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Medication bezoar and esophagitis in a patient with HIV infection receiving combination antiretroviral therapy
Letters to the Editor 1. Chim CS, Liang R, Chan AC, et al. Primary B cell lymphoma of the mediastinum. Hematol Oncol. 1996;14:173–179. 2. Popat U, Przepiork D, Champlin R, et al. High-dose chemotherapy for relapsed and refractory diffuse large B-cell lymphoma: mediastinal localization predicts for a favorable outcome. J Clin Oncol. 1998;16:63– 69. 3. Bum S, Barnes PC. Non-Hodgkins lymphoma presenting with evidence of right ventricular outflow tract obstruction. Br J Clin Pract. 1994;48:73–74. 4. Eyskens B, Lawrenson J, Moerman P, et al. Sudden death following removal of pericardial fluid in a child presenting with mediastinal lymphoma. Med Ped Oncol. 1998;31: 547–548.
MEDICATION BEZOAR AND ESOPHAGITIS IN A PATIENT WITH HIV INFECTION RECEIVING COMBINATION ANTIRETROVIRAL THERAPY To the Editor: Recent advances in the treatment of human immunodeficiency virus (HIV) infection have led to complex treatment regimens with high daily pill burdens. Patients often take three or more antiretroviral drugs in addition to other medications. We describe a patient on combination antiretroviral therapy who developed an obstructing esophageal bezoar. A 25-year-old man with HIV infection was admitted with a 2-day history of odynophagia and dysphagia for solids and liquids. Until the time of admission, he had continued to take all of his oral medications, including stavudine, lamivudine, nelfinavir, ganciclovir, and trimethoprimsulfamethoxazole, which totaled 29 pills per day. On physical examination, he was unable to complete a sentence without stopping to expectorate saliva. He had poor oral hygiene, but no oral or pharyngeal lesions were present. His gag reflex was intact. Repeated attempts to place a nasogastric tube
684
June 1, 2000
were unsuccessful; although the tube could be passed through the nasopharynx, it could not be advanced further. A computed tomographic scan of the neck and chest revealed a mass in the proximal esophagus (Figure). Esophagoscopy was performed; an irregular, friable mass obstructing the esophageal lumen was present at 25 cm. The mass was fractured with biopsy forceps and was found to be a coalescence of pill fragments. A substantial portion of the fragments were light blue, consistent with the exterior color of nelfinavir tablets. The fragments were allowed to pass into the stomach. Mild esophagitis with erosions and erythema were noted at the location of the obstruction. After the procedure, the patient was able to tolerate a soft diet. He was discharged the following morning with instructions to crush the nelfinavir tablets and to ingest all medications with ample liquids. He has had no recurrence of his esophageal symptoms in the 6 months following discharge. Antibiotics and antiviral medications account for 60% of all reported cases of pill-induced esophagitis (1,2). Kikendall and Johnson (3) described esophageal injury in 3 HIV-
infected patients receiving zidovudine. Medications were reported as a cause of a mid-esophageal stricture that subsequently led to food impaction in a patient with advanced HIV infection (4). We believe that nelfinavir was largely responsible for the bottlenecking of pills in our patient’s esophagus, resulting in esophagitis and obstruction. Nelfinavir is the only protease inhibitor available as a tablet rather than as a capsule. The tablets are large and dissolve on contact with saliva; our patients frequently report that they are difficult to swallow. Dipping nelfinavir tablets in olive oil before ingestion has been recommended to make them easier to swallow (data on file, Agouron Pharmaceuticals, La Jolla, California; a coated nelfinavir tablet has recently become available). It is not known whether nelfinavir itself is directly caustic to esophageal mucosa. We recommend that patients with HIV infection receive specific counseling on ways to ingest medications to reduce the risk of esophageal injury. This approach may be of particular importance, as the recent trend toward less frequent dosing of antiretroviral medications may result in a
