Mineralocorticoid hypertension due to a nasal spray containing 9α-fluoroprednisolone: Mantero F,...
1
Hypertension Sa-fluoroprednisolone Nasal spray Fever Renal transplant recipients Pseudoaldosteronism Peterson PK, Balfour HH, Fryd DS, Ferguson RM, Simmons RL: Fever in renal trans- Mantero F, Armanini D, Opocher G, Fallo F, Sampieri L, Cuspidi B, Ambrosi C. Faglia plant recipients: causes, prognostic significance and changing patterns at the Univer- G: Mineralocorticoid hypertension due to a nasal spray containing So+fluoropredniso- sky of Minnesota Hospital. Am J Med 198 1; 7 1: 345-35 1. lone. Am J Med 1981; 71: 352-357. During a three year period in which 433 renal transplants were performed, 194 episodes of The finding of hypokalemia and low PRA in a hypertensive patient suggests a diagnosis of pri- fever were documented in allograft recipients hospitalized at the University of Minnesota. Viral mary hypermineralocorticoidism. Medications containing compounds wtth mineralocorticoid-like infections were responsible for over half of the febrile episodes, and 98 of the fevers were as- activity may also cause the same syndrome. Recently, detailed studies were carried out in 10 sociated with cytomegalovirus (CMV), either occurring alone or in conjunction with allograft patients with severe hypertension and hypokalemic alkalosis, suppressed PRA and low aldo- rejection or another systemic infection. Bacterial infections, fungal infections and rejection were sterone levels. In most of them, plasma cortisol and ACTH levels were suppressed, and de- other causes of fever. Most fevers occurred in the first four months after transplantation; about oxycorticosterone and corticosterone levels were not significantly higher than normal. Dexa- two thirds of these fevers were due to CMV. Of the febrile illnesses associated with transplant methasone and aminoglutethimide therapy was ineffective, but spironolactone and amiloride nephrectomy or death, a majority occurred in patients with CMV disease. Secondary bacterial therapy resulted in substantial amelioration of both the hypertension and hypokalemia. All patients and/or fungal infections were observed in a large majority of patients with lethal CMV disease. had chronic rhinitis and were habitual users of nasal sprays containing 9a!-fluoroprednisolone During the third year of this study there was a significant decrease in the proportion of febrile and vasoconstrictor agents. Following the discontinuation of their use, the hypokalemia remitted episodes due to CMV. in all patients. This report reveals another cause of factitious mineralocorticoid excess which may be considered in the differential diagnosis of hypokalemic hypertensive syndromes. Peritonitis LeVeen shunt Perioperative contamination Fungemia Antigenemia Mortality, high Systemic antimicrobial therapy Parenteral nutrition Candida infections Wormser GP. Hubbard RC: Peritonitis in cirrhotic patients with LeVeen shunts. Am J Meunier-Carpentier F, Kiehn TE, Armstrong D: Fungemia in the immunocompromised Med 1981; 71: 358-382. host: changing patterns, antigenemia, high mortality. Am J Med 1981; 71: 363-370. Six cirrhotic patients are described in whom peritonitis developed 10 days to 15 months after Fungemias were reviewed in 110 immunosuppressed patients between November 1, 1974, insertion of a LeVeen shunt. The presenting clinical features of fever, increasing ascites and and December 31, 1977, at Memorial Sloan-Kettering Cancer Center. The incidence of Candida deterioration in mental status resembled those previously reported for cirrhotic patients without tropicalis fungemta increased each year. In 76 percent of the patients with C. tropicalis fungemia shunts but with spontaneous peritonitis. Important differences were observed, however, in and in 32.5 percent of those with C. albicans fungemia, either leukemia or lymphoma was microbiology, incidence of bacteremia and therapy. Staphylococcus aureus, a rare cause of present. Df the C. parapsilosis fungemias, 77 percent were related to total parenteral nutrition. spontaneous peritonitis, was found in one half of our cases, suggesting that perioperative The source of fungemia was often difficult to determine: in 60 percent of the patients only blood contamination during shunt placement was an important etiologic factor. All six had concomitant cultures were positiie for C. tropicalis or Torulopsis glabrata. Results of serologic tests, including bacteremia which may be attributable to the direct peritoneal-venous connection. The admin- a highly sensitive passive hemagglutination test, showed fourfold increases in titer only in- istration of appropriate systemic antimicrobial therapy wtthout shunt removal failed to eradicate consistently. A passive hemagglutination inhibition test for circulating antigen was positive in the infection irrespective of shunt patency or absence of inflammation at insertion sites. Rec- 50.9 percent of 57 patients tested and may be a valid indication for treatment. The over-all ommended treatment for suspected peritonitis in patients with shunts is systemic antimicrobial mortality of these 110 patients was 79 percent, but of the patients with C. parapsilosis fungemia therapy with an agent active against staphylococci plus an aminoglycoside, followed by shunt only 23 percent died. Among the patients who received >200 mg of amphotericin B, 71 percent removal if the diagnosis is confirmed. died despite treatment. Continued on page A39
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Transcript of Mineralocorticoid hypertension due to a nasal spray containing 9α-fluoroprednisolone: Mantero F,...
