Abstract

Purpose/Introduction: Trimetropim sulfamethoxazole (TMP-SMX) is a widely prescribed antibiotic. Both hepatitis and pancreatitis are uncommon side effects, and reports in non-immunosuppressed patients are rare. To our knowledge, there are only two previous case reports of concomitant hepatitis and pancreatitis occurring in an inmunocompetent patient. Case Presentation: A 65-year-old male with previous history of coronary artery disease, hypertension and dyslipidemia presented to the emergency room with abdominal pain, jaundice and a skin rash. The patient had been started on TMP-SMX for otitis media two weeks before arriving to the emergency department. During this period of time, the patient presented with nausea, vomiting, weight loss and fever. On physical examination, he was found to be jaundice, and a generalized non-pruritic macular rash was noticed. There was no history of alcohol use. On admission, liver function test and pancreatic markers were elevated. ALT peaked to 510, AST to 445 U/L, total and direct bilirubin to 19 and 8.9 mg/dL respectively, lipase to 578 U/L and amylase 102 U/L, albumin was decreased and coagulation studies were normal, and remained normal during and after hospitalization. Other causes of pancreatitis were rule out. Triglycerides were within normal limits and calcium and SPEP were normal. Acute viral hepatitis, CMV and EBV serology were negative, and titers of autoimmune markers were normal. Abdominal CT did not show hepatic or pancreatic abnormalities, and the abdominal ultrasound did not show gallstones or dilation of the intrahepatic ducts. Upper endoscopy showed esophagitis and gastritis. Pancreatitis and hepatitis were managed with fluid resuscitation and supportive care. The patient improved clinically, a decrease in lipase and aminotransferase was noted during hospitalization and a gradual decrease of bilirubin occurred after hospitalization. Discussion: Clinical observation is an important tool to identify adverse effects from medications. In this particular case, we have a Naranjo score of six (probable drug reaction). The mechanism of idiosyncratic adverse effects to TMP-SMX is not clearly understood, but inmuno-allergic mechanisms have been proposed. This case underlines the importance of considering commonly used medications as the causative event of severe medical conditions.

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