Figure. Computed tomographic scan of the chest demonstrating a mass (arrow) obstructing the proximal esophagus at the level of the thoracic inlet.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 108
Letters to the Editor
greater pill burden at each dosing interval. Specific recommendations include drinking ample fluids (120 mL or more) with medications, maintaining an upright posture after ingestion, avoiding taking medications at bedtime, crushing pills, and when feasible and without adversely affecting bioavailibility, mixing pills with liquids or soft foods (1). Some patients may find capsules easier to swallow than tablets. Powdered or liquid formulations of many antiretroviral medications are also available and can be used by patients with dysphagia or by patients who report difficulty in swallowing tablets or capsules. Deborah Hutter, MD, Suat Akgun, MD Ravi Ramamoorthy, MD Lisa L. Dever, MD Medical Service VA New Jersey Health Care System East Orange, New Jersey Department of Medicine UMDNJ-New Jersey Medical School Newark, New Jersey 1. Kikendall JW. Pill-induced esophageal injury. Gastroenterol Clin N Am.1991;20:835– 846. 2. Kikendall JW, Friedman AC, et al. Pill-induced esophageal injury. Case reports and review of the medical literature. Dig Dis Sci. 1983;28:174 –182. 3. Kikendall JW, Johnson LF. Pill-induced esophageal injury. In: Castell DO, ed. The Esophagus. Boston: Little Brown; 1991. 4. Shapiro BD, Ehrenpreis ED, Tomaka FL, et al. Idiopathic midesophageal stricture: a new cause of dysphagia in a patient with AIDS. South Med J. 1997;90:80 – 82.
tant Staphylococcus aureus (MRSA) are increasing (1–3). Control of MRSA has been especially important since the detection of strains with intermediate resistance to vancomycin (4). Asymptomatic colonization with MRSA is more likely in patients on hemodialysis and in patients with wounds, dermatologic diseases, diabetes mellitus, immunodeficiency, and foreign bodies; if colonized, these patients should be treated to eradicate colonization (3,5). Eradication of MRSA with local and systemic antibiotics is not entirely effective and bears the risk of leading to resistant organisms (3,5). The use of skin disinfectants has been recommended as an alternative (6). We therefore tested the efficacy of skin disinfection in the eradication of MRSA. Five hospitalized patients who were colonized with MRSA at different body sites were isolated from other patients and visitors and underwent systematic local disinfection with 0.1% octenidine dihydrochloride plus 2% phenoxyethanol (Octenisept), a cation-active bispyridine that is effective against MRSA (7,8). The patient’s entire skin was washed thoroughly with disinfectant every other day; the mouth was irrigated twice per day. Local mupirocin (2%) was applied to the nostrils three times
per day. Smear-cultures were taken daily from the hairline, nostrils, oral cavity, sputum, axilla, genital and anal skin, and wounds, and cultured for MRSA. Successful eradication was defined as 5 days of negative cultures from all sites. Treatment was continued until hospital discharge or successful eradication. After 25 ⫾ 13 (mean ⫾ SD) days of treatment, 4 patients were still colonized with MRSA in the oral cavity, in sputum samples, or on the genital or anal skin (Table). MRSA was eradicated from all of the affected sites in only 1 patient. MRSA was eradicated from the hairline, axilla, and wounds in all patients, although the time needed for disinfection of these sites exceeded the 3 to 6 days usually recommended for disinfection (6). Colonization of the nostrils was eradicated in all patients by local application of mupirocin, but the time needed was greater than the 7 days usually recommended (5). The sites requiring the longest treatment were the anal skin (22 days) and the oral cavity (18 days). The incomplete eradication of MRSA in 4 of the 5 patients may be due partly to reduced patient compliance. Systematic disinfection is further limited by the time needed for washing the patients (1 to 2 hours per