Hyp
erte
nsi
on
S
a-fl
uo
rop
red
nis
olo
ne
Nas
al s
pra
y F
ever
R
enal
tra
nsp
lan
t re
cip
ien
ts
Pse
ud
oal
do
ster
on
ism
Pet
erso
n P
K,
Bal
fou
r H
H,
Fry
d D
S,
Fer
gu
son
RM
, S
imm
on
s R
L:
Fev
er i
n r
enal
tra
ns-
M
ante
ro F
, A
rman
ini
D,
Op
och
er G
, F
allo
F,
Sam
pie
ri
L,
Cu
spid
i B
, A
mb
rosi
C
. F
aglia
p
lan
t re
cip
ien
ts:
cau
ses,
pro
gn
ost
ic s
ign
ific
ance
an
d c
han
gin
g p
atte
rns
at t
he
Un
iver
- G
: M
iner
alo
cort
ico
id
hyp
erte
nsi
on
du
e to
a n
asal
sp
ray
con
tain
ing
So
+flu
oro
pre
dn
iso
- sk
y o
f M
inn
eso
ta H
osp
ital
. A
m J
Med
198
1;
7 1:
345
-35
1.
lon
e. A
m J
Med
198
1;
71:
352-
357.
Du
rin
g a
th
ree
year
per
iod
in
wh
ich
433
re
nal
tra
nsp
lan
ts w
ere
per
form
ed,
194
epis
od
es o
f T
he
fin
din
g o
f h
ypo
kale
mia
an
d l
ow
PR
A i
n a
hyp
erte
nsi
ve p
atie
nt
sug
ges
ts a
dia
gn
osi
s o
f p
ri-
feve
r w
ere
do
cum
ente
d i
n a
llog
raft
rec
ipie
nts
ho
spit
aliz
ed a
t th
e U
niv
ersi
ty o
f M
inn
eso
ta.
Vir
al
mar
y h
yper
min
eral
oco
rtic
oid
ism
. M
edic
atio
ns
con
tain
ing
co
mp
ou
nd
s w
tth
min
eral
oco
rtic
oid
-lik
e in
fect
ion
s w
ere
resp
on
sib
le f
or
ove
r h
alf
of t
he
feb
rile
ep
iso
des
, an
d 9
8 o
f th
e fe
vers
wer
e as
- ac
tivi
ty m
ay a
lso
cau
se t
he
sam
e sy
nd
rom
e. R
ecen
tly,
det
aile
d s
tud
ies
wer
e ca
rrie
d o
ut
in 1
0 so
ciat
ed w
ith
cyt
om
egal
ovi
rus
(CM
V),
ei
ther
occ
urr
ing
alo
ne
or
in c
on
jun
ctio
n w
ith
allo
gra
ft
pat
ien
ts w
ith
sev
ere
hyp
erte
nsi
on
an
d h
ypo
kale
mic
al
kalo
sis,
su
pp
ress
ed P
RA
an
d l
ow
ald
o-
reje
ctio
n o
r an
oth
er s
yste
mic
in
fect
ion
. Bac
teri
al i
nfe
ctio
ns,
fun
gal
infe
ctio
ns
and
rej
ecti
on
wer
e st
ero
ne
leve
ls.
In m
ost
of
them
, p
lasm
a co
rtis
ol
and
AC
TH
le
vels
wer
e su
pp
ress
ed,
and
de-
o
ther
cau
ses
of
feve
r. M
ost
fev
ers
occ
urr
ed i
n th
e fi
rst
fou
r m
on
ths
afte
r tr
ansp
lan
tati
on
; ab
ou
t o
xyco
rtic
ost
ero
ne
and
co
rtic
ost
ero
ne
leve
ls w
ere
no
t si
gn
ific
antl
y h
igh
er t
han
no
rmal
. D
exa-
tw
o t
hir
ds
of
thes
e fe
vers
wer
e d
ue
to C
MV
. O
f th
e fe
bri
le i
llnes
ses
asso
ciat
ed w
ith
tra
nsp
lan
t m
eth
aso
ne
and
am
ino
glu
teth
imid
e th
erap
y w
as i
nef
fect
ive,
b
ut
spir
on
ola
cto
ne
and
am
ilori
de
nep
hre
cto
my
or
dea
th,
a m
ajo
rity
occ
urr
ed i
n p
atie
nts
wit
h C
MV
dis
ease
. S
eco
nd
ary
bac
teri
al
ther
apy
resu
lted
in s
ub
stan
tial
am
elio
rati
on
of
bo
th th
e h
yper
ten
sio
n a
nd
hyp
oka
lem
ia.
All
pat
ien
ts
and
/or
fun
gal
in
fect
ion
s w
ere
ob
serv
ed i
n a
lar
ge
maj
ori
ty o
f p
atie
nts
wit
h l
eth
al C
MV
dis
ease
. h
ad c
hro
nic
rh
init
is a
nd
wer
e h
abit
ual
use
rs o
f n
asal
sp
rays
co
nta
inin
g 9
a!-f
luo
rop
red
nis
olo
ne
Du
rin
g t
he
thir
d y
ear
of
this
stu
dy
ther
e w
as a
sig
nif
ican
t d
ecre
ase
in th
e p
rop
ort
ion
of
feb
rile
an
d v
aso
con
stri
cto
r ag
ents
. F
ollo
win
g th
e d
isco
nti
nu
atio
n o
f th
eir
use
, th
e h
ypo
kale
mia
rem
itte
d
epis
od
es d
ue
to C
MV
. in
all
pat
ien
ts.
Th
is r
epo
rt r
evea
ls a
no
ther
cau
se o
f fa
ctit
iou
s m
iner
alo
cort
ico
id
exce
ss
wh
ich
m
ay b
e co
nsi
der
ed i
n th
e d
iffe
ren
tial
dia
gn
osi
s o
f h
ypo
kale
mic
h
yper
ten
sive
syn
dro
mes
.
Per
ito
nit
is
LeV
een
sh
un
t P
erio
per
ativ
e co
nta
min
atio
n
Fu
ng
emia
A
ntig
enem
ia
Mo
rtal
ity,
hig
h
Sys
tem
ic
anti
mic
rob
ial
ther
apy
Par
ente
ral
nu
trit
ion
C
and
ida
infe
ctio
ns
Wo
rmse
r G
P.
Hu
bb
ard
RC
: P
erit
on
itis
in
cir
rho
tic
pat
ien
ts w
ith
LeV
een
sh
un
ts.
Am
J
Meu
nie
r-C
arp
enti
er
F,
Kie
hn
TE
, A
rmst
ron
g D
: F
un
gem
ia i
n th
e im
mu
no
com
pro
mis
ed
Med
198
1; 7
1: 3
58-3
82.
ho
st:
chan
gin
g p
atte
rns,
an
tig
enem
ia,
hig
h m
ort
alit
y. A
m J
Med
198
1; 7
1: 3
63-3
70.
Six
cir
rho
tic
pat
ien
ts a
re d
escr
ibed
in
wh
om
per
ito
nit
is d
evel
op
ed
10 d
ays
to 1
5 m
on
ths
afte
r F
un
gem
ias
wer
e re
view
ed
in 1
10 i
mm
un
osu
pp
ress
ed
pat
ien
ts b
etw
een
N
ove
mb
er
1, 1
974,
in
sert
ion
of
a L
eVee
n
shu
nt.
Th
e p
rese
nti
ng
clin
ical
fea
ture
s o
f fe
ver,
in
crea
sin
g a
scit
es a
nd
an
d D
ecem
ber
31
, 19
77,
at M
emo
rial
Slo
an-K
ette
rin
g C
ance
r C
ente
r. T
he
inci
den
ce o
f C
and
ida
det
erio
rati
on
in
men
tal
stat
us
rese
mb
led
th
ose
pre
vio
usl
y re
po
rted
fo
r ci
rrh
oti
c p
atie
nts
wit
ho
ut
tro
pic
alis
fu
ng
emta
incr
ease
d e
ach
yea
r. I
n 7
6 p
erce
nt
of
the
pat
ien
ts w
ith
C.
tro
pic
alis
fu
ng
emia
sh
un
ts b
ut
wit
h s
po
nta
neo
us
per
ito
nit
is.
