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Posts Tagged ‘immunocompromised’

keep-calm-it-s-only-c-diffThe comedy of medical errors continues after the myelogram/CT scan on May 21st designed to gather information about my neck and back. That intervention resulted in a case of bacterial meningitis, hospitalization, and ten days on a strong, broad spectrum (kills most everything) antibiotic called ceftriaxone administered via infusion through a PICC line. The meningitis was vanquished and the PICC line pulled. But then a secondary infection took root.

One of the listed side effects for cephalasporin antibiotics like ceftriaxone are that they kill many of the helpful bacteria living in the gut but do not kill potentially harmful microbes including one called Clostridium difficile or C diff. Symptoms of C diff include the following:

There is a lab test for the bacteria (don’t ask about how it is obtained). When C diff bacteria gain a foothold in the intestines, they release toxins that damage the intestines (colitis) and the toxins can get into the bloodstream. Dehydration is a major concern. It is a spore forming bacteria and the spores are difficult to kill. It is a common infection in hospitals and other health care facilities and is especially problematic in elderly, unhealthy, and immunocompromised patients (hey, that last one is me!). Over 500,000 Americans get C diff annually with almost 30,000 deaths associated with the infection annually. C diff is now seen as a more serious hospital related infection risk than even the much-feared MRSA staph bacteria.

Treatment for C diff starts with an antibiotic. Metronidazole, or Flagyl, is usually the first line antibiotic used for C diff. But my infectious disease docter went straight to the second line antibiotic, vancomycin, when he learned that I take Rituxan for RA and am immunocompromised. I’m currently taking an oral version of vanco. Up to 20% of patients relapse after the first round of antibiotics and must take additional rounds. If the good bacteria are wiped out, then it stands to reason that probiotics may be helpful in repopulating these flora. The research results on probiotics for C diff are mixed but my doctor recommended that I take them. I opted to take a medical grade probiotic called VSL #3. There are published research studies that the bacteria strains in VSL #3 help colitis symptoms. It’s available at many pharmacies but is kept behind the counter in a refrigerator.

It seems that RA is the gift that keeps on giving. I’ll just be glad to move onto the more “traditional” primary RA issues!

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After the latest ordeal of the past week, the weekend was pretty low key although I was still fighting bad headaches, dizziness, and general malaise. On Monday afternoon, a nurse from the hospital’s emergency department called to say that after four days, the spinal fluid culture came back positive for a bacteria called Streptococcus viridans. They wanted me to come back to the ER immediately. Upon arrival, an IV dose of the antibiotic Ceftriaxone was given along with 1000ml of saline. The doctor came in and said that they were admitting me to the hospital for meningitis which is a general term for an infection of the cerebral spinal fluid and tissues around the brain and spinal cord. This can be a very serious disease and this was the reason for admission. An infectious disease doctor came by to discuss my case. He indicated that this strep bacteria is commonly found on the skin, mouth, and nose and is rarely found in meningitis. He suspected that the original lumbar puncture of the myelogram from the previous week introduced the bacteria into the spinal fluid. While the number of bacteria found in the culture was low, the fact that I’m immunocompromised from taking Rituxan for RA caused the doctors to take an aggressive approach. The infectious disease doctor prescribed a course of IV treatment with the antibiotic Ceftriaxone. This began while in the hospital and requires two doses every 12 hours for 10 days. Fortunately, the IV infusion only takes 10-15 minutes. It was decided that I could be discharged after one sleepless night in the hospital (hospitals are not places to get a good night’s rest). But I would need to continue the IV antibiotics for the next nine days. IMG_0072Instead of returning to the infusion center twice a day, a peripherally inserted central catheter or PICC line was put in (see picture). This was a rather intense installation process as the catheter is put into a larger vein in your arm and the tube goes all the way to an area close to the heart. It involved a specialist nurse using ultrasound guidance and a sterile field in order to get the tube in the right place. The PICC line allows the patient to self-administer the medicine at home. A local speciality infusion pharmacy handled the prescription and a nurse came to my house with the medicine and supplies and spent over an hour teaching me how to safely administer the antibiotic. After self-injecting RA meds over the years, this process is fairly easy.