Table. Frequency of MRSA Colonization in 5 Patients at Different Body Sites at the Beginning and the End of Systemic Local Disinfection with Octenidine ⫹ Phenoxyethanol Colonization
DECOLONIZATION OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BY DISINFECTION OF THE SKIN To the Editor: The rates of colonization and morbidity and mortality due to nosocomial infection with methicillin-resis-
Site
Before Disinfection
After Disinfection
Mean (⫾ SD) Duration of Treatment (Days)
Number Anal skin Axilla Genital skin Hairline Nostrils Oral cavity Sputum Wound
4 1 5 3 4 5 5 2
June 1, 2000
1 0 2 0 0 1 2 0
THE AMERICAN JOURNAL OF MEDICINE威
22 ⫾ 18 13 ⫾ 10 17 ⫾ 18 6⫾2 10 ⫾ 4 18 ⫾ 8 21 ⫾ 12 18 ⫾ 1
Volume 108 685
MEDICATION BEZOAR AND ESOPHAGITIS IN A PATIENT WITH HIV INFECTION RECEIVING COMBINATION ANTIRETROVIRAL THERAPY To the Editor: Recent advances in the treatment of human immunodeficiency virus (HIV) infection have led to complex treatment regimens with high daily pill burdens. Patients often take three or more antiretroviral drugs in addition to other medications. We describe a patient on combination antiretroviral therapy who developed an obstructing esophageal bezoar. A 25-year-old man with HIV infection was admitted with a 2-day history of odynophagia and dysphagia for solids and liquids. Until the time of admission, he had continued to take all of his oral medications, including stavudine, lamivudine, nelfinavir, ganciclovir, and trimethoprimsulfamethoxazole, which totaled 29 pills per day. On physical examination, he was unable to complete a sentence without stopping to expectorate saliva. He had poor oral hygiene, but no oral or pharyngeal lesions were present. His gag reflex was intact. Repeated attempts to place a nasogastric tube
684
June 1, 2000
were unsuccessful; although the tube could be passed through the nasopharynx, it could not be advanced further. A computed tomographic scan of the neck and chest revealed a mass in the proximal esophagus (Figure). Esophagoscopy was performed; an irregular, friable mass obstructing the esophageal lumen was present at 25 cm. The mass was fractured with biopsy forceps and was found to be a coalescence of pill fragments. A substantial portion of the fragments were light blue, consistent with the exterior color of nelfinavir tablets. The fragments were allowed to pass into the stomach. Mild esophagitis with erosions and erythema were noted at the location of the obstruction. After the procedure, the patient was able to tolerate a soft diet. He was discharged the following morning with instructions to crush the nelfinavir tablets and to ingest all medications with ample liquids. He has had no recurrence of his esophageal symptoms in the 6 months following discharge. Antibiotics and antiviral medications account for 60% of all reported cases of pill-induced esophagitis (1,2). Kikendall and Johnson (3) described esophageal injury in 3 HIV-
infected patients receiving zidovudine. Medications were reported as a cause of a mid-esophageal stricture that subsequently led to food impaction in a patient with advanced HIV infection (4). We believe that nelfinavir was largely responsible for the bottlenecking of pills in our patient’s esophagus, resulting in esophagitis and obstruction. Nelfinavir is the only protease inhibitor available as a tablet rather than as a capsule. The tablets are large and dissolve on contact with saliva; our patients frequently report that they are difficult to swallow. Dipping nelfinavir tablets in olive oil before ingestion has been recommended to make them easier to swallow (data on file, Agouron Pharmaceuticals, La Jolla, California; a coated nelfinavir tablet has recently become available). It is not known whether nelfinavir itself is directly caustic to esophageal mucosa. We recommend that patients with HIV infection receive specific counseling on ways to ingest medications to reduce the risk of esophageal injury. This approach may be of particular importance, as the recent trend toward less frequent dosing of antiretroviral medications may result in a
Figure. Computed tomographic scan of the chest demonstrating a mass (arrow) obstructing the proximal esophagus at the level of the thoracic inlet.
