolent) myeloma, and monoclonal gammopathy of undetermined significance (MGUS).[2,3] Interestingly, non-secretory multiple myeloma is associated with an absence of an M-spike(s) by SPE, UPE, or IFE.

In 1999, a panel of experts published 9 guidelines for the clinical and laboratory evaluation of patients with monoclonal gammopathies[4] that are summarized in Table 3 .

Despite the fact that the patient had no evidence of residual disease on examination of her bone marrow, she continued to have an abnormal serum protein electrophoresis pattern (SPEP). Moreover, the SPEP originally seen on electrophoresis of her serum had changed significantly from a single IgG kappa M-protein to an oligoclonal pattern consisting of IgG kappa, IgG lambda, and free lambda light chains. It is likely that the patient's markedly decreased platelet count and modestly decreased hemoglobin and hematocrit values ( Table 1 ) were due to continued bone marrow recovery following melphalan therapy and stem cell transplantation.

Transient oligoclonal (ie, ≥2 M-protein bands on SPEP) and monoclonal gammopathies occur in at least 50% of all patients after stem cell transplant and in at least 10% of patients with multiple myeloma treated with stem cell transplant.[3,6] These bands have been shown to appear between 2 to 6 months post-stem cell transplant and persist on SPEPs for an average of 6 months.[3]

When oligoclonal bands or a monoclonal band with a different immunophenotype than the band observed initially are observed, the differential diagnosis includes a change in M-protein production by the original plasma cell clone, the emergence of a second malignant clone, or the evidence for immune system regeneration following stem cell transplant therapy. To date, most studies favor the latter hypothesis; the bands represent a benign phenomenon associated with the recovery of immune function in patients who have received a stem cell transplant with or without myeloablative bone marrow therapy prior to stem cell transplantation.[3,6-8]One study of patients with multiple myeloma who were treated with stem cell transplantation, with or without prior myeloablation, revealed a significant relationship between the appearance of abnormal protein bands by SPE and IFE after transplantation and a higher likelihood of positive clinical response, event-free survival, and overall survival.[6]

For more than 2 decades, the standard therapy for patients with symptomatic multiple myeloma has included a wide variety of chemotherapeutic regimens. The most commonly used regimens include combined melphalan and prednisone therapy and the combination of vincristine, adriamycin, and dexamethasone (VAD).[1] Such treatments are associated with a median survival of 2 to 3 years. Other chemotherapeutic regimens, which have been used as both frontline and relapse therapies, include pulse dexamethasone and combined therapy with thalidomide and dexamethasone.[1] Unfortunately, almost all patients who initially respond to chemotherapy eventually relapse. In recent years, high-dose chemotherapy followed by autologous stem cell transplantation has become an important alternative frontline treatment for younger patients (<70 years) as well as a rescue therapy for patients who relapse after chemotherapy. This treatment achieves higher complete response rates compared to chemotherapy alone. Prolonged survival (>6 years), however, remains rare.[9]  Printer- Friendly Email This

Lab Med.  2005;36(8):482-485.  ©2005 American Society for Clinical Pathology
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Bactrim: Resistant ‘Superbugs’ Create Need for Novel Antibiotics

Which Bacteria Are Called ‘Superbugs'?

In the 1990s, MRSA, VRSA, and VRE were the major superbugs which required clinical attention and pharmacological ingenuity. Sta phylococcus aureus and enterococcus were the glycopeptide-resistant gram-positive cocci of major concern. Some strains of staphylococcus, completely resistant to vancomycin, were called vancomycin-resistant staphylococcus aureus (VRSA). Some strains had some susceptibility to vancomycin and were called vancomycin intermediately susceptible staphylococcus aureus (VISA) or glycopeptide intermediately susceptible staph ylococcus aureus (GISA). This terminology also was used for enterococci: VRE and GRE (Pfeltz & Wilkinson, 2004; Shah, 2005).