Imp
ort
ant
dif
fere
nce
s w
ere
ob
serv
ed,
ho
wev
er,
in
and
in
32.
5 p
erce
nt
of
tho
se w
ith
C.
alb
ican
s fu
ng
emia
, ei
ther
le
uke
mia
o
r ly
mp
ho
ma
was
m
icro
bio
log
y, i
nci
den
ce o
f b
acte
rem
ia
and
th
erap
y.
Sta
ph
ylo
cocc
us
aure
us,
a r
are
cau
se o
f p
rese
nt.
Df
the
C.
par
apsi
losi
s fu
ng
emia
s, 7
7 p
erce
nt
wer
e re
late
d t
o t
ota
l p
aren
tera
l n
utr
itio
n.
spo
nta
neo
us
per
ito
nit
is,
was
fo
un
d i
n o
ne
hal
f o
f o
ur
case
s,
sug
ges
tin
g t
hat
per
iop
erat
ive
Th
e so
urc
e o
f fu
ng
emia
was
oft
en d
iffi
cult
to d
eter
min
e: i
n 6
0 p
erce
nt
of t
he
pat
ien
ts o
nly
blo
od
co
nta
min
atio
n d
uri
ng
sh
un
t pla
cem
ent
was
an
im
po
rtan
t eti
olo
gic
fac
tor.
All
six
had
co
nco
mit
ant
cult
ure
s w
ere
po
siti
ie f
or
C. t
rop
ical
is o
r T
oru
lop
sis
gla
bra
ta. R
esu
lts
of
sero
log
ic te
sts,
in
clu
din
g
bac
tere
mia
w
hic
h m
ay b
e at
trib
uta
ble
to
th
e d
irec
t p
erit
on
eal-
ven
ou
s co
nn
ecti
on
. T
he
adm
in-
a h
igh
ly s
ensi
tive
p
assi
ve h
emag
glu
tin
atio
n t
est,
sh
ow
ed f
ou
rfo
ld i
ncr
ease
s in
tit
er o
nly
in
- is
trat
ion
of
app
rop
riat
e sy
stem
ic a
nti
mic
rob
ial
ther
apy
wtt
ho
ut s
hu
nt r
emo
val
faile
d t
o e
rad
icat
e co
nsi
sten
tly.
A p
assi
ve h
emag
glu
tin
atio
n i
nh
ibit
ion
test
fo
r ci
rcu
lati
ng
an
tig
en w
as p
osi
tive
in
th
e in
fect
ion
irr
esp
ecti
ve o
f sh
un
t pat
ency
or
abse
nce
of
infl
amm
atio
n a
t in
sert
ion
sit
es.
Rec
- 50
.9
per
cen
t o
f 57
pat
ien
ts t
este
d a
nd
may
be
a va
lid i
nd
icat
ion
fo
r tr
eatm
ent.
T
he
ove
r-al
l o
mm
end
ed t
reat
men
t fo
r su
spec
ted
per
ito
nit
is i
n p
atie
nts
wit
h s
hu
nts
is s
yste
mic
an
tim
icro
bia
l m
ort
alit
y o
f th
ese
110
pat
ien
ts w
as 7
9 p
erce
nt,
bu
t of t
he
pat
ien
ts w
ith
C.
par
apsi
losi
s fu
ng
emia
th
erap
y w
ith
an
ag
ent
acti
ve a
gai
nst
sta
ph
ylo
cocc
i p
lus
an a
min
og
lyco
sid
e,
follo
wed
by
shu
nt
on
ly 2
3 p
erce
nt
die
d. A
mo
ng
th
e p
atie
nts
wh
o r
ecei
ved
>20
0 m
g o
f am
ph
ote
rici
n B
, 71
per
cen
t re
mo
val
if t
he
dia
gn
osi
s is
co
nfi
rmed
. d
ied
des
pit
e tr
eatm
ent.
Co
ntin
ue
d o
n p
ag
e A
39
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