CASE REPORTS 17

Quetiapine interaction \*jisjFirst report of an interaction with concomitantoxcarbazepine leading to extrapyramidal disorders inan elderly patient: case report

A 77-year-old man was hospitalised with symptoms ofLewy body dementia and started treatment withquetiapine and oxcarbazepine [dosages not stated]. Oneweek later, he developed extrapyramidal disorders, withdramatic worsening of the Webster scale and an inabilityto walk. Quetiapine and oxcarbazepine were discontinuedand his symptoms resolved.

Author comment: "The speed of increasing dose of theantipsychotic drug . . . might be a possible influencingfactor as well as a (pharmacokinetic) interaction ofquetiapine and oxcarbazepine."Schuhmann T. Lewy body dementia, pharmacotherapeutic security and differentialindication of antipsychotics according to adverse effects - a case report.Pharmacopsychiatry 38: 62-63, No. I, Jan 2005 [abstract] -Switzerland 801005254

> Editorial comment: A search of AdisBase andMedline did not reveal any previous case reports of aninteraction between quetiapine and oxcarbazepine. TheWHO Adverse Drug Reactions database contained228 reports involving the concomitant use of quetiapineand oxcarbazepine.

Reteplase l ^First report of choiesterol emboiisation leading torenal failure and gastric ulcers in an elderly patient:case report

A 68-year-old woman developed renal failure andgastric ulcers associated with cholesterol emboiisationfollowing treatment with reteplase and for a myocardialinfarction.

The woman was hospitalised and received reteplase[dosage not stated] followed by a heparin infusion; sheexperienced an episode of hypotension (BP 70/38mm Hg)after administration of reteplase and was treated with IVfluids. Her creatinine level increased from 2 mg/dL onadmission to 3.2 mg/dL by hospital day 8, and laboratoryinvestigations revealed persistent peripheral eosinophiliafrom day 2. She also experienced epigastric disconifortand, on day 9, developed melaena.Oesophagoduodenoscopy revealed erosive gastritis withmultiple shallow gastric ulcers, and a mucosal biopsyshowed cholesterol crystal clefts in the lumen ofarterioles.

The woman received prednisone for 2 weeks, but herrenal function did not improve and haemodialysis wassubsequently initiated. At follow-up 10 months later, sheremained dependent on haemodialysis.Hitti WA, Anderson J. Cholesterol emboU-induced renal failure and gastric ulcerafter thrombolytic therapy. Southeni Medical Journal 98: 235-237, No. 2, Feb 2005- U S A 801003307

> Editorial comment: A search of AdisBase, Medlineand the WHO Adverse Drug Reactions database did notreveal any previous case reports of cholesterol crystalemboli associated with reteplase.

RisperidoneMorning pseudoneutropenia: case report

A 33-year-old woman developed morningpseudoneutropenia during treatment with risperidone forparanoid schizophrenia.

The woman began receiving risperidone 1 mg/day,titrated to 4 mg/day within 4 weeks. After 6 weeks ofoutpatient treatment she was hospitalised. On admission,at 8:00am, she had a WBC count of 3240/mm3, and anabsolute neutrophil count (ANC) of 1560/mm'. The nextmorning, at 8:00am, both counts had further decreased,indicating neutropenia and leucopenia. Six hours later, arepeat blood sample revealed her WBC count and ANChad normalised. During the next 8 weeks, risperidone wastitrated to 12 mg/day; blood tests taken at 8:00am and2:00pm twice weekly revealed consistently that, at8:00am, her WBC count was 2910-3620/mm3, and herANC was 1310-1850/nmi', and at 2:00pm, these levelswere within the normal range. As her ANCs were withinnormal range at 2:00pm, efficacious risperidone treatmentwas not interrupted.

Esposito D, Corruble E. Hardy P, Chouinard G. Risperidone-induced momingpseudoneutropenia. American Journal of Psychiatry 162: 397, No. 2, Feb 2005 -France 8010O7M4

Sildenafilsee Nitric oxide/sildenafil

Tacrolimus 12^Interaction with voriconazole leading to renalimpairment in a renal transplant recipient: case report

A 55-year-old male renal transplant recipient receivingimmunosuppressive therapy with tacrolimus developedincreased tacrolimus serum concentrations leading to renalimpairment, during treatment with voriconazole for aPseudallescheria boydii skin infection.

The man, who had a history of cholestasis, wasswitched from itraconazole to oral voriconazole [V-Fend]4 mg/kg twice daily, with concomitant tacrolimus2 mg/day, after 1 month of itraconazole treatment; histacrolimus dosage had been reduced by 50% whenitraconazole was initiated 1 month prior to admission.After 7 days, his previously stable tacrolimus troughconcentration (< 12 ng/mL) increased markedly. After 10and 17 days, his tacrolimus trough concentrationincreased to 20 ng/mL and 25 ng/mL, respectively, andwas associated with renal graft fiincdon impairment; hisserum creatinine levels increased from 1.2 to 1.9 mg/dLafter 10 days, and 3.9 mg/dL after 17 days.

The man's tacrolimus dosage was reduced over 3 days,ending with 0.5mg every other day, and then slowlyrecovered.

Author comment: "Because voriconazole ismetabolized by the hepatic CYP-450 systems, druginteraction with calcineurin inhibitors occurs, resulting inincreased serum concentration and sometimes leading torenal toxicity. . . Perhaps, in this case, the interactionmight have been aggravated by the chronic cholestasisour patient was suffering from."Tintillier M, Kirch L, Goffin B, Cuvelier C, Pochet J-M. Interaction betweenvoriconazole and tacrolimus in a kidney-transplanted patient. Nephrology DialysisTransplantation 20: 664-665, No. 3, Mar 2005 - Belgium 801005301

0114-9954/05/1048-00017/$11.00 2005 Adis Data Information BV. All rights reserved Reactions 23 Apr 2005 No. 1046