As attention has been on staphylococcus and enterococcus for the past decade, another bacterium, streptococcus pneumoniae (also called pneumococcus), has been developing resistance. It classically has been a major cause of community-acquired infections, such as upper respiratory infections, bronchitis, pneumonia, otitis media, pharyngitis, and meningitis. Al though the bacterium was once eradicated easily with penicillin, significant antibiotic resistance has now become a major problem in strains of pneumococcus (Cen ters for Disease Control [CDC], 2003; Whitney et al., 2000).

Strains of S. pneumoniae have developed resistance to penicillin, trimethoprimsulfmeth oxazole (BactrimAE), macrolides (for example, azithromycin [Zith ro maxAE]), tetracyclines (for ex ample., minocycline [MinocinAE]), and fluoroquinolones (for example, ciprofloxacin [CiproAE]) (Hoff man-Roberts, Bab cock, & Mitro poulous, 2005; Karchmer, 2004). In 2002, the CDC reported that 34% of all S. pneumoniae infections were resistant to at least one antibiotic and 17% were resistant to three or more antibiotics (CDC, 2003). Drug-resistant streptococcus pneumoniae (DRSP) or penicillin-resistant streptococcus pneumoniae (PRSP) became the newest superbug of concern in 2002.

The trend of rising bacterial resistance continues to challenge health care providers. Antibiotic resistance has now become worthy of concern in pseudomonas aeruginosa, acinetobacter baumannii, and group A beta hemolytic streptococcus (GABHS, also called streptococcus pyogenes). These bacteria have not posed a major threat yet, but are anticipated to be the next highly resistant superbugs (Navon-Venezia, Ben-Ami, & Carmeli, 2005).

The health care literature uses a number of acronyms to describe the significant antibiotic-resistant bacteria which exist within the community and clinical settings. Nurses should be familiar with the terminology in Table 1 .   Printer- Friendly Email This

Dermatol Nurs.  2007;19(1):65-70.  ©2007 Jannetti Publications, Inc.
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Woman survives ‘losing her skin’ using co-trimoxazole.

Ms Yeargain had intensive handling in a medical specialist scathe unit

A charwoman whose entire skin peeled off after a rare chemical reaction to a drug has made a ‘miraculous’ act.

Sarah Yeargain of from San Diego, California, developed the often fatal malady after taking an antibiotic.

She developed blisters and intumescency on her face and within days, her skin was movement off “in sheets”.

Doctors at the Body of California Regional Burn Inwardness in San Diego saved her life by hiding her in artificial skin which helped her own skin heal.

She lost skin in her entire body Dr Book of the Prophet Daniel Lozano, Body of California

Ms Yeargain had taken the antibiotic Bactrim, also known as trimethoprim-sulfamethoxazole or as co-trimoxazole in the UK, for a bone corruption.

But she experienced a rare severe allergic chemical process called toxic epidermal necrolysis, where the body’s immune method malfunctions after it is exposed to a drug.

She commencement noticed some minor hump and appearance in her face, then blistering on her lips and prominence on her eyes.

Soon, her face, piece of furniture and arms were covered in blisters and skin all over her body began to fall off.

Even the skin on her internal organs and the membranes manual labour her interpreter, opening and eyes came away.

‘A Creator hand’

Doctors at the specializer defect unit treated Sarah by natural covering her entire body with a skin relief, called TransCyte.

They also gave her drugs to prevent internal bleeding and her own skin started to grow back.

Her prioress Katherine told San Diego’s Canal 10 news doctors did not believe her daughter would survive.

She said: “Generally with 100% sloughing there is a 100% mortality rate. We just prayed.”

Sarah said she was determined to argument the procedure. “I wasn’t ready to be finished.”

Dr INSTANCE OFbook Lozano, who treated Sarah, said: “She lost skin in her entire body. It’s rather dramatic to really see this consummation off in sheets.”

He added: “We were able, over a 48-hour division, to fixed cost her construct body with an artificial skin peer that allowed this to first healing rapidly. Within about a week her skin was back.”

Meredith Hotdog, a PCP in the INSTANCE OFpoet unit, said Ms Yeargain’s deed was a event.

“With the importance of the skin loss she had that there was a clergyman hand in her deed.”
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