Abstract
Primary brain tumor patients have multiple risk factors for Pneumocystis jiroveci and may require prophylaxis with TMP-SMZ or dapsone. Although dapsone is generally safe and efficacious, we present a case of a patient diagnosed with a brain stem glioblastoma who developed methemoglobinemia and haemolytic anemia after presenting with worsening confusion and cardiopulmonary system dysfunction. This case highlights one of the potentially severe complications associated with dapsone therapy. Although this illustrates an unusual toxicity of dapsone, a high index of suspicion should be given to high-risk patients due to ethnic heritage, anemia, or advanced age. Furthermore, given the toxicities of TMP-SMZ and dapsone, further work is needed to determine the threshold CD4+ count at which empiric prophylaxis should be initiated.
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References
Hughes MA, Parisi M, Grossman S et al (2005) Primary brain tumors treated with steroids and radiotherapy: low CD4 counts and risk of infection. Int J Radiat Oncol Biol Phys 62:1423–1426. doi:10.1016/j.ijrobp.2004.12.085
Su YB, Sohn S, Krown SE et al (2004) Selective CD4+ lymphopenia in melanoma patients treated with temozolomide: a toxicity with therapeutic implications. J Clin Oncol 22:610–616. doi:10.1200/JCO.2004.07.060
Grossman SA, Desideri S, Ye X, Szajna K, Chamberlain M, Lesser G (2007) Iatrogenic immunosuppression in patients with newly diagnosed high-grade gliomas. J Clin Oncol, 2007 ASCO annual meeting proceedings 25: Abstract 2012
Yu SK, Chalmers AJ (2007) Patients receiving standard-dose temozolomide therapy are at risk of Pneumocystis carinii pneumonia. Clin Oncol (R Coll Radiol) 19:631–632. doi:10.1016/j.clon.2007.06.003
Hughes WT, Rivera GK, Schell MJ et al (1987) Successful intermittent chemoprophylaxis for Pneumocystis carinii pneumonitis. N Engl J Med 316:1627–1632
Medina I, Mills J, Leoung G et al (1990) Oral therapy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. A controlled trial of trimethoprim-sulfamethoxazole versus trimethoprim-dapsone. N Engl J Med 323:776–782
Mansouri A, Lurie AA (1993) Concise review: methemoglobinemia. Am J Hematol 42:7–12. doi:10.1002/ajh.2830420104
Umbreit J (2007) Methemoglobin-it’s not just blue: a concise review. Am J Hematol 82:134–144. doi:10.1002/ajh.20738
Turner MD, Karlis V, Glickman RS (2007) The recognition, physiology, and treatment of medication-induced methemoglobinemia: a case report. Anesth Prog 54:115–117. doi:10.2344/0003-3006(2007)54[115:TRPATO]2.0.CO;2
Coleman MD, Rhodes LE, Scott AK et al (1992) The use of cimetidine to reduce dapsone-dependent methaemoglobinaemia in dermatitis herpetiformis patients. Br J Clin Pharmacol 34:244–249
Reilly TP, Woster PM, Svensson CK (1999) Methemoglobin formation by hydroxylamine metabolites of sulfamethoxazole and dapsone: implications for differences in adverse drug reactions. J Pharmacol Exp Ther 288:951–959
Abidi MH, Kozlowski JR, Ibrahim RB et al (2006) The sulfone syndrome secondary to dapsone prophylaxis in a patient undergoing unrelated hematopoietic stem cell transplantation. Hematol Oncol 24:164–165. doi:10.1002/hon.780
Ash-Bernal R, Wise R, Wright SM (2004) Acquired methemoglobinemia: a retrospective series of 138 cases at 2 teaching hospitals. Medicine (Baltimore) 83:265–273. doi:10.1097/01.md.0000141096.00377.3f
Williams S, MacDonald P, Hoyer JD et al (2005) Methemoglobinemia in children with acute lymphoblastic leukemia (ALL) receiving dapsone for pneumocystis carinii pneumonia (PCP) prophylaxis: a correlation with cytochrome b5 reductase (Cb5R) enzyme levels. Pediatr Blood Cancer 44:55–62. doi:10.1002/pbc.20164
Walenta S, Dotsch J, Bourrat-Flock B et al (1990) Size-dependent oxygenation and energy status in multicellular tumor spheroids. Adv Exp Med Biol 277:889–893
Vulliamy T, Mason P, Luzzatto L (1992) The molecular basis of glucose-6-phosphate dehydrogenase deficiency. Trends Genet 8:138–143
Beutler E (1991) Glucose-6-phosphate dehydrogenase deficiency. N Engl J Med 324:169–174
Dunford LM, Roy DM, Hahn TE et al (2006) Dapsone-induced methemoglobinemia after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 12:241–242. doi:10.1016/j.bbmt.2005.10.008
Kane GC, Hoehn SM, Behrenbeck TR et al (2007) Benzocaine-induced methemoglobinemia based on the Mayo Clinic experience from 28 478 transesophageal echocardiograms: incidence, outcomes, and predisposing factors. Arch Intern Med 167:1977–1982. doi:10.1001/archinte.167.18.1977
Goluboff N, Wheaton R (1961) Methylene blue induced cyanosis and acute hemolytic anemia complicating the treatment of methemoglobinemia. J Pediatr 58:86–89. doi:10.1016/S0022-3476(61)80064-4
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Walker, J.G., Kadia, T., Brown, L. et al. Dapsone induced methemoglobinemia in a patient with glioblastoma. J Neurooncol 94, 149–152 (2009). https://doi.org/10.1007/s11060-009-9813-8
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DOI: https://doi.org/10.1007/s11060-009-9813-8