THE AMERICAN JOURNAL OF MEDICINE威
Volume 108
Letters to the Editor
greater pill burden at each dosing interval. Specific recommendations include drinking ample fluids (120 mL or more) with medications, maintaining an upright posture after ingestion, avoiding taking medications at bedtime, crushing pills, and when feasible and without adversely affecting bioavailibility, mixing pills with liquids or soft foods (1). Some patients may find capsules easier to swallow than tablets. Powdered or liquid formulations of many antiretroviral medications are also available and can be used by patients with dysphagia or by patients who report difficulty in swallowing tablets or capsules. Deborah Hutter, MD, Suat Akgun, MD Ravi Ramamoorthy, MD Lisa L. Dever, MD Medical Service VA New Jersey Health Care System East Orange, New Jersey Department of Medicine UMDNJ-New Jersey Medical School Newark, New Jersey 1. Kikendall JW. Pill-induced esophageal injury. Gastroenterol Clin N Am.1991;20:835– 846. 2. Kikendall JW, Friedman AC, et al. Pill-induced esophageal injury. Case reports and review of the medical literature. Dig Dis Sci. 1983;28:174 –182. 3. Kikendall JW, Johnson LF. Pill-induced esophageal injury. In: Castell DO, ed. The Esophagus. Boston: Little Brown; 1991. 4. Shapiro BD, Ehrenpreis ED, Tomaka FL, et al. Idiopathic midesophageal stricture: a new cause of dysphagia in a patient with AIDS. South Med J. 1997;90:80 – 82.
tant Staphylococcus aureus (MRSA) are increasing (1–3). Control of MRSA has been especially important since the detection of strains with intermediate resistance to vancomycin (4). Asymptomatic colonization with MRSA is more likely in patients on hemodialysis and in patients with wounds, dermatologic diseases, diabetes mellitus, immunodeficiency, and foreign bodies; if colonized, these patients should be treated to eradicate colonization (3,5). Eradication of MRSA with local and systemic antibiotics is not entirely effective and bears the risk of leading to resistant organisms (3,5). The use of skin disinfectants has been recommended as an alternative (6). We therefore tested the efficacy of skin disinfection in the eradication of MRSA. Five hospitalized patients who were colonized with MRSA at different body sites were isolated from other patients and visitors and underwent systematic local disinfection with 0.1% octenidine dihydrochloride plus 2% phenoxyethanol (Octenisept), a cation-active bispyridine that is effective against MRSA (7,8). The patient’s entire skin was washed thoroughly with disinfectant every other day; the mouth was irrigated twice per day. Local mupirocin (2%) was applied to the nostrils three times
per day. Smear-cultures were taken daily from the hairline, nostrils, oral cavity, sputum, axilla, genital and anal skin, and wounds, and cultured for MRSA. Successful eradication was defined as 5 days of negative cultures from all sites. Treatment was continued until hospital discharge or successful eradication. After 25 ⫾ 13 (mean ⫾ SD) days of treatment, 4 patients were still colonized with MRSA in the oral cavity, in sputum samples, or on the genital or anal skin (Table). MRSA was eradicated from all of the affected sites in only 1 patient. MRSA was eradicated from the hairline, axilla, and wounds in all patients, although the time needed for disinfection of these sites exceeded the 3 to 6 days usually recommended for disinfection (6). Colonization of the nostrils was eradicated in all patients by local application of mupirocin, but the time needed was greater than the 7 days usually recommended (5). The sites requiring the longest treatment were the anal skin (22 days) and the oral cavity (18 days). The incomplete eradication of MRSA in 4 of the 5 patients may be due partly to reduced patient compliance. Systematic disinfection is further limited by the time needed for washing the patients (1 to 2 hours per
Table. Frequency of MRSA Colonization in 5 Patients at Different Body Sites at the Beginning and the End of Systemic Local Disinfection with Octenidine ⫹ Phenoxyethanol Colonization
DECOLONIZATION OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS BY DISINFECTION OF THE SKIN To the Editor: The rates of colonization and morbidity and mortality due to nosocomial infection with methicillin-resis-
Site
Before Disinfection
After Disinfection
Mean (⫾ SD) Duration of Treatment (Days)
Number Anal skin Axilla Genital skin Hairline Nostrils Oral cavity Sputum Wound
4 1 5 3 4 5 5 2
June 1, 2000
1 0 2 0 0 1 2 0
THE AMERICAN JOURNAL OF MEDICINE威
22 ⫾ 18 13 ⫾ 10 17 ⫾ 18 6⫾2 10 ⫾ 4 18 ⫾ 8 21 ⫾ 12 18 ⫾ 1
Volume 108 685