So an entire week of my life was devoted to a variety of medical processes and procedures. It all began with an attempt to image potential joint damage in my neck and lower spine and ended up with a serious infection. And it’s not quite over as I have an electromyography(EMG)/nerve conduction test with my neurologist tomorrow afternoon to check on the potential source of my muscle and nerve pain – the original reason for the myelogram. And then an appointment with the infectious disease doctor on June 4th to check progress and hopefully remove the PICC line. Such is life in the RA fast lane!

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Ever since the H1N1 swine flu scare a few years ago, I make it a point to get a flu vaccine every autumn. When receiving a regular physical exam from my general practitioner last week, the doctor suggested that a pneumococcal polysaccharide vaccine be added…

To check out the rest of this post, go to the newly launched website rheumatoidarthritis.net. I will be writing posts for this site periodically as a Patient Advocate and will continue to make regular posts at this personal blog.

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RA patients are commonly immunocompromised due to the drugs they take. Since RA is an autoimmune disease where the body’s immune system attacks itself, the drugs are often designed to slow down some part of the immune process. Read any of the side effect materials of biological or chemical treatments for RA and one of the first on the lists will be upper respiratory infections. That includes sinus infections which are ripe for problems given their moist, warm environment. Add any anatomical problems preventing drainage and infections are going to crop up. As previously documented in this blog, I’ve battled sinus infections pretty much ever since starting on RA treatments. That led to multiple treatments including antibiotics, decongestants, antihistamines, steroids (sprays and oral), and sinus irrigations which all failed to take care of the infections. That led to endoscopic sinus surgery on Tuesday. The surgery had four goals – correct a deviated septum, clean out the ethmoid sinuses, clean out the maxillary sinuses, and reduce the turbinates which are radiator-like flaps in the nose. There are no external cuts as the surgeon uses the scope and a camera to conduct the procedure.

After having three surgeries on my ankles for RA related issues, I had a pretty good idea about the process in general including anesthesia. But operating on the head near the eyes and brain was a new experience. My ear, nose, and throat (ENT) doctor is very experienced doing this kind of surgery so I had full trust in her capabilities. I reported at the outpatient surgery center in the morning and they immediately started me on large doses of Afrin spray which would reduce the bleeding during surgery since the nose and sinuses have some of the most blood vessels of anywhere in the body. You just have to love the wonderful clothing they make you wear which included a gown open in the back, footies, and a cap to cover my head. The anesthesiologist met with me and I told him about previous nausea from general anesthesia and he let me know he would give me everything he could to help manage that. I was led into the operating room which was very cold. I climbed onto the table and the anesthesiologist started an IV. They strapped me down to the table and after a few comments, I went to sleep pretty fast.

The next thing I remember was slowly waking up in a recovery room with an ice pack on my face. I could not breathe out of my nose as they had it packed to prevent bleeding. The nurse gave me some jello, cookies, and a drink. She also injected some fentanyl in my IV for pain. As soon as I could get up, I got dressed and my wife came back to be with me. By noon, I checked out and went home stopping at the pharmacy to pick up some Vicodin for pain and another round of antibiotics.

The first 24 hours were not pleasant. I could not breathe, had nausea from all the drugs and blood draining down my throat, and could not sleep. Add to that a terrible headache which I found out from the surgeon was common right after sinus surgery. I couldn’t wait until the next morning when I went to the doctor’s office to have the nasal packing removed. The gory details will be spared but all I can say is what a relief! I immediately felt much better. The bleeding and inflammation causes lots of pressure and pain that feel like a sinus infection but regular irrigation with saline solution has started to clear that out. I also added some oral prednisone that I use for RA flares. After 48 hours I can breathe through both sides of my nose for the first time in months!

During this time, RA symptoms have been pretty much under check. The copious amounts of pain meds and the prednisone probably help. Add to that the fact that physical activity has been curtailed and joints aren’t being used. Rest is ordered for the next couple of weeks.

My rheumatologist has great hopes for my long term ability to fight off sinus infections after having the surgery. She said that about 10% of her RA patients on biological medicines have recurring sinus infections and that sinus surgery provides relief for most of them. Stopping RA treatment is not a recommended option as the chances for long term damage is too great.

At least I have a great family and set of friends who are helping to care for me. And that includes one of my cats Bella who joined me on the couch this morning!

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