Reversible myoclonus, asterixis, and tremor associated with high dose trimethoprim-sulfamethoxazole: a case report. (2nd January 2016)

• Record Type: Journal Article
• Authors: Gray, Damon A.; Foo, Dominic
• Is Part Of: Journal of spinal cord medicine. Volume 39:Number 1(2016:Jan.)
• Page Start: 115
• Page End: 117
• Publication Date: 2016-01-02
• Subjects: Trimethoprim-sulfamethoxazole combination -- Myoclonus -- Dyskinesias -- Tremor -- Spinal cord injuries -- Pneumocystis jirovecii -- Pneumonia -- Pneumocystis -- Physical and rehabilitation medicine -- Etiracetam; Spinal cord -- Wounds and injuries -- Periodicals; Spinal cord -- Diseases -- Periodicals; 616.8305
• DOI: 10.1179/2045772315Y.0000000018
• Languages: English
• ISSNs: 1079-0268

Abstract

Abstract : Case Diagnosis : Reversible myoclonus, tremor, and asterixis induced by high dose trimethoprim-sulfamethoxazole. Case Description : The patient was a 66-year-old male with T9 AIS 1 C quadriplegia secondary to spinal cord compression by a tumor due to large B cell lymphoma. Subsequent to tumor resection and chemotherapy, the patient was discovered to have Pneumocystis jiroveci pneumonia (PJP). Once started on high dose trimethoprim-sulfamethoxazole (TMP-SMX) therapy (15.6 mg/kg/day of trimethoprim) for the treatment of PJP, he displayed bilateral upper extremity myoclonic jerks at rest, asterixis, and postural tremor. Symptoms resolved once TMP-SMX therapy was discontinued. Discussion : Myoclonus, asterixis, and tremor have been linked to high dose TMP-SMX therapy as a toxic side effect. Our patient's symptoms did improve with levetiracetam therapy, but did not fully resolve until TMP-SMX was discontinued. Conclusions : This is thought to be the first reported case of reversible myoclonus, tremor, and asterixis induced by high dose TMP-SMX in the spinal cord injury population. Early recognition of TMP-SMX induced complications were of key importance as they negatively impacted the rehabilitation process. We also recommend consideration of symptomatic treatment with levetiracetam for the duration of required TMP-SMX therapy as it appeared to mitigate the severity of our patient's movement disorders.