Reactions 1476, p29 - 2 Nov 2013

SPivampicillin

Encephalopathy and cardiac arrhythmia: 6 casereports

Six patients with primary carnitine deficiency developedencephalopathy and cardiac arrhythmia following treatmentwith pivampicillin; five patients died [indications, routes anddosages not stated; not all times to reactions onset stated].

A 34-year-old pregnant woman became comatose afterreceiving pivampicillin. She regained consciousness within2 days. Two months later, she again received pivampicillin andbecame combative and comatose. Following admission to theICU, she developed ventricular fibrillation and wasimmediately defibrillated. She regained consciousness 3 dayslater.

A 26-year-old woman was treated with pivampicillinfollowing a laparotomy. Four days later, she developedvomiting, abdominal pain, stupor and psychotic behaviour.Her bicarbonate level was 27.4 mmol/L. She subsequentlydied after developing ventricular tachycardia and asystole.

A 43-year-old woman with a history of ventricular fibrillationand coma following treatment with pivmecillinam andpivampicillin was hospitalised with nausea and vomiting after6 days of treatment with pivampicillin. Laboratoryinvestigations included the following: sodium 146 mmol/L,blood glucose 10.1 mmol/L, creatinine 167 µmol/L, CRP35 mg/L, WBC count 10.5 × 109/L and AST 852 U/L. She wassuccessfully resuscitated following two episodes of cardiacarrest. An ECG after the second episode was consistent withacute myocardial infarction. Despite treatment withfibrinolysis, she died.

A 14-month-old girl was hospitalised with excessivevomiting after 10 days of treatment with pivampicillin. Thiswas followed by loss of consciousness, seizures and cardiacarrest. Resuscitation attempts were unsuccessful, and shedied.*

A girl developed neurological impairment following anepisode with coma and suspected viral encephalitis at2.5 years of age. Fourteen months later, she experiencedunconsciousness and seizures after treatment withpivampicillin. Her bicarbonate level was 18.5 mmol/L, andtelemetry revealed irregular sinus rhythm with ventricularpremature complexes. She died 4 days later.

A 30-year-old woman who had experienced two previousepisodes of cardiac arrest and had undergone placement of animplantable cardioverter-defibrillator was treated withpivampicillin. Three days later, she was hospitalised withexcessive vomiting and lost consciousness. The following day,she developed bradycardia, ventricular fibrillation andasystole, resulting in death.

Author comment: "Our primary finding was a strong timerelation between consumption of antibiotics containingpivalic acid, encephalopathy and lethal cardiac arrhythmias inpatients with primary carnitine deficiency - six subjects hadall, prior to them developing encephalopathy and severecardiac arrhythmia, taken antibiotics containing pivalic acid."

* This case report has been previously published [Christensen et al.Sudden infant death following pivampicillin treatment in a patient withcarnitine transporter deficiency. J Inherit Metab Dis 23: Suppl 1, 2000;Osa E, Simonsen H. Carnitine transporter deficiency in two Faeroesechildren. Ugeskr Laeger 166 (50): 4612–4613, 2004].

Rasmussen J, et al. Primary carnitine deficiency and pivalic acid exposure causingencephalopathy and fatal cardiac events. Journal of Inherited Metabolic Disease36: 35-41, No. 1, Jan 2013. Available from: URL: http://dx.doi.org/10.1007/s10545-012-9488-8 - Faroe Islands 803095026

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Reactions 2 Nov 2013 No. 14760114-9954/13/1476-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved